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Fugetto F, Filice E, Biagi C, Pierantoni L, Gori D, Lanari M. Single-dose of ondansetron for vomiting in children and adolescents with acute gastroenteritis-an updated systematic review and meta-analysis. Eur J Pediatr 2020; 179:1007-1016. [PMID: 32382791 DOI: 10.1007/s00431-020-03653-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 04/12/2020] [Accepted: 04/15/2020] [Indexed: 10/24/2022]
Abstract
This review aimed to meta-analyze evidence of efficacy and safety of one single dose of ondansetron for vomiting in children and adolescents with acute gastroenteritis. Database searches of MEDLINE (PubMed), Scopus (Elsevier), Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov up to November 2019 were performed. Only randomized clinical trials versus placebo were considered. Fixed and random effect models were used for the analyses of pooled data. Thirteen randomized clinical trials (2146 patients) were finally included. One single dose of ondansetron showed to produce (1) higher chance of vomiting cessation within 8 h (RR 1.41, 95% CI 1.19-1.68; low-quality evidence); (2) lower chances of oral rehydration therapy failure (RR 0.43, 95% CI 0.34-0.55; high-quality evidence), intravenous hydration needs (RR 0.44, 95% CI 0.34-0.57; high-quality evidence), and hospitalization rates within 8 h (RR 0.49, 95% CI 0.32-0.75; high-quality evidence); and (3) no statistically significant differences in return visits to emergency department (RR 1.14, 95% CI 0.74-1.76; high-quality evidence) compared with placebo. Further studies are necessary to better assess long term efficacy and safety of ondansetron in this context.Conclusions: Mixed evidence was found via few studies about the efficacy and safety of a single dose of ondansetron in the pediatric population.What is known:• Ondansetron use for vomiting in pediatric acute gastroenteritis is increasing worldwide.• Actual convictions come from studies evaluating one and more than one dose of the drug.What is new:• This is the first review to collect data about the effects of one single dose of ondansetron on strong and temporally homogeneous clinical outcomes.• This study supports the use of one dose of ondansetron in pediatric acute gastroenteritis.• Further studies are necessary to assess its long-term efficacy and safety.
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Affiliation(s)
- Francesco Fugetto
- Department of Medical and Surgical Sciences (DIMEC), Pediatric Emergency Unit, St. Orsola Hospital, University of Bologna, via Massarenti 9, 40138, Bologna, Italy
| | - Emanuele Filice
- Department of Medical and Surgical Sciences (DIMEC), Pediatric Emergency Unit, St. Orsola Hospital, University of Bologna, via Massarenti 9, 40138, Bologna, Italy.
| | - Carlotta Biagi
- Department of Medical and Surgical Sciences (DIMEC), Pediatric Emergency Unit, St. Orsola Hospital, University of Bologna, via Massarenti 9, 40138, Bologna, Italy
| | - Luca Pierantoni
- Department of Medical and Surgical Sciences (DIMEC), Pediatric Emergency Unit, St. Orsola Hospital, University of Bologna, via Massarenti 9, 40138, Bologna, Italy
| | - Davide Gori
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, via San Giacomo 12, 40128, Bologna, Italy
| | - Marcello Lanari
- Department of Medical and Surgical Sciences (DIMEC), Pediatric Emergency Unit, St. Orsola Hospital, University of Bologna, via Massarenti 9, 40138, Bologna, Italy
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Niño-Serna LF, Acosta-Reyes J, Veroniki AA, Florez ID. Antiemetics in Children With Acute Gastroenteritis: A Meta-analysis. Pediatrics 2020; 145:peds.2019-3260. [PMID: 32132152 DOI: 10.1542/peds.2019-3260] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/22/2020] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Several antiemetics have been used in children with acute gastroenteritis. However, there is still controversy over their use. OBJECTIVE To determine the effectiveness and safety of antiemetics for controlling vomiting in children with acute gastroenteritis. DATA SOURCES Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Latin America and the Caribbean Literature on Health Sciences, and gray literature, until December 2018. STUDY SELECTION We selected randomized clinical trials comparing metoclopramide, ondansetron, domperidone, dexamethasone, dimenhydrinate, and granisetron. DATA EXTRACTION Two reviewers independently screened abstracts and full texts, extracted the data, and assessed the risk of bias. We performed pairwise and network meta-analysis using the random-effects model. RESULTS Twenty-four studies were included (3482 children). Ondansetron revealed the largest effect in comparison to placebo for cessation of vomiting (odds ratio = 0.28 [95% credible interval = 0.16 to 0.46]; quality of evidence: high) and for hospitalization (odds ratio = 2.93 [95% credible interval = 1.69 to 6.18]; quality of evidence: moderate). Ondansetron was the only intervention that reduced the need for intravenous rehydration and the number of vomiting episodes. When considering side effects, dimenhydrinate was the only intervention that was worse than placebo. LIMITATIONS Most treatment comparisons had low- or very low-quality evidence, because of risk of biases and imprecise estimates. CONCLUSIONS Ondansetron is the only intervention that revealed an effect on the cessation of vomiting, on preventing hospitalizations, and in reducing the need for intravenous rehydration. Ondansetron was also considered a safe intervention.
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Affiliation(s)
- Laura F Niño-Serna
- Department of Pediatrics, University of Antioquia, Medellín, Colombia.,Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - Jorge Acosta-Reyes
- Department of Public Health, Universidad del Norte, Barranquilla, Colombia
| | - Areti-Angeliki Veroniki
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece.,Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada.,Department of Surgery and Cancer, Institute of Reproductive and Developmental Biology, Faculty of Medicine, Imperial College, London, United Kingdom; and
| | - Ivan D Florez
- Department of Pediatrics, University of Antioquia, Medellín, Colombia; .,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Schrod L. Pädiatrische Notfälle. KLINISCHE NOTFALLMEDIZIN BAND 1 WISSEN 2020. [PMCID: PMC7325853 DOI: 10.1016/b978-3-437-23248-0.00027-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Silverman RA, House SL, Meltzer AC, Hahn B, Lovato LM, Avarello J, Miller JB, Kalfus IN, Fathi R, Raday G, Plasse TF, Yan EC. Bimodal Release Ondansetron for Acute Gastroenteritis Among Adolescents and Adults: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e1914988. [PMID: 31702802 PMCID: PMC6902785 DOI: 10.1001/jamanetworkopen.2019.14988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
IMPORTANCE Vomiting resulting from acute gastroenteritis is commonly treated with intravenous antiemetics in acute care settings. If oral treatment were beneficial, patients might not need intravenous administered hydration or medication. Furthermore, a long-acting treatment could provide sustained relief from nausea and vomiting. OBJECTIVE To determine whether an experimental long-acting bimodal release ondansetron tablet decreases gastroenteritis-related vomiting and eliminates the need for intravenous therapy for 24 hours after administration. DESIGN, SETTING, AND PARTICIPANTS This placebo-controlled, double-blind, randomized clinical trial included patients from 19 emergency departments and 2 urgent care centers in the United States from December 8, 2014, to February 17, 2017. Patients 12 years and older with at least 2 vomiting episodes from presumed gastroenteritis in the previous 4 hours and symptoms with less than 36 hours' duration were randomized using a 3:2 active to placebo ratio. Analyses were performed on an intent-to-treat basis and conducted from June 1, 2017, to November 1, 2017. INTERVENTION Bimodal release ondansetron tablet containing 6 mg of immediate release ondansetron and 18 mg of a 24-hour release matrix for a total of 24 mg of ondansetron. MAIN OUTCOMES AND MEASURES Treatment success was defined as no further vomiting, no need for rescue medication, and no intravenous hydration for 24 hours after bimodal release ondansetron administration. RESULTS Analysis included 321 patients (mean [SD] age, 29.0 [11.1] years; 195 [60.7%] women), with 192 patients in the bimodal release ondansetron group and 129 patients in the placebo group. Treatment successes were observed in 126 patients in the bimodal release ondansetron group (65.6%) compared with 70 patients in the placebo group (54.3%), with an 11.4% (95% CI, 0.3%-22.4%) absolute probability difference. The proportion of treatment success was 21% higher among patients who received bimodal release ondansetron compared with those who received a placebo (relative risk, 1.21; 95% CI, 1.00-1.46; P = .04). In an analysis including only patients with a discharge diagnosis of acute gastroenteritis and no major protocol violations, there were 123 treatment successes (69.5%) in the bimodal release ondansetron group compared with 67 treatment successes (54.9%) in the placebo group (relative risk, 1.27; 95% CI, 1.05-1.53; P = .01). Adverse effects were infrequent and similar to the known safety profile of ondansetron. CONCLUSIONS AND RELEVANCE This randomized clinical trial found that a long-acting bimodal release oral ondansetron tablet was an effective antiemetic among adolescents and adults with moderate to severe vomiting from acute gastroenteritis. The drug benefits extended to 24 hours after administration. Bimodal release ondansetron may decrease the need for intravenous access and emergency department care to manage acute gastroenteritis. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02246439.
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Affiliation(s)
- Robert A Silverman
- Feinstein Institute for Medical Research, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York
- Department of Emergency Medicine, Northwell Health, New York, New York
| | - Stacey L House
- Department of Emergency Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Andrew C Meltzer
- School of Medicine and Health Sciences, Department of Emergency Medicine, George Washington University, Washington, DC
| | - Barry Hahn
- Department of Emergency Medicine, Northwell Health, New York, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York
| | - Luis M Lovato
- Department of Emergency Medicine, Olive View-UCLA Medical Center, Sylmar, California
| | - Jahn Avarello
- Department of Emergency Medicine, Northwell Health, New York, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York
- Cohens Childrens Medical Center, Department of Pediatrics, Northwell Health, New York, New York
| | - Joseph B Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | | | | | | | | | - Eric C Yan
- Atlantic Research Group, Charlottesville, Virginia
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Hagbom M, Novak D, Ekström M, Khalid Y, Andersson M, Lindh M, Nordgren J, Svensson L. Ondansetron treatment reduces rotavirus symptoms-A randomized double-blinded placebo-controlled trial. PLoS One 2017; 12:e0186824. [PMID: 29077725 PMCID: PMC5659648 DOI: 10.1371/journal.pone.0186824] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 10/06/2017] [Indexed: 12/12/2022] Open
Abstract
Background Rotavirus and norovirus cause acute gastroenteritis with severe diarrhoea and vomiting, symptoms that may lead to severe dehydration and death. The objective of this randomized double-blinded placebo-controlled study was to investigate whether ondansetron, a serotonin receptor antagonist could attenuate rotavirus- and norovirus-induced vomiting and diarrhoea, which would facilitate oral rehydration and possibly accelerate recovery and reduce need for hospitalization. Methods Children with acute gastroenteritis, aged 6 months to 16 years where enrolled (n = 104) and randomized to one single oral dose (0.15mg/kg) of ondansetron (n = 52) or placebo (n = 52). The number of diarrhoea and vomiting episodes during the 24 hours following treatment was reported as well as the number of days with symptoms. Pathogens in faeces were diagnosed by real-time PCR. Outcome parameters were analyzed for rotavirus- and norovirus-positive children. Results One dose of oral ondansetron reduced duration of rotavirus clinical symptoms (p = 0.014), with a median of two days. Furthermore, ondansetron reduced diarrhea episodes, most pronounced in children that had been sick for more than 3 days before treatment (p = 0.028). Conclusion Ondansetron may be a beneficial treatment for children with rotavirus gastroenteritis. Trial registration European Clinical Trial Database EudraCT 2011-005700-15.
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Affiliation(s)
- Marie Hagbom
- Department of Clinical and Experimental Medicine, Division of Molecular Virology, Medical Faculty, Linköping University, Linköping, Sweden
| | - Daniel Novak
- Sahlgrenska University Hospital, The Queen Silvia Children’s Hospital, The Emergency Department, Gothenburg, Sweden
| | - Malin Ekström
- Sahlgrenska University Hospital, The Queen Silvia Children’s Hospital, The Emergency Department, Gothenburg, Sweden
| | - Younis Khalid
- Sahlgrenska University Hospital, The Queen Silvia Children’s Hospital, The Emergency Department, Gothenburg, Sweden
| | - Maria Andersson
- Department of Infectious Diseases/Section of Clinical Virology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Lindh
- Department of Infectious Diseases/Section of Clinical Virology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Johan Nordgren
- Department of Clinical and Experimental Medicine, Division of Molecular Virology, Medical Faculty, Linköping University, Linköping, Sweden
| | - Lennart Svensson
- Department of Clinical and Experimental Medicine, Division of Molecular Virology, Medical Faculty, Linköping University, Linköping, Sweden
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
- * E-mail:
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Hoffman RJ, Alansari K. Effect of intravenous ondansetron on QTc interval in children with gastroenteritis. Am J Emerg Med 2017; 36:754-757. [PMID: 29029798 DOI: 10.1016/j.ajem.2017.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 10/03/2017] [Accepted: 10/03/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND The potential for ondansetron to cause QT prolongation and fatal dysrhythmia is well-reported, including a 2011 FDA report on the topic. Few clinical trials evaluating this phenomenon in the ED setting exist, and only one is pediatric. OBJECTIVE We have sought to determine the effect of a standardized dose of intravenous ondansetron on the QTc duration of children under 14years of age treated for gastroenteritis-associated vomiting in a pediatric ED. This study is modeled closely after an FDA "thorough QT study". METHODS EGCs were obtained before and 15, 30, 45, and 60min after a 0.15mg/kg IV dose of ondansetron given for gastroenteritis-associated vomiting. QT intervals were measured manually with digital calipers, and the QTc interval calculated both by Bazett's (QTcB) and Fridericia's (QTcF) correction. A paired t-test comparing QTc was conducted, and frequency of categorical outcomes of prolongation>30msec, >60 msec, and absolute prolongation >450 msec, >480 msec, and >500msec were evaluated. RESULTS In a 4-month period, 134 patients were included in the study, 46% were male. The average QTc prior to ondansetron administration was: QTcB 415 msec (95% CI 343-565) and QTcF 373 (95% CI 304-499). The mean difference in QTc after ondansetron was 0.4msec for QTcB (95% CI -35-45msec) and 0.1msec for QTcF (95% CI -40-18msec). CONCLUSION In these children, 0.15mg/kg of intravenous ondansetron did not cause prolongation of QTcB or QTcF measured 15min after administration, nor at later times.
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Affiliation(s)
- Robert J Hoffman
- Sidra Medical and Research Center, Department of Emergency Medicine, PO Box 26999, Doha, Qatar
| | - Khalid Alansari
- Sidra Medical and Research Center, Department of Emergency Medicine, PO Box 26999, Doha, Qatar; Hamad General Hospital, Department of Pediatrics, PO Box 3050, Doha, Qatar.
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Abstract
INTRODUCTION Ondansetron is commonly used to treat vomiting in gastroenteritis, but has a United States Food and Drug Administration black box warning for risk of Q wave to T wave time interval (QT) prolongation. We report 2 pediatric cases of fatal refractory cardiac arrest after administration of ondansetron. CASES A 10-year-old previously healthy boy presented to the emergency room with gastroenteritis symptoms. After intravenous fluids, morphine, antibiotics, and 2 doses of ondansetron, the patient became unresponsive with agonal respirations and a wide complex tachycardia consistent with ventricular tachycardia. In a second case, an 86-day-old infant with previously unidentified congenital cardiomyopathy presented to our emergency department with gastroenteritis symptoms. The patient received ondansetron and subsequently experienced repeated bouts of supraventricular tachycardia which progressed to ventricular fibrillation. Resuscitation efforts failed in each case, and both patients expired. DISCUSSION Ondansetron can cause dose-dependent QT prolongation effects, which are more clinically relevant when other proarrhythmic elements are present. There is very limited published experience on use of ondansetron in children younger than 2 years. Our 2 cases join 2 previous case reports of death after ondansetron administration for gastroenteritis. The pharmacology of ondansetron's cardiac effects and drug-induced QT prolongation is discussed. CONCLUSIONS Patients may have hidden risk factors that, together with ondansetron, could result in a proarrhythmic state that could lead to adverse effects, such as arrhythmias. Administration of ondansetron should be individualized and used cautiously in patients with risk factors for arrhythmia.
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Das JK, Kumar R, Salam RA, Freedman S, Bhutta ZA. The effect of antiemetics in childhood gastroenteritis. BMC Public Health 2013; 13 Suppl 3:S9. [PMID: 24564795 PMCID: PMC3847618 DOI: 10.1186/1471-2458-13-s3-s9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction Diarrheal diseases are the second leading cause of childhood morbidity and mortality in developing countries and an important cause of malnutrition. An estimated 0.75 million children below 5 years of age die from diarrhea. Vomiting associated with acute gastroenteritis (AGE) is a distressing symptom and limits the success of oral rehydration in AGE leading to an increased use of intravenous rehydration, prolonged emergency department stay and hospitalization. In this review we estimate the effect of antiemetics in gastroenteritis in children. Methods We conducted a systematic review of all the efficacy and effectiveness studies. We used a standardized abstraction and grading format and performed meta-analyses for all outcomes with more than two studies. The estimated effect of antiemetics was determined by applying the standard Child Health Epidemiology Reference Group (CHERG) rules. Results We included seven studies in the review. Antiemetics significantly reduced the incidence of vomiting and hospitalization by 54%. Antiemetics also significantly reduced the intravenous fluid requirements by 60%, while it had a non-significant effect on the ORT tolerance and revisit rates. Conclusion Antiemetics are effective for the management of gastroenteritis in children and have the potential to decrease morbidity and mortality burden due to diarrhea, when introduced and scaled up.
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Carter B, Fedorowicz Z. Antiemetic treatment for acute gastroenteritis in children: an updated Cochrane systematic review with meta-analysis and mixed treatment comparison in a Bayesian framework. BMJ Open 2012; 2:e000622. [PMID: 22815462 PMCID: PMC3401831 DOI: 10.1136/bmjopen-2011-000622] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Accepted: 06/20/2012] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE To assess the evidence for the safety and effectiveness of antiemetics on gastroenteritis-induced vomiting in children and adolescents. DESIGN Systematic review. DATA SOURCES The Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE searched from 1980 to March 2012. METHODS Methods included comprehensive searches, data synthesis, meta-analysis and mixed treatment comparisons (MTC). REVIEW METHODS Reference lists were checked, and missing or inconsistent data were sought from trial investigators. Randomised controlled trials comparing antiemetics in participants younger than 18 years and who were vomiting due to acute gastroenteritis. Four meta-analyses and three MTC were carried out. RESULTS 10 trials (1479 participants) and five treatments were included: dexamethasone, dimenhydrinate, granisetron, metoclopramide and ondansetron. There was clear evidence that ondansetron (oral or intravenous) compared with placebo increased the proportion of patients with cessation of vomiting (orally administered) (RR 1.44, 95% CI 1.29 to 1.61), reduced the immediate hospital admission rate (orally administered) (RR 0.40, 95% CI 0.19 to 0.83) and the need for intravenous rehydration therapy (orally administered) (RR 0.41, 95% CI 0.29 to 0.59). No significant difference was noted in the revisit rates, but ondansetron was associated with an increase in episodes of diarrhoea. There was no evidence for the use of dexamethasone or metoclopramide and limited evidence that dimenhydrinate or granisetron increased the cessation of vomiting. The MTC analysis suggested that ondansetron was the most likely treatment to stop the child vomiting. Nine studies were carried out in secondary care and one in primary care. CONCLUSIONS This systematic review used a method novel to this clinical area and found clear evidence that ondansetron was the most likely treatment to allow oral rehydration therapy to commence. Given the significance of these results, the authors urge healthcare policy makers to consider the wider use of ondansetron in secondary care. Furthermore, randomised controlled trials are needed to investigate the effectiveness of antiemetic treatment in primary care (including ambulatory care interventions).
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Affiliation(s)
- Ben Carter
- North Wales Centre for Primary Care Research, Bangor University, Wrexham, UK
| | - Zbys Fedorowicz
- Bahrain Branch (UK CC) The Cochrane Collaboration, Awali, Bahrain
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Abstract
OBJECTIVE Emergency department use of ondansetron in children with gastroenteritis is increasing; however, its effect on clinical outcomes is unknown. We aimed to determine whether increasing ondansetron usage is associated with improved outcomes in children with gastroenteritis. METHODS A retrospective cohort study was conducted at The Hospital for Sick Children, Toronto, Canada. Eligible children included those younger than 18 years old with gastroenteritis who presented to an emergency department between 2003 and 2008. There were 22,125 potentially eligible visits; 20% were selected at random for chart review. The primary outcome measure, the intravenous rehydration rate, was evaluated using an interrupted time-series analysis with segmented logistic regression. Secondary outcomes included emergency department revisits, hospitalization, and length of stay. RESULTS A total of 3508 patient visits were included in the final analysis. During the study period, there was a significant reduction in intravenous rehydration usage (27%-13%; P < 0.001) and an increase in ondansetron administration (1%-18%; P < 0.001). Time-series analysis demonstrated a level break (P = 0.03) following the introduction of ondansetron. The mean length of stay for children declined from 8.6 ± 3.4 to 5.9 ± 2.8 hours, P = 0.03. During the week following the index visit, there was a reduction in return visits (18%-13%; P = 0.008) and need for intravenous rehydration (7%-4%; P = 0.02). CONCLUSIONS Ondansetron use has increased significantly and is associated with reductions in the use of intravenous rehydration, emergency department revisits, and length of stay. The selective use of ondansetron is associated with improved clinical outcomes.
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Fedorowicz Z, Jagannath VA, Carter B. Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents. Cochrane Database Syst Rev 2011; 2011:CD005506. [PMID: 21901699 PMCID: PMC6768985 DOI: 10.1002/14651858.cd005506.pub5] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Vomiting is a common manifestation of acute gastroenteritis in children and adolescents. When untreated it can be a hindrance to oral rehydration therapy, which is the cornerstone in the management of acute gastroenteritis. Evidence is needed concerning the safety and efficacy of antiemetic use for vomiting in acute gastroenteritis in children. OBJECTIVES To assess the safety and effectiveness of antiemetics on gastroenteritis induced vomiting in children and adolescents. SEARCH STRATEGY We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register comprising references identified from comprehensive electronic database searches and hand searches of relevant journals and abstract books of conferences.The search was re-run and is up to date as on 20 July 2010. SELECTION CRITERIA Randomized controlled trials comparing antiemetics with placebo or no treatment, in children and adolescents under the age of 18, for vomiting due to gastroenteritis. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. MAIN RESULTS We included seven trials involving 1,020 participants. Mean time to cessation of vomiting in one study was 0.34 days less with dimenhydrinate suppository compared to placebo (P value = 0.036). Pooled data from three studies comparing oral ondansetron with placebo showed: a reduction in the immediate hospital admission rate (RR 0.40, NNT 17, 95% CI 10 to 100) but no difference between the hospitalization rates at 72 hours after discharge from the Emergency Department (ED); a reduction in IV rehydration rates both during the ED stay (RR 0.41, NNT 5, 95% CI 4 to 8), and in follow-up to 72 hours after discharge from the ED stay (worst-best scenario for ondansetron RR 0.57, NNT 6, 95% CI 4 to 13) and an increase in the proportion of patients with cessation of vomiting (RR 1.34, NNT 5, 95% CI 3 to 7)). No significant difference was noted in the revisit rates or adverse events, although diarrhea was reported as a side effect in four of the five ondansetron studies. In one study the proportion of patients with cessation of vomiting in 24 hours was (58%) with IV ondansetron, (17%) placebo and (33%) in the metoclopramide group (P value = 0.039). AUTHORS' CONCLUSIONS Oral ondansetron increased the proportion of patients who had ceased vomiting and reduced the number needing intravenous rehydration and immediate hospital admission. Intravenous ondansetron and metoclopramide reduced the number of episodes of vomiting and hospital admission, and dimenhydrinate as a suppository reduced the duration of vomiting.
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Affiliation(s)
- Zbys Fedorowicz
- Ministry of Health, BahrainUKCC (Bahrain Branch)Box 25438AwaliBahrain
| | - Vanitha A Jagannath
- American Mission HospitalDepartment of PaediatricsManamaManamaBahrainPO Box 1
| | - Ben Carter
- Cardiff UniversityNorth Wales Clinical School, Department of Primary Care & Public Health, School of MedicineWrexhamUKLL13 7YP,
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Metoclopramide versus ondansetron for the treatment of vomiting in children with acute gastroenteritis. J Pediatr Gastroenterol Nutr 2011; 53:156-60. [PMID: 21788756 DOI: 10.1097/mpg.0b013e3182132d8d] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE To compare the efficacy and safety of ondansetron versus less expensive metoclopramide in the treatment of children with persistent vomiting with acute gastroenteritis. MATERIALS AND METHODS A double-blind trial including consecutive consented patients ages 1 to 14 years was conducted in an urban infirmary setting from June 2008 through December 2008. Children were randomized to receive a single dose of intravenous ondansetron or metoclopramide. The primary efficacy outcome was the proportion of patients with cessation of vomiting shortly after completion of the study medication infusion in each group. Observed adverse effects and diarrhea frequency during admission and in follow-up were recorded to assess safety. RESULTS One hundred sixty-seven previously healthy children (median age 3 years) diagnosed as having acute gastroenteritis with persistent vomiting completed treatment and observation. Cessation of vomiting was achieved in 68/84 patients (81%) of the ondansetron and 60/83 (72%) of the metoclopramide groups, P = 0.14. Mean time to complete cessation of vomiting was 39 minutes (SD 111) for ondansetron, and 61 minutes (SD 110) for metoclopramide, P = 0.2. The mean length of infirmary stay was 550 minutes (SD 427) for ondansetron and 575 minutes (SD 449) for metoclopramide, P = 0.71. Revisit rate, readmissions rate, and frequency of diarrhea after discharge were similar in the 2 treatment groups. No adverse reaction or other safety concerns were identified. CONCLUSIONS In the sample size tested, intravenous metoclopramide therapy did not differ from ondansetron in the treatment of persistent vomiting for children with gastroenteritis admitted for intravenous fluid hydration.
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Marchetti F, Maestro A, Rovere F, Zanon D, Arrighini A, Bertolani P, Biban P, Da Dalt L, Di Pietro P, Renna S, Guala A, Mannelli F, Pazzaglia A, Messi G, Perri F, Reale A, Urbino AF, Valletta E, Vitale A, Zangardi T, Tondelli MT, Clavenna A, Bonati M, Ronfani L. Oral ondansetron versus domperidone for symptomatic treatment of vomiting during acute gastroenteritis in children: multicentre randomized controlled trial. BMC Pediatr 2011; 11:15. [PMID: 21310051 PMCID: PMC3045958 DOI: 10.1186/1471-2431-11-15] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Accepted: 02/10/2011] [Indexed: 12/05/2022] Open
Abstract
Background Vomiting in children with acute gastroenteritis (AG) is not only a direct cause of fluid loss but it is also a major factor of failure of oral rehydration therapy (ORT). Physicians who provide care to paediatric patients in the emergency department (ED) usually prescribe intravenous fluid therapy (IVT) for mild or moderate dehydration when vomiting is the major symptom. Thus, effective symptomatic treatment of vomiting would lead to an important reduction in the use of IVT and, consequently, of the duration of hospital stay and of frequency of hospital admission. Available evidence on symptomatic treatment of vomiting shows the efficacy of the most recently registered molecule (ondansetron) but a proper evaluation of antiemetics drugs largely used in clinical practice, such as domperidone, is lacking. Objectives To compare the efficacy of ondansetron and domperidone for the symptomatic treatment of vomiting in children with AG who have failed ORT. Methods/Design Multicentre, double-blind randomized controlled trial conducted in paediatric EDs. Children aged from 1 to 6 years who vomiting, with a presumptive clinical diagnosis of AG, and without severe dehydration will be included. After the failure of a initial ORS administration in ED, eligible children will be randomized to receive: 1) ondansetron syrup (0,15 mg/Kg of body weight); 2) domperidone syrup (0,5 mg/Kg of body weight); 3) placebo. The main study outcome will be the percentage of patients needing nasogastric or IVT after symptomatic oral treatment failure, defined as vomiting or fluid refusal after a second attempt of ORT. Data relative to study outcomes will be collected at 30 minute intervals for a minimum of 6 hours. A telephone follow up call will be made 48 hours after discharge. A total number of 540 children (i.e. 180 patients in each arm) will be enrolled. Discussion The trial results would provide evidence on the efficacy of domperidone, which is largely used in clinical practice despite the lack of proper evaluation and a controversial safety profile, as compared to ondansetron, which is not yet authorized in Italy despite evidence supporting its efficacy in treating vomiting. The trial results would contribute to a reduction in the use of IVT and, consequently, in hospital admissions in children with AG. The design of this RCT, which closely reflect current clinical practice in EDs, will allow immediate transferability of results. Trial Registration ClinicalTrials.gov: NCT01257672
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Affiliation(s)
- Federico Marchetti
- Department of Pediatrics and Epidemiology and Biostatistics Unit, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy.
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Freedman SB, Powell EC, Nava-Ocampo AA, Finkelstein Y. Ondansetron dosing in pediatric gastroenteritis: a prospective cohort, dose-response study. Paediatr Drugs 2010; 12:405-10. [PMID: 21028919 DOI: 10.2165/11537770-000000000-00000] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Ondansetron is increasingly used to prevent emesis in children with acute gastroenteritis; however, the optimal dose is unknown. OBJECTIVE To determine if higher doses of oral ondansetron are associated with greater efficacy or side effects. METHODS We analyzed data from a prospective clinical trial performed between January 2004 and April 2005. Data were collected on 105 children with dehydration due to gastroenteritis who received an ondansetron oral disintegrating formulation. The following outcomes of efficacy were analyzed: number of vomiting episodes, volume of oral rehydration fluids consumed, percent weight gain, and the proportions of children who had ongoing vomiting, received intravenous rehydration, and were hospitalized. In addition, the number of episodes of diarrhea was evaluated to measure whether there were dose-dependent side effects. RESULTS Participants were aged 0.5-8.2 years and the dose ranged between 0.13 and 0.26 mg/kg. There was no significant association between the dose of ondansetron and the outcomes of number of vomiting episodes, volume of fluids consumed, increase in bodyweight, or number of diarrhea episodes/hour. The mean dose of ondansetron (mg/kg) administered was not different amongst those who did and did not have ongoing vomiting, undergo hospitalization, and receive intravenous rehydration. CONCLUSIONS Within the dose range of 0.13-0.26 mg/kg, higher doses of ondansetron were not superior to lower doses, nor were they associated with increased side effects. Thus, ondansetron in this dose range was shown to result in a similar reduction in emesis in children with acute gastroenteritis.
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Affiliation(s)
- Stephen B Freedman
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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15
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Oral ondansetron administration in emergency departments to children with gastroenteritis: an economic analysis. PLoS Med 2010; 7:e1000350. [PMID: 20967234 PMCID: PMC2953527 DOI: 10.1371/journal.pmed.1000350] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Accepted: 09/01/2010] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The use of antiemetics for children with vomiting is one of the most controversial decisions in the treatment of gastroenteritis in developed countries. Ondansetron, a selective serotonin receptor antagonist, has been found to be effective in improving the success of oral rehydration therapy. However, North American and European clinical practice guidelines continue to recommend against its use, stating that evidence of cost savings would be required to support ondansetron administration. Thus, an economic analysis of the emergency department administration of ondansetron was conducted. The primary objective was to conduct a cost analysis of the routine administration of ondansetron in both the United States and Canada. METHODS AND FINDINGS A cost analysis evaluated oral ondansetron administration to children presenting to emergency departments with vomiting and dehydration secondary to gastroenteritis from a societal and health care payer's perspective in both the US and Canada. A decision tree was developed that incorporated the frequency of vomiting, intravenous insertion, hospitalization, and emergency department revisits. Estimates of the monetary costs associated with ondansetron use, intravenous rehydration, and hospitalization were derived from administrative databases or emergency department use. The economic burden in children administered ondansetron plus oral rehydration therapy was compared to those not administered ondansetron employing deterministic and probabilistic simulations. We estimated the costs or savings to society and health care payers associated with the routine administration of ondansetron. Sensitivity analyses considered variations in costs, treatment effects, and exchange rates. In the US the administration of ondansetron to eligible children would prevent approximately 29,246 intravenous insertions and 7,220 hospitalizations annually. At the current average wholesale price, its routine administration to eligible children would annually save society US$65.6 million (US$49.1-US$81.1) and health care payers US$61.1 million (US$46.2-US$76.3). In Canada the administration of ondansetron to eligible children would prevent 4,065 intravenous insertions and 1,003 hospitalizations annually. Its routine administration would annually save society CDN$1.72 million (CDN$1.15-CDN$1.89) and the health care system CDN$1.18 million (CDN$0.88-CDN$1.41). CONCLUSIONS In countries where intravenous rehydration is often employed, the emergency department administration of oral ondansetron to children with dehydration and vomiting secondary to gastroenteritis results in significant monetary savings compared to a no-ondansetron policy. Please see later in the article for the Editors' Summary.
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16
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Chow CM, Leung AK, Hon KL. Acute gastroenteritis: from guidelines to real life. Clin Exp Gastroenterol 2010; 3:97-112. [PMID: 21694853 PMCID: PMC3108653 DOI: 10.2147/ceg.s6554] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Indexed: 01/13/2023] Open
Abstract
Acute gastroenteritis is a very common disease. It causes significant mortality in developing countries and significant economic burden to developed countries. Viruses are responsible for approximately 70% of episodes of acute gastroenteritis in children and rotavirus is one of the best studied of these viruses. Oral rehydration therapy is as effective as intravenous therapy in treating mild to moderate dehydration in acute gastroenteritis and is strongly recommended as the first line therapy. However, the oral rehydration solution is described as an underused simple solution. Vomiting is one of the main reasons to explain the underuse of oral rehydration therapy. Antiemetics are not routinely recommended in treating acute gastroenteritis, though they are still commonly prescribed. Ondansetron is one of the best studied antiemetics and its role in enhancing the compliance of oral rehydration therapy and decreasing the rate of hospitalization has been proved recently. The guidelines regarding the recommendation on antiemetics have been changed according to the evidence of these recent studies.
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Affiliation(s)
- Chung M Chow
- Department of Paediatrics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, PR China
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Gener B, Burns JM, Griffin S, Boyer EW. Administration of ondansetron is associated with lethal outcome. Pediatrics 2010; 125:e1514-7. [PMID: 20439600 DOI: 10.1542/peds.2009-2795] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
We report here the case of a child with a known muscular abnormality and susceptibility to malignant hyperthermia who abruptly died after receiving a therapeutic dose of ondansetron. Also, we discuss the pharmacodynamic relationship of ondansetron to malignant hyperthermia in a susceptible host.
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Affiliation(s)
- Blanca Gener
- Clinical Genetics, Department of Pediatrics, Hospital de Cruces, Barakaldo, Spain
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18
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Utilización de ondansetrón en urgencias de pediatría. An Pediatr (Barc) 2010; 72:369-70. [DOI: 10.1016/j.anpedi.2010.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2009] [Revised: 01/08/2010] [Accepted: 01/29/2010] [Indexed: 11/22/2022] Open
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Yilmaz HL, Yildizdas RD, Sertdemir Y. Clinical trial: oral ondansetron for reducing vomiting secondary to acute gastroenteritis in children--a double-blind randomized study. Aliment Pharmacol Ther 2010; 31:82-91. [PMID: 19758398 DOI: 10.1111/j.1365-2036.2009.04145.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Abstract
BACKGROUND Vomiting as a consequence of gastroenteritis frequently occurs in children. It is still debatable whether vomiting should be treated with antiemetic drugs. AIM To investigate potential beneficial effects of ondansetron in treating vomiting during acute gastroenteritis. METHODS A randomized, double blind, placebo-controlled trial was performed in our emergency departments. Children, aged 5 months to 8 years, were randomized to receive either ondansetron 0.2 mg/kg or placebo at 8h intervals. The primary outcome measure was the frequency of emesis during an 8-h-period after enrollment. RESULTS A hundred and nine patients were enrolled; 54 received placebo and 55 received ondansetron. As compared with the children who received placebo, children who received ondansetron were less likely to vomit both during the first 8-h follow-up in the emergency department [relative risk (RR): 0.33, 95% CI: 0.19-0.56, NNT: 2, 95% CI: 1.6-3.5], and during the next 24-h follow-up (RR: 0.15, 95% CI: 0.07-0.33, NNT: 2, 95% CI: 1.3-2.1). CONCLUSION Ondansetron may be an effective and efficient treatment that reduces the incidence of vomiting from gastroenteritis during both the first 8 h and the next 24 h, and is probably a useful adjunct to oral rehydration.
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Affiliation(s)
- H L Yilmaz
- Department of Pediatric Emergency Medicine, Medical School of Cukurova University, Adana, Turkey.
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Abstract
PURPOSE OF REVIEW The alleviation of vomiting due to gastroenteritis in children can help promote oral rehydration and prevent medical visits for dehydration. RECENT FINDINGS Recent randomized, placebo-controlled trials of newer antiemetics, such as serotonin antagonists like ondansetron, have demonstrated efficacy in relief of vomiting, decreased need for intravenous fluid therapy and hospitalizations, without serious adverse effects. SUMMARY The ability to arrest further vomiting and prevent intravenous fluid therapy and hospitalization aids children with vomiting so they may tolerate oral fluids and be discharged from medical care. This can reduce the medical care burdens and enhance patient satisfaction. This new pharmaceutical therapy may change how gastroenteritis is managed as it is studied further.
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Leung AK, Robson WLM. In children with vomiting related to acute gastroenteritis, are antiemetic medications an effective adjunct to fluid and electrolyte therapy?: Part B: Clinical commentary. Paediatr Child Health 2009; 13:393-4. [PMID: 19412370 DOI: 10.1093/pch/13.5.393] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Leung AK, Robson WLM. In children with vomiting related to acute gastroenteritis, are antiemetic medications an effective adjunct to fluid and electrolyte therapy?: Part A: Evidence-based answer and summary. Paediatr Child Health 2009; 13:391-4. [PMID: 19412369 DOI: 10.1093/pch/13.5.391] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2008] [Indexed: 11/14/2022] Open
Affiliation(s)
- Alexander Kc Leung
- Department of Pediatrics, University of Calgary, Alberta Children's Hospital
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Abstract
Acute gastroenteritis is a common reason for children to seek health care. Among the potential complications of acute gastroenteritis, the most common is dehydration. For mild to moderate dehydration, treatment options include oral and intravenous rehydration. Outpatient treatment failure for either method, when it occurs, is often due to persistent nausea and vomiting. Some authorities have suggested that the early administration of dextrose to patients receiving intravenous rehydration may help terminate vomiting and result in fewer outpatient treatment failures. The purpose of this report was to review the evidence supporting the effectiveness of early intravenous dextrose administration in the outpatient management of dehydration in children with acute gastroenteritis.
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Affiliation(s)
- Samuel R Reid
- Pediatric Emergency Medicine, Children's Hospitals and Clinics of Minnesota, St Paul, MN 55102, USA.
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Abstract
Emergency medicine research requires the enrollment of subjects with varying decision-making capacities, including capable adults, adults incapacitated by illness or injury, and children. These different categories of subjects are protected by multiple federal regulations. These include the federal Common Rule, the Department of Health and Human Services (DHHS) regulations for pediatric research, and the Food and Drug Administration's (FDA) Final Rule for the Exception from the Requirements of Informed Consent in Emergency Situations. Investigators should be familiar with the relevant federal research regulations to optimally protect vulnerable research subjects, and to facilitate the institutional review board (IRB) review process. IRB members face particular challenges in reviewing emergency research. No regulations exist for research enrolling incapacitated subjects using proxy consent. The wording of the Final Rule may not optimally protect vulnerable subjects. It is also difficult to apply conflicting regulations to a single study that enroll subjects with differing decision-making capacities. This article is intended as a guide for emergency researchers and IRB members who review emergency research. It reviews the elements of Federal Regulations that apply to consent, subject selection, privacy protection, and the analysis of risks and benefits in all emergency research. It explores the challenges for IRB review listed above, and offers potential solutions to these problems.
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Affiliation(s)
- Andrew McRae
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada.
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