What are the appropriate antiemetics for pediatric patients?

From the Guidelines

For pediatric patients requiring antiemetics, a combination of a 5-HT3 receptor antagonist and dexamethasone is recommended as the first-line treatment, with ondansetron being a commonly used 5-HT3 receptor antagonist due to its efficacy and safety profile. The typical dosing of ondansetron is 0.15 mg/kg/dose (maximum 8 mg) given every 8 hours as needed 1. For children under 4 years or weighing less than 15 kg, the dose is typically 2 mg; for those 4-11 years, 4 mg; and for those 12 years and older, 8 mg.

Key Considerations

• Ondansetron works by blocking serotonin receptors in the chemoreceptor trigger zone and is particularly effective for vomiting associated with gastroenteritis, chemotherapy, and post-operative nausea.
• Alternative options include promethazine for children over 2 years (0.25-1 mg/kg/dose every 4-6 hours, maximum 25 mg/dose), metoclopramide (0.1-0.2 mg/kg/dose every 6 hours, maximum 10 mg/dose), and dimenhydrinate for motion sickness (1-1.5 mg/kg/dose every 6 hours, maximum 50 mg/dose) 1.
• It's essential to note that promethazine should be avoided in children under 2 years due to the risk of respiratory depression, and metoclopramide carries a risk of extrapyramidal side effects, especially with prolonged use.
• Adequate hydration should always be maintained when treating vomiting in children, and underlying causes should be addressed whenever possible.

Additional Guidance

• The combination of a 5-HT3 receptor antagonist and dexamethasone has been shown to be more efficacious than a 5-HT3 receptor antagonist alone in preventing chemotherapy-induced nausea and vomiting in pediatric patients 1.
• For pediatric patients receiving highly or moderately emetogenic chemotherapy, a 5-HT3 receptor antagonist and corticosteroids are recommended, with higher weight-based dosing potentially required 1.
• The optimal dose and scheduling of 5-HT3 receptor antagonists in children have been evaluated in several trials, but the evidence is limited by small sample sizes, making it challenging to identify the optimal oral and intravenous doses 1.

From the FDA Drug Label

Pediatric Trials Three open-label, single-arm, non-US trials have been performed with 182 pediatric patients aged 4 to 18 years with cancer who were given a variety of cisplatin or non cisplatin regimens. The initial dose of ondansetron tablets injection ranged from 0. 04 to 0.87 mg per kg (total dose of 2. 16 mg to 12 mg) followed by the administration of oral doses of ondansetron tablets ranging from 4 to 24 mg daily for 3 days. In these trials, 58% of the 170 evaluable patients had a complete response (no emetic episodes) on Day 1 In 2 trials the response rates to ondansetron tablets 4 mg three times a day in patients younger than 12 years was similar to ondansetron tablets 8 mg three times daily in patients 12 to 18 years. For children, promethazine hydrochloride tablets, syrup, or rectal suppositories, 12. 5 to 25 mg twice daily, may be administered. For nausea and vomiting in children, the usual dose is 0. 5 mg per pound of body weight, and the dose should be adjusted to the age and weight of the patient and the severity of the condition being treated.

Appropriate antiemetics for pediatric patients include:

• Ondansetron: 4 mg three times a day for patients younger than 12 years, and 8 mg three times daily for patients 12 to 18 years 2
• Promethazine: 12.5 to 25 mg twice daily, or 0.5 mg per pound of body weight, adjusted to the age and weight of the patient and the severity of the condition being treated 3

From the Research

Appropriate Antiemetics for Pediatric Patients

• Ondansetron is an effective antiemetic agent for use in children, with studies showing its efficacy in preventing nausea and vomiting in patients receiving chemotherapy 4, 5, 6 and surgery 4, 7.
• The drug has been compared to other antiemetics, including metoclopramide, and has been found to be more effective in controlling emesis induced by chemotherapy regimens containing cisplatin 6, 8.
• Ondansetron can be administered as a single high-dose or multiple standard-doses, with similar efficacy and tolerability profiles 5.
• The combination of ondansetron with dexamethasone has been shown to be more effective than ondansetron alone in preventing nausea and vomiting in children receiving chemotherapy 4.
• Ondansetron has also been found to be effective in preventing postoperative nausea and vomiting (PONV) in children undergoing surgery, with a lower incidence of emesis compared to droperidol and placebo 7.

Comparison with Other Antiemetics

• Ondansetron has been compared to metoclopramide in several studies, with ondansetron showing superior efficacy in controlling emesis induced by chemotherapy regimens containing cisplatin 6, 8.
• Ondansetron has also been compared to droperidol, with ondansetron showing superior efficacy in preventing PONV in children undergoing surgery 7.
• The combination of ondansetron with other antiemetics, such as dexamethasone, has been shown to be more effective than ondansetron alone in preventing nausea and vomiting in children receiving chemotherapy 4.

Dosage and Administration

• Ondansetron can be administered intravenously or orally, with dosages ranging from 0.075 to 0.15 mg/kg for intravenous administration and 0.1 mg/kg for oral administration 4, 5, 7.
• The drug can be administered as a single high-dose or multiple standard-doses, with similar efficacy and tolerability profiles 5.