What is the next step for a 56-year-old female with gastroenteritis who continues to vomit while on Zofran (ondansetron) and Reglan (metoclopramide)?

From the Guidelines

For a 56-year-old female with gastroenteritis who continues to vomit despite taking ondansetron (Zofran) and metoclopramide (Reglan), I strongly recommend switching to a different antiemetic approach, such as dimenhydrinate, as it has been shown to be beneficial in adults with significant vomiting 1. The current treatment with ondansetron and metoclopramide has not been effective in controlling vomiting, and considering the evidence from the 2017 Infectious Diseases Society of America clinical practice guidelines, a change in approach is necessary 1. Some key points to consider in managing this patient's condition include:

• The importance of oral rehydration, which has been shown to be useful in all ages, and can be achieved with small sips of clear fluids or oral rehydration solutions like Pedialyte 1.
• The potential benefits of antiemetics such as dimenhydrinate in adults with significant vomiting, as mentioned in the guidelines 1.
• The need to temporarily discontinue solid foods and gradually reintroduce bland foods (BRAT diet - bananas, rice, applesauce, toast) once vomiting subsides.
• The importance of monitoring for signs of dehydration (decreased urination, dizziness, dry mouth) and seeking immediate medical evaluation if symptoms persist or worsen significantly. It is also crucial to note that the use of antimotility agents, such as loperamide, may be effective in reducing diarrhea, but their use should be approached with caution, especially in patients with certain underlying conditions or those at risk of complications from diarrhea 1. In this case, the focus should be on controlling vomiting and ensuring adequate hydration, rather than solely on reducing diarrhea. The patient's continued vomiting despite two antiemetics with different mechanisms suggests either severe gastroenteritis or potentially another underlying cause that requires further investigation, and a thorough evaluation is necessary to determine the best course of action 1.

From the Research

Next Steps for Treatment

The patient is a 56-year-old female with gastroenteritis who continues to vomit while on Zofran (ondansetron) and Reglan (metoclopramide). Considering the provided evidence, the following points are relevant:

• The study 2 suggests that ondansetron may be used as a first-line agent for relief of nausea or vomiting for most patient populations in the emergency department due to its safety and efficacy.
• The study 3 provides some evidence that ondansetron and metoclopramide may be effective in reducing vomiting due to gastroenteritis in children, but the evidence is weak and unreliable.
• The study 4 shows that ondansetron is more effective than metoclopramide in controlling nausea and vomiting in uremic patients.
• The study 5 found that the addition of ondansetron to the combination of metoclopramide, dexamethasone, and lorazepam did not improve vomiting prevention in patients receiving high-dose cisplatin.
• The study 6 suggests that ondansetron is a promising new agent for prophylaxis against nausea and vomiting in chemotherapy and radiotherapy, with an improved tolerability and clinical response profile.

Potential Considerations

Some potential considerations for the next steps in treatment include:

• Continuing or adjusting the current medication regimen, as ondansetron has been shown to be effective in some cases 2, 4.
• Monitoring the patient for adverse effects, such as sedation, headache, and akathisia, which have been reported with metoclopramide and ondansetron 2, 5.
• Considering alternative treatments or combinations of medications, as the evidence suggests that ondansetron may not be effective in all cases 3, 5.
• Evaluating the patient's overall condition and adjusting the treatment plan accordingly, taking into account the potential benefits and limitations of each medication 2, 6.