From the Guidelines
Alternatives to Zofran (ondansetron) for inpatient nausea management include palonosetron (Aloxi) 0.25mg IV as a single dose, aprepitant (Emend) 125mg PO on day 1 followed by 80mg daily, or metoclopramide (Reglan) 10mg IV/PO every 6-8 hours. For patients with severe nausea, especially post-operatively or chemotherapy-related, these alternatives may be effective. The choice of alternative depends on the cause of nausea and the patient's medical history. Some key points to consider when choosing an alternative to Zofran include:
- Palonosetron has been shown to be effective in preventing delayed emesis, especially when used in combination with dexamethasone 1.
- Aprepitant is a selective neurokinin-1 receptor blocker that has been shown to be effective in preventing acute and delayed emesis when used in combination with a 5-HT3 receptor antagonist and dexamethasone 1.
- Metoclopramide is a dopamine receptor antagonist that can be effective in treating nausea and vomiting, especially when used in combination with other antiemetic agents 1. It is essential to consider potential side effects and adjust dosing for renal/hepatic impairment and monitor for drug interactions. Non-pharmacological approaches like ginger supplements, acupressure bands, or small frequent meals can complement medication therapy. Always prioritize the patient's quality of life and adjust treatment accordingly.
From the FDA Drug Label
The results of the primary and secondary endpoints for 40 mg aprepitant and 4 mg ondansetron are described in Table 20: Table 20: Response Rates for Select Efficacy Endpoints (Modified-Intention-to-Treat Population) – Study 7 Treatment n/m (%) Aprepitant vs Ondansetron Δ Odds ratio* Analysis PRIMARY ENDPOINTS No Vomiting 0 to 24 hours (Superiority)(no emetic episodes) Aprepitant 40 mg 246/293 (84.0) 12.6% 2.1 P<0.001† Ondansetron 200/280 (71.4)
Table 21: Response Rates for Select Efficacy Endpoints (Modified-Intention-to-Treat Population) – Study 8 Treatment n/m (%) Aprepitant vs Ondansetron Δ Odds ratio* Analysis SECONDARY ENDPOINTS No Vomiting (no emetic episodes, 0 to 24 hours) Aprepitant 40 mg 223/248 (89.9) 16.3% 3.2 <0.001† Ondansetron 181/246 (73. 6)
Alternatives to Zofran (ondansetron) for managing nausea in inpatients include:
- Aprepitant: as shown in the studies, aprepitant had a clinically meaningful effect with respect to the secondary endpoint "no vomiting" during the first 24 hours after surgery and was associated with a 16% improvement over ondansetron for the no vomiting endpoint 2.
From the Research
Alternatives to Zofran (ondansetron) for Managing Nausea in Inpatients
- Aprepitant, a neurokinin-1 receptor antagonist, has shown promise in preventing postoperative nausea and vomiting, with studies indicating its superiority to ondansetron in preventing vomiting, but not necessarily in controlling nausea 3.
- Metoclopramide, a dopamine D2 receptor antagonist, is another alternative, which has been found to be effective in treating delayed nausea and vomiting, although high doses may produce extrapyramidal side effects 4.
- Other options include:
- Netupitant and rolapitant, two new neurokinin-1 receptor antagonists that have been approved by the FDA and incorporated into the latest antiemetic guidelines 5.
- Olanzapine, a multireceptor targeting agent, which has been shown to be effective in preventing nausea, but may cause sedation 5, 6.
- Palonosetron, a 5-HT3 receptor antagonist, which has been found to be effective in controlling nausea, especially when combined with a neurokinin-1 receptor antagonist 6.
- Non-pharmacological methods, such as acupressure and acustimulation, may also be useful as adjunct treatments for nausea and vomiting 4.
- Combination therapies, such as a 5-HT3 receptor antagonist, dexamethasone, and a neurokinin-1 receptor antagonist, may be more effective than single-drug treatments, but may also increase treatment costs 4, 5, 6.