From the FDA Drug Label
The results of the primary and secondary endpoints for 40 mg oral aprepitant and 4 mg ondansetron are described in Table 4.
No Vomiting 0 to 24 hours (Superiority)(no emetic episodes) Oral aprepitant 40 mg246/293 (84.0)12.6%2.1P<0.001‡ Ondansetron200/280 (71.4)
No Vomiting 0 to 48 hours (Superiority) (no emetic episodes) Oral aprepitant 40 mg238/292 (81.5)15.2%2.3P<0.001¶ Ondansetron185/279 (66. 3)
The best antiemetic for a patient with intractable nausea and brain metastases in a palliative care setting is Aprepitant.
- Key points:
- Aprepitant has been shown to be effective in preventing nausea and vomiting in patients undergoing chemotherapy and surgery.
- The patient has already received ondansetron and still reports nausea, so an alternative antiemetic should be considered.
- Aprepitant has a different mechanism of action than ondansetron and may be effective in patients who have not responded to other antiemetics. 1
From the Research
For a patient with intractable nausea and brain metastases in a palliative care setting, dexamethasone is the most appropriate antiemetic choice. Dexamethasone can be started at a dose of 4-8 mg orally or intravenously once daily, with potential to increase to 16 mg daily if needed. The medication works by reducing peritumoral edema in brain metastases and has antiemetic effects, making it particularly effective for complex nausea. For patients with brain metastases, dexamethasone is advantageous because it can help reduce cerebral edema, which may contribute to nausea and vomiting. Side effects to monitor include hyperglycemia, insomnia, and mood changes. If dexamethasone is ineffective, combination therapy with a 5-HT3 antagonist like ondansetron or other antiemetics may be considered. According to a study published in the Journal of Pain and Symptom Management 2, dexamethasone was found to be effective in reducing nausea in patients with advanced cancer. Another study published in Supportive Care in Cancer 3 found that dexamethasone, in combination with palonosetron and aprepitant, was effective in preventing nausea and vomiting in patients receiving chemotherapy.
Some key points to consider when using dexamethasone for nausea in palliative care include:
- Monitoring for side effects such as hyperglycemia and insomnia
- Adjusting the dose based on patient response and tolerance
- Considering combination therapy with other antiemetics if dexamethasone is ineffective
- Evaluating the patient's overall condition and adjusting the treatment plan as needed to prioritize morbidity, mortality, and quality of life.
It's also important to note that while other options like metoclopramide, promethazine, and aprepitant may be considered, dexamethasone is a more appropriate choice for this patient due to its ability to reduce peritumoral edema and its antiemetic effects.