From the Guidelines
The most effective antiemetic for surgical procedures is a multimodal approach combining two or more antiemetic agents, such as 5-HT3 antagonists (e.g., ondansetron) and dexamethasone.
Key Points
- A multimodal approach to nausea and vomiting prevention is quickly becoming a standard of care 1.
- 5-HT3 antagonists (e.g., ondansetron, granisetron) and dexamethasone are effective in reducing intraoperative nausea and vomiting 1.
- Combination regimens, such as 5-HT3 antagonists combined with droperidol or dexamethasone, are significantly more effective than 5-HT3 antagonists alone 1.
- Dexamethasone is a good additive preventative agent, but should be used with caution in diabetics as it can transiently worsen glycemic control 1.
- The international consensus group on PONV recommends using 2 antiemetic drugs to decrease PONV and improve efficacy 1.
Recommended Approach
- Use a multimodal approach to postoperative nausea and vomiting, including non-pharmacological techniques such as avoidance of emetogenic stimuli and pharmacological techniques such as combination antiemetic regimens 1.
- Consider using ondansetron and dexamethasone as first-line antiemetic agents, with antihistamines, butyrophenones, and phenothiazines as second-line options 1.
From the Research
Antiemetic Efficacy
- The most effective antiemetic for surgical procedures is a matter of ongoing research, with various studies comparing the efficacy of different antiemetic drugs 2, 3, 4, 5, 6.
- A study comparing ondansetron and droperidol found that droperidol 1.25 mg was more efficacious than ondansetron 4 mg in preventing postoperative nausea and vomiting (PONV) in the early recovery period (0-2 h) 2.
- A network meta-analysis of 585 studies found that aprepitant, ramosetron, granisetron, dexamethasone, and ondansetron were the most effective single drugs in reducing vomiting, with aprepitant being the most effective 3.
- Another study found that ondansetron was effective in treating PONV in outpatient surgery patients, with complete response rates of 57-61% compared to 30% for placebo 4.
- A study comparing ondansetron and droperidol in pediatric patients undergoing ambulatory surgery found that ondansetron was more effective in reducing the incidence of emesis, but had no significant effect on recovery parameters compared to placebo 5.
- A comparison of oral granisetron and intravenous ondansetron for antiemetic prophylaxis in patients undergoing laparoscopic surgery found that both drugs had similar efficacy in preventing postdischarge nausea and vomiting (PDNV) and improving quality of recovery 6.
Drug Comparisons
- Ondansetron and droperidol have been compared in several studies, with droperidol 1.25 mg being more efficacious than ondansetron 4 mg in preventing PONV in the early recovery period (0-2 h) 2.
- Aprepitant, ramosetron, granisetron, dexamethasone, and ondansetron have been found to be the most effective single drugs in reducing vomiting, with aprepitant being the most effective 3.
- Ondansetron and granisetron have been compared in a study, with both drugs having similar efficacy in preventing PDNV and improving quality of recovery 6.
Safety and Side Effects
- The safety and side effects of antiemetic drugs have been evaluated in several studies, with ondansetron being found to have a similar incidence of adverse events compared to placebo 4, 5.
- Droperidol has been found to have a higher incidence of sedation and extrapyramidal symptoms compared to ondansetron 2, 3.
- Aprepitant, ramosetron, granisetron, dexamethasone, and ondansetron have been found to have a low incidence of serious adverse events, but the certainty of evidence for safety outcomes is generally low to moderate 3.