In this engaging session, Annie Massart, MD, associate professor in the division of hospital medicine and associate vice chair of faculty development in the department of medicine at Emory University School of Medicine in Atlanta, walked hospitalists at SHM Converge through a practical, evidence‑based approach to managing nausea. Her talk blended physiology, pharmacology, and bedside decision making, with a particular focus on how and why to choose specific antiemetic medications.
Dr. Massart opened by acknowledging a reality many internists recognize: most receive little formal training in nausea management. As a result, ondansetron (Zofran) has become the default empiric choice for nausea in hospitalized patients. She explained that its widespread use may have less to do with superiority and more to do with timing and exposure—ondansetron entered the market in the 1990s as the first anti-serotonergic antiemetic, was aggressively marketed, and quickly became familiar to clinicians in the absence of broader education on alternatives. One of her primary goals for the session, she noted, was to expand hospitalists’ understanding of the full range of available options.
From there, Dr. Massart reviewed the neuroanatomic pathways involved in nausea and the receptors associated with each. She described how the vestibular system signals nausea through muscarinic acetylcholine and histamine 1 receptors; how the gastrointestinal tract primarily involves 5-hydroxytryptamine 3 receptors, 5-hydroxytryptamine 4 receptors, and dopamine receptors; and how both the brain’s vomiting center and the chemoreceptor trigger zone rely on overlapping sets of receptors, including those for dopamine, neurokinin-1, and 5-hydroxytryptamine 3. She also highlighted the role of the cerebral cortex, where gamma-aminobutyric acid and histamine 1 receptors contribute to nausea perception.
Using this framework, Dr. Massart emphasized an etiology-centered approach to treatment. Rather than reflexively ordering a single medication, she encouraged clinicians to identify which pathway is most likely driving a patient’s symptoms and to select antiemetics accordingly. She stressed the importance of scheduled dosing rather than as-needed use, noting that consistent receptor blockade is often more effective. If nausea persists, she recommended adding a second agent with a different mechanism of action instead of discontinuing and cycling through individual medications.
A significant portion of the talk addressed QTc prolongation and the risk of torsade de pointes (TdP), beginning with a discussion of clinicians’ perceptions of risk. Dr. Massart reviewed available data on common antiemetics, focusing particularly on ondansetron. She acknowledged that a single, 4-mg, IV dose can increase the QTc interval by approximately 16 to 20 milliseconds but pointed out that more recent evidence suggests the overall risk of TdP may be overestimated. She also clarified that the 2017 American Heart Association guidelines recommend obtaining a baseline QTc in patients with known QT prolongation or other risk factors when starting TdP-associated medications, including older age, female sex, or electrolyte abnormalities.
Dr. Massart then turned to haloperidol, explaining that it partially fell out of favor after an expanded U.S. Food and Drug Administration QTc warning in 2007. She noted that this shift was influenced in part by the drug’s age and reputation, rather than evidence of excessive risk. In fact, she explained, haloperidol’s QTc prolongation risk is comparable to that of serotonin antagonists such as ondansetron, and she recommended keeping the total daily dose under 5 mg when monitoring is a concern.
She also reviewed data on metoclopramide, highlighting that as of 2024, the Food and Drug Administration’s adverse event reporting system included only five cases of TdP and sixteen cases of prolonged QTc associated with the drug. While acknowledging these risks, Dr. Massart stressed that neurological adverse effects, including tardive dyskinesia, are ultimately the greater concern as they are much more common.
Discussion then shifted to phenothiazines, including prochlorperazine and promethazine. Dr. Massart noted that the literature on QTc risk for this class is limited. She cited the 2025 National Comprehensive Cancer Network guidelines, which acknowledge the potential for QTc prolongation but do not provide specific quantitative estimates. She also emphasized an important safety point: IV promethazine should never be used, given its acidic formulation and the risk of severe tissue injury if extravasation or improper injection occurs.
Dr. Massart also highlighted olanzapine as an underutilized option for nausea management. She reviewed evidence supporting its effectiveness in chemotherapy‑induced vomiting, as well as its role in improving appetite and promoting weight gain in patients with advanced cancer. She noted additional benefits in broader cancer‑related nausea and postoperative settings, emphasizing that once‑daily dosing and reduced need for multiple antiemetics make olanzapine particularly appealing for patients with a high pill burden.
To close, Dr. Massart discussed QTc‑friendly antiemetic strategies, focusing on oral agents such as olanzapine and aprepitant, which have less impact on cardiac ion channels compared with many IV medications. She also highlighted palonosetron, a second‑generation serotonin antagonist with more selective receptor interactions, and reviewed data from a meta‑analysis showing that isopropyl alcohol wipes can be surprisingly effective for nausea—often outperforming placebo and even medications like ondansetron.
Key Takeaways
- Guide selection of antiemetics by identifying the cause and choosing a medication that will effectively target neuroanatomic pathways involved in nausea and the receptors associated with each.
- Patients with significant nausea should receive scheduled, not as-needed, antiemetics.
- Brief inhalation of isopropyl alcohol wipes is rapidly and highly effective for reducing nausea and can be carried and deployed extremely easily by hospitalists on the wards.
Dr. Nave
Ms. Hall
Dr. Nave is an assistant professor in Emory’s division of hospital medicine and the vice president of the mid revenue cycle for Emory Healthcare in Atlanta. Ms. Hall is the senior medical writer in Emory’s division of hospital medicine in Atlanta.