Medicines Q&As
Q&A 86.3
Can cyclizine be given to a patient who has an MI?
Prepared by UK Medicines Information (UKMi) pharmacists for NHS healthcare professionals
Before using this Q&A, read the disclaimer at www.ukmi.nhs.uk/activities/medicinesQAs/default.asp
Date prepared: 10th April 2013
Background
Both myocardial infarction (MI) and opiates used to control the accompanying pain cause nausea and
vomiting. However there are no established treatment guidelines for acute MI which make specific
recommendations on choice of anti-emetics. Cyclizine, a piperazine derivative, is a histamine H1
receptor antagonist, with anti-emetic and anticholinergic properties. It is licensed in the UK for the
prevention and treatment of nausea and vomiting but its use is cautioned in patients with severe heart
failure. In such patients, cyclizine may cause a fall in cardiac output associated with increases in heart
rate, mean arterial pressure and pulmonary wedge pressure (1). In the past, cyclizine has been
recommended as a first-line anti-emetic for patients with MI but there have been concerns about such
use because of these haemodynamic and cardiac effects which may aggravate heart failure (2).
Answer
Tan et al conducted a small study in patients with severe heart failure (n=11) which found that
cyclizine is associated with adverse haemodynamic and cardiac effects. Patients were given a single
IV dose of cyclizine (50mg) half an hour before IV diamorphine (2.5-5mg). Haemodynamic data,
recorded 10 and 30 minutes after the injection of cyclizine and 10 minutes after diamorphine,
demonstrated a significant increase in heart rate and right atrial, pulmonary arterial, pulmonary
wedge, and systemic arterial pressures. Subsequent diamorphine demonstrated a trend to change
these variables back to baseline except right atrial and pulmonary arterial pressures. The authors
noted that not only did cyclizine raise ventricular filling pressures on its own but it also negated the
beneficial venodilatory effects of diamorphine. They concluded that cyclizine should not be used
routinely as an anti-emetic in acute MI or severe heart failure (2).
A brief review which aimed to establish whether cyclizine adversely affected haemodynamic
parameters in patients with cardiac disease provided a critique of this study. The authors stated that
that this was a well controlled but small study conducted in a very specific population but there were
no comparative data with other anti-emetics. They concluded that since it is difficult to predict the
clinical course of a patient when first assessed it may be advisable to avoid cyclizine in all patients
with acute coronary events (3). Another critique of this study noted a lack of data for the simultaneous
administration of cyclizine with opioids - nor other commonly used anti-emetics (metoclopramide,
prochlorperazine) - which are often co-administered in clinical practice. The authors note that caution
is required if the conclusions of the Tan et al study are to be translated into advice about clinical care
(4)
A retrospective review of cyclizine abuse by teenagers in Utah found that tachycardia was present in
52% of them presenting to a hospital following cyclizine ingestion and 69% had systolic hypertension
(5). However IV cyclizine injection can also cause hypotension (1).
The BNF states that cyclizine may counteract the haemodynamic benefits of opioids, and cautions its
use in severe heart failure. In its guidance notes on the management of myocardial infarction with STsegment elevation (STEMI), the BNF states that an anti-emetic such as metoclopramide (or, if left
ventricular function is not compromised, cyclizine) should be given by IV injection (6).
The Drug and Therapeutics Bulletin, in its ‘Drugs for the Doctor’s Bag ‘ article does not recommend
the use of cyclizine in MI patients because it causes peripheral vasoconstriction, and may therefore
aggravate heart failure and counteract the haemodynamic benefits of opioids; it suggests that IV
metoclopramide is a better choice (7).
European and draft NICE guidance on the management of MI do not address use of a specific
Available through NICE Evidence Search at www.evidence.nhs.uk
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Medicines Q&As
antiemetic (8, 9). A Cochrane review is being undertaken to address the use of anti-emetics for
nausea and vomiting in adults in the emergency department setting. The protocol notes that there are
no established guidelines for this diverse clinical setting and that extrapolation from other clinical
settings cannot be made because of differences in aetiologies, patient populations and other factors
(10).
Summary
Because of its tachycardic and hypertensive effects, which may compromise cardiac function, the
limited data suggest that IV cyclizine is probably not the first choice of routine anti-emetic for MI
patients; IV metoclopramide has been suggested as a safer alternative, possibly because of its lack of
adverse cardiac effects.
Limitations
There appears to be little published on this subject, other than the findings of a small
pharmacodynamic study, so this answer is based on limited published data.
References
1. Summary of Product Characteristics – Valoid injection. Amdipharm. Date of revision of text:
October 2009. Available at:
http://www.medicines.org.uk/emc/medicine/14783/SPC/Valoid+Injection/
2. Tan LB, Bryant S, Murray RG. Detrimental haemodynamic effects of cyclizine in heart failure.
Lancet 12 Mar 1988, vol 1, no 8585: 560-561
3. May G, Kumar R. Use of intravenous cyclizine in cardiac chest pain. Emerg Med J 2006. 2361–
62.62.
4. Cooke RA, Cooke MW. Use of intravenous cyclizine in cardiac chest pain. Emerg Med J. 2006
July; 23(7): 584.
5. Bassett KE, Schunck JE, Crouch BI. Cyclizine abuse by teenagers in Utah. Am J Emerg Med 1996
(Sep); 14(5): 472-574
6. Martin J, editor. British National Formulary No. 64. London: BMJ Group and Pharmaceutical Press;
September 2012, page 160 and 257
7. Anon. Drugs for the doctor’s bag: 1 – Adults. Drug & Therapeutics Bulletin 2005; 43(9): 65-68
8. NICE. The acute management of myocardial infarction with ST-segment-elevation (draft guidance
Feb 2013). Available at: http://www.nice.org.uk/nicemedia/live/13300/62703/62703.pdf
9. Steg G, James SK, Atar, D et al. ESC Guidelines for the management of acute
myocardial infarction in patients presenting
with ST-segment elevation. European Heart Journal (2012) 33, 2569–2619. Available at:
http://www.escardio.org/guidelines-surveys/escguidelines/GuidelinesDocuments/Guidelines_AMI_STEMI.pdf
10.Smith E, Wasiak J, Boyle M. Prophylactic antiemetic therapy in the emergency and ambulance
setting for preventing opioid induced nausea and vomiting. (Protocol) The Cochrane Database
Syst Rev2004, Issue 3.
Quality Assurance
Prepared by
Carolyn Longbottom, Medicines Information Pharmacist, London and SE Medicines Information
Service, Guy’s and St Thomas’ NHS Foundation Trust (June 2006)
Updated by Claire Christmas, Medicines Information Pharmacist, London and SE Medicines
Information Service, Guy’s and St Thomas’ NHS Foundation Trust (June 2009).
Updated by Sheetal Ladva, Medicines Information Pharmacist, London and SE Medicines Information
Service, Guy’s and St Thomas’ NHS Foundation Trust (April 2013)
Date Prepared
29th June 2009; updated 10th April 2013
Checked by
Yuet Wan, Medicines Information Pharmacist, London and SE Medicines Information Service, Guy’s
and St Thomas’ NHS Foundation Trust.
Available through NICE Evidence Search at www.evidence.nhs.uk
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Medicines Q&As
Date of check
1st July 2009 and 11th June 2013
Search strategy
April 2013
 Embase: exp. cyclizine AND heart infarction (no new data)
 Medline: exp. cyclizine AND myocardial infarction (no new data)
 In house sources (Martindale, Micromedex, AHFS)
 Manufacturer: Amdipharm (Rina Kundi, 7th May 2013; e-mail communication)
 Clinical expert: Duncan McRobbie, Principal Clinical Pharmacist, Guy’s and St Thomas’ NHS
Foundation Trust
June 2009
 Embase: cyclizine AND exp. heart infarction
 Medline: cyclizine AND myocardial infarction
 In-house database/ resources (including Micromedex)
 Manufacturer: Amdipharm (Lee Tyrell, 15th June 2009 e-mail communication)
 Clinical expert: Duncan McRobbie, Principal Clinical Pharmacist, Guy’s and St Thomas’ NHS
Foundation Trust
June 2006
 Medline 1950 – 2006: cyclizine.DE AND myocardial-infarction#.DE
 Embase 1974 – 2006: cyclizine.DE AND heart-infarction#.DE
 In-house resources (including Micromedex).
Available through NICE Evidence Search at www.evidence.nhs.uk
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