Yesterday gave carbomazole 10 mg TID , propanol 40 mg BD had vomiting

+3 more

Yesterday gave carbomazole 10 mg TID , propanol 40 mg BD had vomiting now rabicer -d BD give or ondansetron 4 mg BD

Reading File

Finding Sources

Searching the Web

carbimazole propranolol vomiting ondansetron vs rabeprazole domperidone antiemetic choice hyperthyroidism

Finding Sources

Based on the patient's labs and clinical context, here is a focused clinical assessment:

Patient Summary — Mr. Mallesh, 56 M

Diagnosis: Graves' Hyperthyroidism (confirmed)

T3 >651 µg/dL (markedly elevated), T4 >24.86 µg/dL, TSH <0.005 µIU/mL
Anti-TPO: 21.63 IU/mL (within normal <60, but Graves' is primarily TSH-receptor antibody mediated)
USG neck: Bilateral thyromegaly with multiple cystic foci — colloid goitre pattern
GFR 101 (normal renal function), LFT essentially normal (ALP 211 slightly elevated — can be seen in hyperthyroidism)
CBC: Hb 11.2 (mild anaemia), Platelets 1,22,000 (mildly low — monitor), WBC 9,000 (normal)

Current treatment started yesterday:

Carbimazole 10 mg TID ✓
Propranolol 40 mg BD ✓

Vomiting — Cause & Antiemetic Choice

Most likely cause of vomiting: Carbimazole-induced GI side effect. Nausea and vomiting occur in 3–5% of patients on thionamides, typically early in treatment. Propranolol can also contribute.

Rabicer-D vs Ondansetron 4 mg BD

Rabicer-D = Rabeprazole 20 mg + Domperidone 10 mg (a prokinetic antiemetic combination)

	Rabicer-D BD	Ondansetron 4 mg BD
Mechanism	Domperidone: D2 blocker (prokinetic) + Rabeprazole: PPI	5-HT3 antagonist
Prokinetic effect	✅ Yes (domperidone helps gastric emptying)	❌ No
GI-specific nausea	✅ Better suited	Good but not prokinetic
QT prolongation concern	Domperidone can prolong QT	Ondansetron also can prolong QT
Headache/dizziness SE	Less	Occasional
Added acid suppression	✅ Rabeprazole helps if gastritis component	Not present

Recommendation: Rabicer-D BD is the better choice here

Rationale:

Carbimazole causes GI upset partly through gastric irritation — the PPI component (rabeprazole) addresses this directly
Domperidone's prokinetic action helps drug-induced nausea from thionamides specifically
Ondansetron is excellent for chemotherapy/post-op nausea but is less targeted for drug-induced GI irritation
The patient's mild thrombocytopenia (1,22,000) and early treatment course make minimising polypharmacy preferable — Rabicer-D covers two mechanisms in one

However — important caution:

Check ECG/QTc before starting either drug, given the elevated thyroid hormones (hyperthyroidism itself prolongs QT), and domperidone also carries QT risk
Domperidone is contraindicated if QTc >470 ms; use ondansetron instead in that scenario, but at lowest effective dose (4 mg OD rather than BD if possible)

Alternative practical approach:

If ECG is not immediately available, ondansetron 4 mg BD for 3–5 days is safer from a cardiac monitoring standpoint, with the understanding that as carbimazole takes effect and thyroid levels drop, the GI side effects will diminish over 1–2 weeks.

Continue Current Medications

Carbimazole 10 mg TID — continue, do not reduce dose due to vomiting after just 1 day; dose is appropriate for severely elevated T3/T4
Propranolol 40 mg BD — continue for symptom control (tachycardia, tremor); helps GI motility as a side benefit
Monitor CBC weekly for first month — agranulocytosis risk with carbimazole (warn patient to report fever/sore throat immediately)
LFTs at 4–6 weeks (ALP already slightly elevated)
MRI neck as advised by radiologist for the cystic thyroid lesions