POST OPERATIVE NAUSEA AND VOMITING

Robert Ferrante

Pharmacy Candidate

Objectives• Discuss the prevalence of Post Operative Nausea and

Vomiting (PONV) and why reducing PONV is so important to hospitals

• Review the evolution of PONV treatment• Examine the current medications used for PONV

Post Operative Nausea and Vomiting(PONV)1

• Up to 35% of ambulatory patients affected• 70% of high risk patients

• Number one concern of patients• … above pain, death, and MI

• Patients often classified by risk

Risk Factors

• Younger• Female• “Large body habitus”• History of:

• PONV• Motion Sickness• Anxiety

• Procedures:• Head/Neck• Intraabdominal• Larparoscopic• Gynecologic

• Medications:• Opiods

Why So Important?• Medical Consequences

• Patient satisfaction

• Shorter PACU stays • More patients

• MORE MONEY• Mo’ Problems?

http://www.frca.co.uk/article.aspx?articleid=354#faq

Antiemetics

https://www.inkling.com/read/pharmacology-brenner-stevens-4th/chapter-28/figure-28-3

Droperidol3

• Potent D2 Receptor antagonist

• PONV: 0.625-1.25 mg IM/IV Q3-4h

• Adjust for renal, hepatic, and age-related factors.• 75% renal elimination• Extensive liver metabolism• T ½ - 135 mins

Droperidol Brief History1,2,3

• Droperidol was the foundation for PONV• Effective and inexpensive

• December 2001: FDA issue BBW• Arrhythmic-Effects

• Heavily disputed.

• Should be reserved for resistant patients• Requires excessive monitoring

• ECG • Cost increase

Droperidol3

• Contraindications• First line treatment for anything but PONV• Known or suspected QT interval

• Major drug interactions• Drugs that may cause QT prolongation

• Including antiarrhythmics, opiods antipsychotics, and, diuretics

Reglan (Metoclopramide)4

• MOA:• Peripheral dopamine receptor inhibiton• Sensitizes tissues to acetylcholine (does not stimulate).

• Postoperative nausea and vomiting: 10 to 20 mg IV/IM every 4 to 6 hours as needed• CrCl < 40mL/min: 50% dose• Geriatric: Initiate at 50% dose

• Adverse Effects:• Asthenia• Headache, Fatigue, Somnolence• N/V

Reglan (Metoclopramide)• BBW – Tardive dyskinesia

• Contraindications:• Concomitant use with drugs likely to cause extrapyramidal

reactions • Epilepsy• Gastrointestinal hemorrhage, mechanical obstruction, or

perforation.

• REMS program required for other Indications

Reglan Efficacy5

• Metoclopramide vs Ondansetron• According to a meta-analysis of 54 studies, metoclopramide is as

effective as ondansetron in preventing postoperative nausea (59% vs 48%, respectively; p = 0.125)

• Metoclopramide prevented postoperative vomiting in only 35% of patients compared with 50% of those using ondansetron (p < 0.001)

• Metoclopramide vs Droperidol• Metoclopramide was inferior to droperidol in preventing both

postoperative nausea and vomiting. • The incidence of nausea was 41% for droperidol and 52% for

metoclopramide (p < 0.008); • The incidence of vomiting was 26% for droperidol versus 34% for

metoclopramide (p < 0.001)

Aloxi (Palonosetron)6

• PONV; Prophylaxis: 0.075 mg IV as a single dose immediately before induction of anesthesia Major side effects • No Dose adjustments!

• Contraindications?... Not really• Pregnancy Category B• Major drug interactions?... Not really…

• Apomorphine

Aloxi (Palonosetron)

• Adverse Effects:• Bradyarrhythmia (1-4%)• Constipation (5%)• Headache (9%)

• One vial = about $400

Aloxi Vs. Ondansetron7

• A Randomized, Double-blind Trial of Palonosetron Compared with Ondansetron in Preventing Postoperative Nausea and Vomiting after Gynaecological Laparoscopic Surgery.

• Study design:• Induced with propofol• Intubated with rocuronium• NM blockade reversed with pyridostigmine and glycopyrolate

Aloxi Vs. Ondansetron7

• 0.075 mg Palonosetron , n = 45• 8 mg Ondansetron, n = 45

• Results:• Over 24 hours, overall PONV in 30 ondansetron patients, 19 in

palonosetron• Rescue antiemetics were used in an equal number of patients

• Adverse Events:• Headache, Dizziness, Constipation, Myalgia

• Basically the same

• Patient Satisfaction:• 21 in ondansetron• 30 in palonosetron

References• 1.) Ting, P. Post-operative Nausea and Vomiting (PONV): An Overview. Available

from http://anesthesiologyinfo.com/articles/04252004.php• 2.) Brenner GM, Stevens CW. Pharmacology. 4th Edition. Tulsa, OK. 2013• 3.) Cherry W. Jackson, Amy Heck Sheehan, Jennifer G. Reddan. Evidence-Based

Review of the Black-box Warning for Droperidol. Am J Health Syst Pharm. 2007;64(11):1174-1186. 

• 4.) Metoclopramide. In: DRUGDEX Evaluations [database on the Internet]. Greenwood Village (CO): Thompson Micromedex; 1974-2014 [cited 18 Sep 2014].

• 5.) Domino KB, Anderson EA, Polissar NL, Posner KL. Comparative efficacy and safety of ondansetron, droperidol, and metoclopramide for preventing postoperative nausea and vomiting: a meta-analysis. Anesth Analg 1999;88:1370-9.

• 6.) Palonosetron. In: DRUGDEX Evaluations [database on the Internet]. Greenwood Village (CO): Thompson Micromedex; 1974-2014 [cited 18 Sep 2014].

• 7.)Park SK, Cho EJ. A Randomized, Double-blind Trial of Palonsetron Compared with Ondansetron in Preventing Postoperative Nausea and Vomiting after Gynaecological Lapaoscopic Surgery. J Int Med Res. 2011 39: 399

Questions?