What are alternative medications to Zofran (ondansetron) for treating nausea?

From the Guidelines

For patients experiencing nausea, alternatives to Zofran (ondansetron) include prochlorperazine, metoclopramide, and haloperidol, which can be used as first-line treatments, with the addition of serotonin receptor antagonists like granisetron if nausea persists 1. When considering alternative medications to Zofran for treating nausea, it's essential to assess the cause of nausea and consider patient-specific factors.

• Prochlorperazine can be dosed at 10 mg PO every 6 hours as needed,
• metoclopramide can be given at 10-20 mg PO every 6-8 hours,
• and haloperidol can be used at 0.5-1 mg PO every 6-8 hours. If nausea persists, adding therapies that target different mechanisms of action, such as serotonin receptor antagonists like granisetron, may be helpful 1. Other options like scopolamine, dronabinol, or olanzapine may also be considered for management of nausea, with corticosteroids being beneficial for reducing opioid-induced nausea and vomiting, especially in combination with metoclopramide and ondansetron 1. The choice of medication depends on the cause of nausea, patient-specific factors, and potential side effects, with the goal of minimizing morbidity, mortality, and improving quality of life. Key considerations include the potential for constipation as a side effect with certain medications, such as serotonin antagonists, and the importance of reassessing the cause and severity of nausea if it persists for more than a week, potentially leading to opioid rotation or other interventions 1.

From the FDA Drug Label

Aprepitant 40 mg minus Ondansetron. * Estimated odds ratio for Aprepitant versus Ondansetron. The use of aprepitant did not affect the time to first use of rescue medication when compared to ondansetron. However, compared to the ondansetron group, use of aprepitant delayed the time to first vomiting, as depicted in Figure 3 Aprepitant 40 mg223/248 (89.9)16.3%3.2<0.001† Ondansetron181/246 (73.6) No Vomiting 0 to 48 (Superiority) (no emetic episodes, 0 to 48 hours) Aprepitant 40 mg209/247 (84.6)17.7%2.7<0.001† Ondansetron164/245 (66. 9)

Alternative medications to Zofran (ondansetron) for treating nausea include:

• Aprepitant: The drug label shows that aprepitant is effective in preventing nausea and vomiting, with a significant difference in favor of aprepitant compared to ondansetron in some endpoints 2. Key points about aprepitant include:
• Aprepitant delayed the time to first vomiting compared to ondansetron
• Aprepitant had a clinically meaningful effect on the secondary endpoint “no vomiting” during the first 24 hours after surgery
• The use of 40 mg aprepitant was associated with a 16% improvement over ondansetron for the no vomiting endpoint 2

From the Research

Alternative Medications to Zofran (Ondansetron) for Treating Nausea

• Aprepitant (APR) has been shown to be effective in preventing chemotherapy-induced nausea and vomiting (CINV) when used in combination with ondansetron and dexamethasone 3.
• Olanzapine (OLN) has also been found to be effective in preventing CINV, with a study showing that OLN10 (10mg of olanzapine) was more effective than APR in reducing nausea 3.
• Metoclopramide has been compared to ondansetron in several studies, with mixed results. One study found that ondansetron was more effective than metoclopramide in preventing acute nausea and vomiting 4, while another study found that metoclopramide was more effective than ondansetron in controlling delayed nausea 4.
• Granisetron, a selective serotonin3 (5-hydroxytryptamine3, 5-HT3) receptor antagonist, has been shown to be effective in controlling acute nausea and vomiting induced by antineoplastic therapy, with efficacy equivalent or superior to that of ondansetron 5.
• Droperidol, promethazine, and prochlorperazine are other antiemetic agents that have been studied, but their use may be limited due to side effects such as sedation, akathisia, and QT prolongation 6.

Comparison of Antiemetic Agents

• A study comparing ondansetron, metoclopramide, and lorazepam found that ondansetron was more effective than metoclopramide in preventing acute nausea and vomiting, but metoclopramide was more effective in controlling delayed nausea 7.
• Another study found that granisetron was more effective than ondansetron in controlling vomiting, but the difference was not statistically significant 5.
• Ondansetron has been found to be as effective as promethazine in relieving nausea and vomiting, but with fewer side effects 6.