Inhaled Isopropyl Alcohol for the Treatment of Nausea and Vomiting in a Patient Receiving Palliative Care: A Case Report

Introduction

Nausea and vomiting can be one of the most distressing symptoms experienced by patients with advanced illness. Uncontrolled nausea and vomiting can lead to a host of subsequent issues, such as decreased quality of life, malnutrition, dehydration, and electrolyte abnormalities.^1–3 There are many underlying causes of nausea and vomiting, including medication-related infection, renal failure, impaired gastric emptying, vestibular pathology, and increased intracranial pressure. Thus, managing nausea and vomiting requires understanding the suspected etiology to choose a safe and effective pharmacologic treatment. ⁴ Often, clinicians employ medications that target signaling pathways in the vomiting center in the brain, such as 5-HT3 receptor antagonists (e.g., ondansetron), dopamine antagonists, antihistamines, and anticholinergics. However, these medications are not without risk, as most medications within these classes are known to prolong the QT interval and may incur subsequent risks of ventricular arrhythmias—most notably torsades de pointes. ⁵

In palliative care, assessing the entire clinical picture, including prognosis, severity of symptoms, and disease progression, is paramount to balance the benefits and burdens of a given intervention. In some cases, such as near the end of life, treating nausea and vomiting with aggressive symptom management takes precedence over a possible risk of QT prolongation with conventional medications. However, in searching for safe and effective therapies to treat nausea and vomiting, especially in patients at risk for developing torsades de pointes where the burdens and risks outweigh the possible benefits, clinician-researchers have focused on nonpharmacologic alternatives; one such intervention is inhaled isopropyl alcohol. ⁶ This case report aims to share the experience of successful treatment of nausea and vomiting for a patient with advanced illness.

Case Description

A 57-year-old man with a past medical history that includes atrial fibrillation, chronic obstructive pulmonary disease, chronic kidney disease, chronic low back pain due to an automobile accident three years prior, and nonischemic cardiomyopathy and resultant heart failure with reduced ejection fraction for which he received a left-ventricular assist device (LVAD) that was placed two years before the current admission. Since the LVAD implantation, the patient followed as an outpatient with the advanced heart failure and palliative care teams, both as an inpatient and outpatient.

The patient was admitted as a transfer from an outside hospital due to the presence of the LVAD to manage anemia and hypovolemia; his hemoglobin was 6.6 mg/dL at the time of admission. On day one of admission, he had four episodes of emesis and reported dizziness while standing. On day two of admission, he had two more episodes of emesis and associated nausea. Initial QTc (Bazett correction formula) was 552 ms with a ventricular rate of 100 beats per minute and a QRS duration of 194 ms. Antiserotonergic and antidopaminergic antiemetics were withheld due to the concern for prolonged QTc interval. As an alternative, lorazepam 1 mg by mouth was given for management without resolution of symptoms, and the patient denied subsequent doses of this medication. The inpatient palliative care team was consulted on hospital day three for assistance with symptom management and continuity of care, as this patient followed up with the outpatient palliative care telehealth team.

Upon consultation, the patient was having intermittent, moderate nausea, which he attributed to medications, particularly oxycodone, that were being used for the management of his back pain. The patient had been taking oxycodone 10 mg by mouth three times daily for at least six months before the admission. Additionally, the patient continued to utilize oxycodone throughout the admission. Other potential etiologies of his nausea and vomiting include disruption in the vestibular system, given the presence of orthostatic symptoms while standing, chronic kidney disease, edema due to heart failure, or other oral medications such as digoxin. The orthostatic symptoms improved after the patient received one unit of packed red blood cells and 500 mL of normal saline. The patient's digoxin levels were consistently low during the admission, ranging from 0.2 to 0.4 ng/mL.

Given the prolonged QTc and preference to avoid medications that could further prolong the QTc interval, the patient was provided 70% isopropyl alcohol swabs to inhale as needed for nausea. The palliative care team instructed the patient to inhale the isopropyl alcohol fumes from the swab by opening the package, holding the swab under their nose, and inhaling one to three breaths through the nose every two hours as needed for nausea. During follow-up visits for symptom management, the patient reported significant improvement in nausea, with a decrease from moderate nausea to mild-to-no nausea and no additional episodes of emesis while using the inhaled isopropyl alcohol. The patient reported using the isopropyl alcohol swabs an average of once a day for the two days after the initial recommendation. The patient denied any adverse effects from this intervention and planned to continue to use the isopropyl alcohol swabs as an ongoing nonpharmacologic intervention for his nausea. On a follow-up visit with the palliative care team during a subsequent hospital admission, he reported continued use of isopropyl alcohol swabs at home, which remained efficacious for treating nausea.

Discussion

Much of the recent research on inhaled isopropyl alcohol focused on treating nausea and vomiting in the emergency department and perioperative settings,^7–14 and overall, the results of these studies are mixed. However, there remains the question of whether the conclusions drawn by these studies are applicable to other care settings. Namely, can the lessons learned from the research on inhaled isopropyl alcohol translate to caring for patients with advanced illness in the palliative care setting? One recent case series on inhaled isopropyl alcohol suggests that this could be a safe and effective method to manage nausea and vomiting of differing suspected etiologies. ¹⁵ In this case series, the three patients examined had nausea likely due to multiple etiologies, including cancer, end-stage renal disease, medication, and infection. The current case report adds to this previous case series suggesting that inhaled isopropyl alcohol may be a safe and effective intervention for patients receiving palliative care who are experiencing nausea or vomiting with a multifactorial or unknown etiology.

For patients receiving palliative care, clinicians must consider multiple factors, such as prognosis and severity of symptoms, when determining appropriate pharmacotherapy for symptom management. However, it remains paramount to focus on the intervention's safety, and the traditional antiemetics carry the potentially lethal risk of prolonging the QTc interval and associated risk of torsades de pointes. ⁵ As an example, ondansetron – often a first-line treatment for nausea and vomiting that clinicians feel comfortable utilizing without electrocardiogram monitoring – has been shown to significantly prolong the QTc interval and carries a risk of associated torsades de pointes.^16,17 Clinicians should exercise careful consideration of QTc interval when recommending medications that could potentially prolong it further, especially in those with underlying risk factors for developing torsades de points, such as hypokalemia, hypomagnesemia, advancing age, heart failure, existing cardiac arrhythmia, and female sex, where the benefits are unlikely to exceed the risks. ¹⁸

In conclusion, no medication is without risk of adverse effects, and utilizing inhaled isopropyl alcohol in lieu of antiserotonergic, anticholinergic, and antidopaminergic medications, patients can realize the benefits of decreasing exposure medications, risk of drug–drug interactions, adverse effects, and decreasing pill burden. Inhaled isopropyl alcohol is an inexpensive, nonpharmacologic intervention that should be further explored for treating nausea and vomiting in patients living with serious illnesses.

Author's Contributions

The author is responsible for conceptualization, methodology, and writing of original draft.

Funding Information

No funding was received for this article.