Palonosetron versus ondansetron as rescue medication for postoperative nausea and vomiting: a randomized, multicenter, open-label study

Rescue Treatment of Postoperative Nausea and Vomiting: A Systematic Review of Current Clinical Evidence

Although prophylactic antiemetics are commonly used perioperatively, an estimated 30% of surgical patients still suffer from postoperative nausea and vomiting (PONV). Very few prospective trials have studied rescue treatment of PONV after failure of prophylaxis, providing limited evidence to support clinical management. In patients who have failed PONV prophylaxis, administering a rescue antiemetic from the same drug class has been reported to be ineffective. For many antiemetics currently used in PONV rescue, significant uncertainty remains around the effective dose range, speed of onset, duration of effect, safety, and overall risk-benefit ratio. As prompt, effective PONV rescue after failure of prophylaxis is important to optimize postoperative recovery and resource utilization, we conduct this systematic review to summarize the current evidence available on the topic.

Effect of Palonosetron on Physical Symptoms of Surgical Patients: A Systematic Review and Meta-Analysis

Background. Postoperative nausea and vomiting (PONV) is a typical and unpleasant physical symptom that occurs in patients after surgery, and it may be one of the most challenging elements of the recovery process. PONV can be caused by a variety of factors, including surgery itself, anesthesia, or medications. Palonosetron is a medication that is now licensed by the Food and Drug Administration for the treatment of this ailment. The efficacy of palonosetron in reducing physical symptoms in patients following surgery was investigated in this meta-analysis and comprehensive review. Methods. Following a quick search of databases such as CENTRAL, EMBASE, CINAHL, Google Scholar, the Science quotation index’s Web site, the United States clinical trial check-in, the United Kingdom clinical trial check-in, the New Zealand clinical trial check-in, and the Australia check-in, as well as outlines of major anesthesia meetings held in the previous five years, we were able to get a good start on our research. Growing adults who had surgery and were given other drugs were compared to individuals who did get palonosetron in randomized controlled trials. Results. A total of 8324 participants were recruited in 10 different clinical studies. It has been shown that palonosetron may significantly reduce the 24-hour PONV incidence and 95% confidence interval (CI) 0.41–0.86. When comparing the 6-hour and 48-hour time periods, the incidences of experiencing PONV were neither statistically different (RR: 0.82, 95% confidence interval: 0.61–1.09) or considerably different (RR: 0.60, 95% confidence interval: 0.33–1.10). Following in a similar vein, there was no significant difference between the groups in the occurrence of PONV after 48 hours (RR: 0.82, 95 percent CI: 0.59–1.14). The most often reported side effects of the medicine were headaches and dizziness, which were the most common. Regardless of the drug used, the difference in adverse reactions was not statistically significant. Conclusion. When it comes to the prevention of early PONV, it has been shown that palonosetron is more effective than other medications. Palonosetron, on the other hand, has been demonstrated to be more effective than other medications in preventing vomiting after laparoscopic surgery.

Prevention and Treatment of Postoperative Nausea and Vomiting (PONV): A Review of Current Recommendations and Emerging Therapies

Postoperative nausea and vomiting is one of the most frequent adverse events after surgery and anesthesia. It is distressing for the patient and can lead to other postoperative complications. Management of PONV involves a framework of risk assessment, multimodal risk reduction, and prophylactic measures, as well as prompt rescue treatment. There has been a significant paradigm shift in the approach towards PONV prevention. There have also been several emerging therapeutic options for PONV prophylaxis and treatment. In this review, we will discuss the up-to-date PONV management guidelines and highlight novel therapeutic options which have emerged in the last few years.

A pharmacological profile of intravenous amisulpride for the treatment of postoperative nausea and vomiting

INTRODUCTION

The issue of postoperative nausea and vomiting (PONV) remains important in surgical practice, contributing to patient distress, slower recovery, and increased use of healthcare resources. Many surgical patients report it to be a worse problem than the pain. New antiemetics of different classes are still needed to help manage PONV effectively, especially the treatment of established PONV after the failure of common prophylactic antiemetics such as 5-HT₃-antagonists and corticosteroids. Intravenous amisulpride, a drug with a long history of safe use in oral form as an antipsychotic, has recently been approved in the US (trade name: Barhemsys) as an intravenous antiemetic for the prevention and treatment of PONV.

AREAS COVERED

This review article summarizes the published data on the clinical pharmacology, safety, and efficacy of intravenous amisulpride as an antiemetic, supplemented by published data on oral amisulpride, where relevant to the intravenous form. Literature was obtained via the PubMed search terms 'intravenous amisulpride' and 'amisulpride AND safety.' Both primary and secondary pharmacology are covered, along with clinical pharmacokinetics (distribution, metabolism, and excretion). The review of clinical safety and efficacy includes data from four studies in the prevention of PONV, two in the treatment of PONV and two investigating effects on the QT interval of the electrocardiogram in healthy volunteers.

EXPERT OPINION

Given the importance of sufficient PONV prevention for patients and the healthcare system, the availability of intravenous amisulpride is helpful, restoring the dopamine-antagonist class as a potential mainstay in both combination prophylaxis and treatment.

Efficacy of amisulpride on postoperative nausea and vomiting: a systematic review and meta-analysis

AIM AND BACKGROUND

Postoperative nausea and vomiting (PONV) remains a significant clinical problem for surgical patients. Amisulpride is a well-studied D_2/D₃ antagonist that has the potential to be used for preventing and treating PONV. Our aim was to assess the efficacy and safety of amisulpride for prevention and treatment of PONV through a systematic review and meta-analysis.

METHOD

A systematic literature search was performed using MEDLINE, EMBASE, PUBMED, clinicaltrials.gov, and the Cochrane Central Register of Controlled Trials from their inception to Feb 15th, 2019. The efficacy outcome was the incidence of complete response, defined as no emesis and no rescue antiemetic use in a 24-h period after study drug administration. The safety outcomes were the adverse effects associated with amisulpride.

RESULTS

Five studies comprising 3243 patients met inclusion critieria. Compared with placebo, amisulpride showed a significantly improved incidence of complete response [relative risk (RR): 1.30; 95% confidence interval (CI): 1.20-1.41; P < 0.00001, I² = 0%] with firm evidence from the trial sequential analysis. Particularly, the amisulpride at 5 mg dose indicated a significant benefit than placebo [relative risk (RR): 1.28; 95% confidence interval (CI): 1.18-1.39; P < 0.00001, I² = 4%]. The adverse event profile of amisulpride was generally similar to the placebo.

CONCLUSION

Based on our findings, low-dose, intravenous amisulpride is safe and efficacious for the prevention and treatment of PONV compared to placebo. Further studies are needed to explore the optimal dose and timing.

CLINICAL TRIAL REGISTRATION

PROSPERO: CRD42019121483.

Amisulpride for the Rescue Treatment of Postoperative Nausea or Vomiting in Patients Failing Prophylaxis

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Although antiemetics are commonly used to prevent postoperative nausea or vomiting, the failure rate is appreciable and there is currently no generally accepted standard for rescue treatment of postoperative nausea or vomiting after failed prophylaxis. This prospective, randomized, double-blind, parallel-group, placebo-controlled, multicenter study was designed to test the hypothesis that intravenous amisulpride, a dopamine D2/D3-antagonist, is superior to placebo at treating established postoperative nausea or vomiting after failed prophylaxis.

Methods

A total of 2,285 adult patients undergoing surgery under general inhalational anesthesia and receiving standard antiemetic prophylaxis were enrolled at 23 sites in Canada, France, Germany, and the United States. Of these, 702 patients experienced postoperative nausea or vomiting in the 24-h period after surgery and were randomized to receive a single dose of 5 or 10 mg intravenous amisulpride or matching placebo. The primary endpoint was complete response, defined as no emesis or rescue antiemetic use for 24 h after study drug administration, excluding emesis in the first 30 min. Secondary endpoints included incidence of emesis and rescue medication use, nausea burden, time to treatment failure, and length of stay in postanesthesia care unit and hospital.

Results

Complete response occurred in significantly more patients receiving 10 mg amisulpride (96 of 230, 41.7%) than placebo (67 of 235, 28.5%), a 13.2% difference (95% CI, 4.6 to 21.8; odds ratio, 1.80; P = 0.006). A 5-mg dose of amisulpride did not show a significant benefit (80 of 237, 33.8%); the difference from placebo was 5.2% (95% CI, 3.1 to 13.6; odds ratio, 1.24; P = 0.109). The total number of adverse events recorded and proportion of patients with at least one adverse event were comparable between the placebo and amisulpride groups. No clinically relevant toxicities were observed.

Conclusions

A single 10-mg dose of intravenous amisulpride was safe and more effective than placebo at treating established postoperative nausea or vomiting in patients failing postoperative nausea or vomiting prophylaxis.

Comparison of palonosetron and dexamethasone with ondansetron and dexamethasone for postoperative nausea and vomiting in postchemotherapy ovarian cancer surgeries requiring opioid-based patient-controlled analgesia: A randomised, double-blind, active controlled study

BACKGROUND AND AIMS

Patients undergoing ovarian cancer surgery after chemotherapy and requiring opioid-based patient-controlled analgesia (PCA) are at high-risk of postoperative nausea and vomiting (PONV). We aimed to assess the effect of palonosetron and dexamethasone combination for these patients for prevention of PONV.

METHODS

This study included 2 groups and 150 patients. At the time of wound closure, patients in group A received ondansetron 8 mg intravenous (IV) + dexamethasone 4 mg IV and group B received palonosetron 0.075 mg IV + dexamethasone 4 mg IV. Postoperatively for 48 hours, group A patients received ondansetron 4 mg 8 hourly IV, group B patients received normal saline 8 hourly IV in 2 cc syringe. The primary objective was the overall incidence of PONV. Independent t-test, Chi-square test, and Fisher's exact test were used and multivariate regression analysis was done.

RESULTS

Vomiting was significantly higher in group A (37.3%) as compared with group B (21.3%) at 0-48 hours (P = 0.031). Significantly more patients in Group A had nausea as compared with group B at 90-120 minutes (30.66% vs 18.66%, P = 0.043) and 6-24 hours (32.0% vs 22.66%, P = 0.029). PCA opioid usage in microgram was significantly higher in group A at 0-24 hours (690.53 ± 332.57 vs 576.85 ± 250.79, P = 0.024) and 0-48 hours (1126.10 ± 512.18 vs 952.13 ± 353.85, P = 0.030).

CONCLUSION

Palonosetron with dexamethasone is more effective than ondasetron with dexamethasone for prevention of PONV in post-chemotherapy ovarian cancer surgeries receiving opioid-based patient controlled analgesia.

Effects of palonosetron and ondansetron on preventing nausea and vomiting after laparoscopic surgery

Background

This meta-analysis was performed to evaluate the efficacy and safety of palonosetron and ondansetron in preventing postoperative nausea and vomiting (PONV) in patients undergoing laparoscopic surgery with general anesthesia.

Methods

We searched for randomized controlled clinical trials in PubMed, Embase, and The Cochrane Library.

Results

Nine studies were enrolled in this meta-analysis and showed no statistically significant difference between palonosetron and ondansetron in the prevention of PONV in the first 24 hours after surgery (relative risk [RR], 0.62; 95% confidence interval [CI], 0.35–1.10). Palonosetron more effectively prevented vomiting at various time intervals during the first 24 hours postoperatively than did ondansetron: 0–2 hours (RR, 0.45; 95% CI, 0.26–0.78), 2–6 hours (RR, 0.74; 95% CI, 0.39–1.40), and 6–24 hours (RR, 1.20; 95% CI, 0.55–2.64). No significant differences in side effects were found between palonosetron and ondansetron (RR, 0.67; 95% CI, 0.40–1.14).

Conclusion

This meta-analysis demonstrated that palonosetron is not more efficacious than ondansetron in the prevention of early PONV. However, palonosetron was more efficacious than ondansetron in the prevention of vomiting after laparoscopic surgery.

Effect of sevoflurane anesthesia on the comprehensive mRNA expression profile of the mouse hippocampus

Postoperative nausea and vomiting (PONV) is a common complication after general anesthesia. Recent studies suggested that the hippocampus is involved in PONV. Hypothesising that hippocampal dopaminergic neurons are related to PONV, we examined the comprehensive mRNA profile of the hippocampus, using a sevoflurane-treated mouse model to confirm this. This study was conducted after approval from our institutional animal ethics committee, the Animal Research Center of Sapporo Medical University School of Medicine (project number: 12-033). Eight mice were assigned to two groups: a naïve group and a sevoflurane group (Sev group). In the Sev group, four mice were anesthetised with 3.5% sevoflurane for 1 hour. Subsequently, mRNA was isolated from their hippocampal cells and RNA sequencing was performed on an Illumina HiSeq 2500 platform. Mapping of the quality-controlled, filtered paired-end reads to mouse genomes and quantification of the expression levels of each gene were performed using R software. The Rtn4rl2 gene that encodes the Nogo receptor was the most up-regulated gene in the present study. The expression levels of dopamine receptor genes and the tachykinin gene were increased by sevoflurane exposure, while the genes related to serotonin receptors were not altered by sevoflurane exposure. The expression levels of LIM-homeodomain-related genes were highly down-regulated by sevoflurane. These findings suggest that sevoflurane exposure induces dopaminergic stimulation of hippocampal neurons and triggers PONV, while neuronal inflammation caused by LIM-homeodomain-related genes is down-regulated by sevoflurane.

Use of Aprepitant and Factors Associated With Incidence of Postoperative Nausea and Vomiting in Patients Undergoing Facial Plastic Surgery

IMPORTANCE

Patients who experience immediate postoperative nausea and vomiting (PONV) after their facial plastic surgery procedure have a higher incidence of complications and dissatisfaction.

OBJECTIVES

To determine whether a single dose of aprepitant administered preoperatively can decrease the incidence of immediate PONV in patients undergoing facial plastic surgery compared with patients who are administered ondansetron hydrochloride alone and whether patient-related factors pose a greater risk of developing immediate PONV after surgery.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective study, we reviewed 172 patients undergoing facial plastic surgery with general anesthesia at an accredited office-based surgery practice from January 1, 2012, through December 31, 2013.

INTERVENTIONS

All patients received prophylactic treatment to mitigate against immediate PONV. Fifty-six patients received aprepitant in addition to ondansetron as prophylaxis for PONV.

MAIN OUTCOMES AND MEASURES

Patients undergoing facial plastic surgery were assessed during the immediate postoperative period for PONV. In addition, patient age, type of procedure, duration of surgery, and sex were reported.

RESULTS

The addition of aprepitant preoperatively effectively reduced the PONV rate from 15.5% to 1.8% (P = . 02). Logistic regression analysis revealed that duration of surgery longer than 90 minutes (odds ratio [OR], 2.936; 95% CI, 0.560-15.385; P = .20), female sex (OR, 1.893; 95% CI, 0.379-9.448; P = .44), and type of procedure increased the likelihood of PONV after facial plastic surgery with an odds ratio of greater than 1 in this sample population. However, the odds ratios were not statistically significantly greater than 1 for the 95% CIs. Of the 19 patients who experienced PONV, 17 were women, and 17 patients had a duration of surgery longer than 90 minutes. Patient age did not appear to affect the rate of PONV (P = .32).

CONCLUSIONS AND RELEVANCE

Preoperative aprepitant administered within 1 hour before facial plastic surgery in patients at risk of developing PONV effectively reduce the rate of immediate PONV. Female patients and patients with facial surgery duration of longer than 90 minutes might benefit from the added expense of aprepitant to further reduce the likelihood of PONV.

LEVEL OF EVIDENCE

3.

Postoperative Nausea and Vomiting: Palonosetron with Dexamethasone vs. Ondansetron with Dexamethasone in Laparoscopic Hysterectomies

OBJECTIVES

Postoperative nausea and vomiting (PONV) is the most common complication seen following laparoscopic surgery. Our study sought to evaluate the efficacy of the newer drug palonosetron with that of ondansetron, in combination with dexamethasone, for PONV in patients undergoing laparoscopic hysterectomies. .

METHODS

A total of 90 patients, aged between 30-50 years old, posted for elective laparoscopic hysterectomies under general anesthesia belonging to the American Society of Anesthesiologist (ASA) physical status I and II were included in the study. Patients were randomly divided into one of two groups (n=45). Before induction, patients in the first group (group I) received 0.075mg palonosetron with 8mg dexamethasone and patients in the second group (group II) received 4mg ondansetron with 8mg dexamethasone. Postoperatively, any incidences of early or delayed vomiting, requirement of rescue antiemetic, and side effects were recorded. Patient's hemodynamics were also monitored. Statistical analysis was done using Student's t-test, chi-square test, and Fisher's exact test. .

RESULTS

Preoperative, intraoperative, and postoperative heart rate, mean arterial pressure, peripheral capillary oxygen saturation were statistically not significant (p>0.050) in either group. In group II, eight patients had nausea in the first two hours and three patients had nausea in the two to six-hour postoperative period. In group I, three patients experienced nausea in the first six hours period. Eight patients in group II had vomited in the first two-hour period compared to one patient in group I (p=0.013). The requirement of rescue antiemetic was greater in group II than group I (20% vs. 4%). No side effects of antiemetic use were observed in either group. .

CONCLUSION

The combination of palonosetron with dexamethasone is more effective in treating early, delayed, and long term PONV compared to ondansetron with dexamethasone in patients undergoing elective laparoscopic hysterectomies under general anesthesia.