Testicular function after chemotherapy for acute lymphoblastic leukemia

Balancing immunotherapy and corticosteroids in cancer treatment: dilemma or paradox?

Corticosteroids are widely used to prevent and treat chemotherapy-induced nausea and vomiting (CINV) due to their pleiotropic biological effects. However, concerns have been raised about their immunosuppressive properties when combined with immunotherapy. Specifically, their potential impact on the efficacy of immunotherapy, mainly immune checkpoint inhibitors (ICIs), remains a subject of debate. This manuscript discusses the mechanisms by which corticosteroids mitigate CINV, the challenges associated with their concurrent use with immunotherapy, and emerging therapeutic strategies evaluating dexamethasone-free regimens. A careful balance must be struck in corticosteroid use to effectively manage CINV while optimizing the outcomes of immunotherapy.

Differential Glucocorticoid-Dependent Regulation and Function of the ERRFI1 Gene in Triple-Negative Breast Cancer

Glucocorticoids (GCs; eg, hydrocortisone [CORT]) are routinely used as chemotherapeutic, anti-emetic, and palliative agents in breast cancer (BCa) therapy. The effects of GC signaling on BCa progression, however, remain a contentious topic as GC treatment seems to be beneficial for receptor-positive subtypes but elicits unfavorable responses in triple-negative BCa (TNBC). The mechanistic basis for these conflicting effects of GC in BCa is poorly understood. In this study, we sought to decipher the molecular mechanisms that govern the GC-dependent induction of the tumor suppressor ERRFI1 gene, an inhibitor of epidermal growth factor receptor (EGFR) signaling, and characterize the role of the GC-ERRFI1 regulatory axis in TNBC. Treatment of TNBC cell lines with a protein synthesis inhibitor or GC receptor (GR) antagonist followed by gene expression analysis suggests that ERRFI1 is a direct GR target. Using in silico analysis coupled with enhancer-reporter assays, we identified a putative ERRFI1 enhancer that supports CORT-dependent transactivation. In orthogonal assays for cell proliferation, survival, migration, and apoptosis, CORT mostly facilitated an oncogenic phenotype regardless of malignancy status. Lentiviral knockdown and overexpression of ERRFI1 showed that the CORT-enhanced oncogenic phenotype is restricted by ERRFI1 in the normal breast epithelial model MCF10A and to a lesser degree in the metastatic TNBC line MDA-MB-468. Conversely, ERRFI1 conferred pro-tumorigenic effects in the highly metastatic TNBC model MDA-MB-231. Taken together, our findings suggest that the progressive loss of the GC-dependent regulation and anti-tumorigenic function of ERRFI1 influences BCa progression and may contribute to the unfavorable effects of GC therapy in TNBC.

Therapeutic potential of medicinal plants indicated by the Brazilian public health system in treating the collateral effects induced by chemotherapy, radiotherapy, and chemoradiotherapy: A systematic review

OBJECTIVE

This study, through a systematic review, evaluated the therapeutic effect of medicinal plants that were of interest to the Unified Health System (SUS) in treating the side effects induced by chemotherapy, radiotherapy and chemoradiotherapy in cancer patients.

METHODOLOGY

According to the PRISMA guidelines, a systematic search was conducted in the PubMed, Lilacs and Scopus databases from January 2009 to December 2018, using the groups of descriptors (Cancer OR Neoplasia OR Tumor) and (controlled clinical trial OR randomized clinical trial) associated with the scientific names of the 71 medicinal plants described in RENISUS. The study is registered in PROSPERO CRD42019129927.

RESULTS

Of the 29 articles selected, only 17 demonstrated the therapeutic potential of plants included in RENISUS to prevent or treat the side effects induced by chemotherapy, radiotherapy or chemoradiotherapy, either solely or through an adjuvant effect from drugs already used in the medical clinic. The two plant-based therapies that had the most studies exploring their therapeutic potential on side effects were Zingiber officinale and Aloe vera.

CONCLUSION

This study showed that some plants listed in RENISUS have shown preventive and curative potential on side effects induced by conventional treatments in patients with different types of cancer. Therefore, the use of scientifically proven herbal products, in conjunction with conventional therapies, can contribute to a better quality of life in cancer patients undergoing conventional treatments.

Which Antiemetic?

The choice of antiemetic should not be arbitrary, but should be based on knowledge of the different pathways of the various stimuli that lead to nausea and vomiting and the neuroreceptors involved. The steps to be taken in choosing an appropriate antiemetic are described. They are (a) to establish the probable cause of the nausea and vomiting, (b) to consider the afferent pathways involved, (c) to define the neuroreceptors activated at each of these sites, (d) to select the group of antiemetics that antagonizes these neuroreceptors, and (e) to choose the most potent antiemetic with the fewest side effects in that group. Causes for failure to respond to a chosen antiemetic are considered and the action to be taken is described.

Microbial biotransformation of bioactive and clinically useful steroids and some salient features of steroids and biotransformation

Steroids are perhaps one of the most widely used group of drugs in present day. Beside the established utilization as immunosuppressive, anti-inflammatory, anti-rheumatic, progestational, diuretic, sedative, anabolic and contraceptive agents, recent applications of steroid compounds include the treatment of some forms of cancer, osteoporosis, HIV infections and treatment of declared AIDS. Steroids isolated are often available in minute amounts. So biotransformation of natural products provides a powerful means in solving supply problems in clinical trials and marketing of the drug for obtaining natural products in bulk amounts. If the structure is complex, it is often an impossible task to isolate enough of the natural products for clinical trials. The microbial biotransformation of steroids yielded several novel metabolites, exhibiting different activities. The metabolites produced from pregnenolone acetate by Cunning hamella elegans and Rhizopus stolonifer were screened against tyrosinase and cholinesterase showed significant inhibitory activities than the parent compound. Diosgenin and its transformed sarsasapogenin were screened for their acetyl cholinesterase and butyryl cholinesterase inhibitory activities. Sarsasapogenin was screened for phytotoxicity, and was found to be more active than the parent compound. Diosgenin, prednisone and their derivatives were screened for their anti-leishmanial activity. All derivatives were found to be more active than the parent compound. The biotransformation of steroids have been reviewed to a little extent. This review focuses on the biotransformation and functions of selected steroids, the classification, advantages and agents of enzymatic biotransformation and examines the potential role of new enzymatically transformed steroids and their derivatives in the chemoprevention and treatment of other diseases. tyrosinase and cholinesterase inhibitory activities, severe asthma, rheumatic disorders, renal disorders and diseases of inflammatory bowel, skin, gastrointestinal tract.

Stability of azasetron-dexamethasone mixture for chemotherapy-induced nausea and vomiting administration

Combination antiemetic therapy has become common practice for the prevention of nausea and vomiting caused by anticancer drugs. In this study, we investigated the stability of azasetron hydrochloride 0.1 mg/mL plus dexamethasone sodium phosphate 0.05, 0.1, or 0.2 mg/mL in 0.9% sodium chloride injection and stored in polyolefin bags and glass bottles over a period of 14 days at 4°C and 48 hours at 25°C. The stability studies were evaluated by visual inspection, pH measurement, and a high-pressure liquid chromatography assay of drug concentrations. During the study period, the concentration of each drug in the various solutions remained above 97% of the initial concentration at both 4°C and 25°C when protected from room light. Under the condition of 25°C with exposure to room light, the concentrations of both drugs were significantly lowered over 48 hours. The pH value decreased, and the color changed from colorless to pink. Our study demonstrates that the azasetron-dexamethasone mixture at a clinically relevant concentration seems to be stable for 48 hours at 25°C and for 14 days at 4°C when packaged in polyolefin bags or glass bottles and protected from room light. The room light is the main influential factor on stability. Clinicians should be aware that combinations of azasetron hydrochloride and dexamethasone sodium phosphate in solution with light exposure should be avoided.

Effects of preoperative dexamethasone on postoperative pain, nausea, vomiting and respiratory function in women undergoing conservative breast surgery for cancer: Results of a controlled clinical trial

The objective was to evaluate whether preoperative administration of dexamethasone improved postoperative nausea and vomiting (PONV), pain and respiratory function tests in women undergoing conservative surgery for breast cancer. This was a controlled clinical trial conducted between June 2013 and October 2014. Eighty patients were evaluated. Patients received a preoperative dose of 8 mg of dexamethasone (n = 40) or placebo (n = 40). The data on PONV and pain intensity was obtained and forced spirometry tests were performed, 1 hr before and at 1, 6, 12 and 24 hr after surgery. Any use of additional analgesic/antiemetic drugs was recorded. Patients were followed until 30 days after surgery for any surgical or medical complications. The pain intensity was lower in the treatment group for all periods; PONV was lower at 6, 12 and 24 hr; Additional analgesics/antiemetics were required less frequently (all p < .05). Both groups exhibited a restrictive ventilatory pattern immediately after surgery, which was reversed in the following hours. However, spirometric values were higher in the dexamethasone group. There were no pulmonary or metabolic complications after surgery. Our conclusions were that dexamethasone significantly reduced the incidences of PONV, pain and improved respiratory parameters, and reduced the need for additional postoperative analgesic and antiemetic drugs.

Original article. Efficacy of intravenous dexamethasone for the prevention of vomiting associated with intrathecal chemotherapy and ketamine sedation in children: a randomized, double-blinded, crossover, placebocontrolled trial

Background: Chemotherapy-induced nausea and vomiting remains a significant problem for children with leukemia. There is limited evidence to support using prophylactic antiemetic prior to the administration of intrathecal chemotherapy.

Objective: Determine whether vomiting and nausea associated with intravenous ketamine and intrathecal chemotherapy may be reduced by the addition of prophylactic dexamethasone in children.

Method:A randomized, double-blinded, crossover, placebo-controlled trial was completed in 33 children receiving intrathecal chemotherapy with methotrexate and ketamine sedation at Pharmongkutklao Hospital. Patients were randomly assigned in a double-blinded fashion to receive one of two interventions during the first period, either an infusion of normal saline or intravenous dexamethasone at 0.25 mg/kg/dose. Each patient acted as his or her own control, and each patient was studied at two time-points.

Results: Period effect, sequence effect, and carry over effect were not demonstrated. The absolute risk reduction of vomiting was significantly greater after infusion of dexamethasone than after placebo at 33.3 % (p=0.02). The number needed to treat was three to prevent one episode of vomiting. Fifteen patients in the treatment group reported nausea versus 26 patients in the placebo group (p= 0.007). In the group of patients treated with dexamethasone, five required antiemetic vs. 16 of those receiving placebo (p=0.02). There was no complication from dexamethasone.

Conclusion: Intravenous dexamethasone reduced vomiting associated with intrathecal chemotherapy and ketamine sedation, without significant side-effects. It may be recommended a reasonable option before intrathecal chemotherapy

Dexamethasone reduces nausea and vomiting but not pain after thyroid surgery: a meta-analysis of randomized controlled trials

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common complication after thyroidectomy. The aim of this article was to evaluate the efficacy of dexamethasone for prevention of PONV and pain in patients undergoing thyroidectomy.

MATERIAL AND METHODS

We performed this meta-analysis based on the QUORUM (Quality of Reporting of Meta-analyses) guidelines. Our study included randomized controlled trials (RCTs) that compared preoperative single-dose administration of dexamethasone with no dexamethasone in patients undergoing thyroidectomy. The primary outcome was occurrence and severity of PONV, and the secondary outcomes included pain, use of analgesics, and steroid-related complications.

RESULTS

Seven RCTs were included, with a total of 611 patients. A statistically and clinically significant difference in the incidence and severity of PONV was found in favor of dexamethasone (SMD, 0.23; 95% CI, 0.13-0.41; P<0.00001; SMD, 0.53; 95% CI, -1.03 to -0.03; P=0.04). However, there was no significant difference in reduction of pain severity and analgesic consumption in using dexamethasone (SMD, -0.83; 95% CI, -1.85 to 0.18; P=0.14; SMD, -0.19; 95% CI, -0.43 to 0.04; P=0.10). No steroid-related complications were noted.

CONCLUSIONS

A single preoperative administration of dexamethasone reduced the incidence and severity of PONV but not pain severity and analgesic consumption in patients undergoing thyroidectomy. Further studies with a larger sample size are needed to further explore the efficacy of dexamethasone on postoperative pain severity and analgesic consumption.

Efficacy of prophylactic dexamethasone in prevention of postoperative nausea and vomiting

Objective: Many trials have been conducted with regard to the relative benefits of prophylactic anti-emetic interventions given alone or in combination, yet the results remain unknown. This study reviewed the efficacy of a single prophylactic dose of dexamethasone on postoperative nausea or vomiting (PONV) after abdominal hysterectomy.

Methods: In a prospective study of 100 women undergoing total abdominal hysterectomy (TAH) under general anesthesia, the dexamethasone group (n = 50) received a single dose (8 mg) immediately after the operation, and the saline group (n = 50) received a dose of saline as a placebo, in addition to conventional management. The incidence of nausea, vomiting, the need for an anti-emetic and patient satisfaction with the management of PONV were evaluated during the first 24 postoperative hours.

Results: The overall frequency of nausea during the initial postoperative 24 in the dexamethasone and saline groups were 12% and 18%, respectively, and vomiting was 10% and 16%, respectively (P = 0.001). However, there was a lower need for a rescue anti-emetic drugs in the dexamethasone group (18% vs 24%), but it was not statistically significant (P = 0.06).

Conclusion: The results of this study indicate that a single prophylactic dose of dexamethasone after an operation can reduce postoperative nausea and vomiting.

Effect of Prophylactic Ondansetron on Postoperative Nausea and Vomiting in Patients on Preoperative Steroids Undergoing Craniotomy for Supratentorial Tumors

The exact incidence of postoperative nausea and vomiting (PONV) in patients on steroids undergoing neurosurgical procedures is not known. This prospective randomized double-blind study was planned to know the efficacy of prophylactic ondansetron in the prevention of PONV in patients on steroids as compared with placebo. Seventy adult patients of either sex who had received preoperative steroids (dexamethasone) for at least 24 hours and were scheduled to undergo craniotomy for supratentorial tumors were included. Patients were randomly allocated using a randomization chart to 1 of the 2 groups to receive either ondansetron 4 mg (group O) or 0.9% saline (group S) intravenously at the time of dural closure. Numeric Rating Scale score for nausea and pain intensity was recorded preoperatively and till 24 hours postoperatively. The 6-hour postoperative nausea score was significantly lower in group O [median, 0; interquartile range (IQR), 0 to 20] than in group S (median, 20; IQR, 0 to 20) (P<0.05). The incidence of vomiting was lower in group O (23%) than in group S (46%) (P<0.05). The total number of emetic episodes, the number of doses of rescue antiemetics given in the first 6 postoperative hours, and the total number of rescue antiemetics given were significantly lower in group O than in group S (P<0.05). Intravenous administration of 4 mg of ondansetron at the time of dural closure was effective in reducing the incidence of PONV and the rescue antiemetics requirement in patients on preoperative steroids undergoing craniotomy for supratentorial tumors.

RETRACTED: Dexamethasone for reduction of nausea, vomiting and analgesic use after gynecological laparoscopic surgery

OBJECTIVE

To evaluate the prophylactic use of dexamethasone for reducing postoperative nausea and vomiting (PONV) and analgesic use after gynecological laparoscopic surgery.

METHODS

In a prospective randomized, double-blind, placebo-controlled trial, 90 women received either intravenous placebo, 4 mg dexamethasone or 8 mg dexamethasone at the end of surgery. PONV and analgesic requirements were evaluated.

RESULTS

The rate of patients experiencing PONV within 24 h after anesthesia was 53% in the 4 mg dexamethasone group (P=0.3) and 20% in the 8 mg dexamethasone group (P=0.001), compared with the placebo group (63%). Requests for indomethacin to relieve intolerable pain were less in patients in the 8 mg dexamethasone group compared with the 4 mg dexamethasone (P=0.047) or placebo (P=0.029) groups.

CONCLUSION

Prophylactic use of 8 mg dexamethasone is effective for reducing PONV and analgesic requirements after gynecological laparoscopic surgery.

The effect of dexamethasone on postoperative vomiting and oral intake after adenotonsillectomy

OBJECTIVE

Vomiting is one of the most important postoperative complications of adenotonsillectomy. This study was designed to determine the effectiveness of preoperative intravenous dexamethasone on postoperative emesis.

METHODS

In a double-blind, placebo-controlled clinical trial, 100 patients aged 5-15 years, ASA classes I and II were randomly selected to receive either 0.5 mg/kg IV dexamethasone (n=50), as study group or an equivalent volume of saline preoperatively, as control group. The anesthetic regimen and surgical procedures were standardized for all patients. The incidence of early and late vomiting, the time to first oral intake and duration of intravenous hydration were compared in both groups.

RESULTS

Data analysis showed that the overall incidence of early and late vomiting was significantly lesser in dexamehasone group than the control one. The time to first oral intake and duration of IV therapy were also significantly shorter in dexamethasone group.

CONCLUSION

A single dose of dexamethasone significantly decreased the incidence of postoperative vomiting in early and late recovery phase and shortened the time to first oral intake and the duration of IV therapy.

Comparative activity of antiemetic drugs

Nausea and vomiting continues to be an important problem for cancer patients receiving chemotherapy. Chemotherapy-induced nausea and vomiting (CINV) are classified as acute, occurring within the first 24h, or delayed, occurring after the first 24h. A number of antiemetic agents are available for the management of nausea and vomiting, including 5-HT3-receptor-antagonists, corticosteroids, NK-1-receptor-antagonists, dopamine-receptor antagonists, benzodiazepines, neuroleptics and cannabinoids. With modern antiemetic therapy, vomiting can be prevented in 70-80% of patients, whereas the control of nausea remains suboptimal. The development of acute emesis is known to depend on serotonin. The pathophysiology of delayed emesis is less well understood, and multiple mechanisms may contribute, including substance P. Here, the most recent developments in the antiemetic therapy, including new antiemetic drugs and the latest guidelines for antiemetic prophylaxis, are reviewed.

Randomized clinical trial of the effect of preoperative dexamethasone on nausea and vomiting after laparoscopic cholecystectomy

Background

Preoperative dexamethasone may reduce disabling symptoms such as pain, nausea and vomiting after laparoscopic cholecystectomy.

Methods

This was a randomized, double-blind, placebo-controlled trial. Between March and December 2004, 101 patients undergoing laparoscopic cholecystectomy were randomized to receive 8 mg dexamethasone (n = 49) or placebo (n = 52) intravenously before surgery. Six patients were excluded from the study. All patients received a standardized anaesthetic, surgical and multimodal analgesic treatment. The primary endpoints were: first, postoperative nausea, vomiting and pain; second, postoperative analgesic and antiemetic requirements. The pain scores (visual analogue and verbal response scales), the episodes of nausea (verbal response scale) and vomiting were recorded at 1, 3, 6 and 24 h, respectively, after the operation. Analgesic and antiemetic requirements were also recorded.

Results

No apparent drug side-effects were noted. Seven patients (14 per cent) in the treatment group reported nausea and vomiting compared with 24 (46 per cent) in the control group (P = 0·001). In the group of patients treated with dexamethasone, five (10 per cent) required antiemetics versus 23 (44 per cent) of those receiving placebo (P &lt; 0·001). No difference in postoperative pain scores and analgesic requirements was detected between groups.

Conclusion

Preoperative dexamethasone reduces postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy, with no side-effects, and may be recommended for routine use.

The effect of preoperative dexamethasone on early oral intake, vomiting and pain after tonsillectomy

OBJECTIVE

Postoperative morbidity in patients undergoing tonsillectomy with or without adenoidectomy includes inadequate oral intake, pain, nausea, vomiting and bleeding. The purpose of this study is to evaluate the effect of preoperative 0.5 mg/kg i.v. dexamethasone on postoperative early oral intake, pain, vomiting in patients undergoing adenotonsillectomy while performing standard anesthesia technique and sharp dissection tonsillectomy.

METHODS

In this prospective, double-blinded, placebo-controlled study 62 children, aged 4-12 years, who underwent tonsillectomy with or without adenoidectomy were randomly assigned to receive single dose of 0.5 mg/kg i.v. dexamethasone preoperatively. Patients started to receive 100 ml of clear fluids 2 h postoperatively, then were offered every hour. When pain score was 3 or above, paracetamol was given for pain control. Tolerating 400 ml of clear fluids, no bleeding and no vomiting were accepted as discharge criteria. The discharge time was also recorded. The incidence of early vomiting, pain scores, amount of oral intake were recorded until the discharge time.

RESULTS

Compared with placebo, the patients who received preoperative dexamethasone had significantly less pain score during the first 6 h postoperatively (p<0.05), adequate amount of oral intake time was shorter (p<0.05) and the discharge time was earlier (p<0.05). No difference was found in vomiting incidence in both groups.

CONCLUSION

Preoperative dexamethasone use significantly reduces early posttonsillectomy pain, improves oral intake and facilitates meeting the discharge criteria while using standard anesthesia technique and sharp dissection tonsillectomy without any significant side effects.

RETRACTED: Reduction of postoperative emetic episodes and analgesic requirements with dexamethasone in patients scheduled for dental surgery

STUDY OBJECTIVE

To evaluate the antiemetic and analgesic effects of dexamethasone for the first 24 hours postoperatively in patients scheduled for dental surgery.

DESIGN

Prospective, randomized, double-blind, placebo-controlled study.

SETTING

University hospital.

PATIENTS

One hundred twenty ASA physical status I and II patients (45 men, 75 women; aged 17-48 years) undergoing general anesthesia for dental surgery.

INTERVENTIONS

Patients received intravenously placebo or dexamethasone at 3 different doses (4, 8, or 16 mg) at the end of the surgical procedure. A standard general anesthetic technique, including sevoflurane and nitrous oxide in oxygen, was used.

MEASUREMENT AND MAIN RESULTS

Emetic episodes and analgesic requirements were evaluated. The rate of patients who were emesis free (no nausea, retching, or vomiting) during 0 to 24 hours after anesthesia was 63% with dexamethasone 4 mg (P = NS), 83% with dexamethasone 8 mg (P < .05), and 90% with dexamethasone 16 mg (P < .05), compared to placebo (60%). The need for diclofenac sodium for intolerable pain was less in patients who had received dexamethasone 8 mg or dexamethasone 16 mg than in those who had received placebo or dexamethasone 4 mg (P < .05). No clinically important adverse events were observed in any group.

CONCLUSIONS

Prophylactic dexamethasone 8 mg is effective for the prevention of nausea and vomiting after dental surgery and in the management of postoperative pain. Increasing the dose to 16 mg provides no further benefit.

RETRACTED: Randomized, double-blind comparison of subhypnotic-dose propofol alone and combined with dexamethasone for emesis in parturients undergoing cesarean delivery

BACKGROUND

Nausea, retching, and vomiting are common in parturients undergoing cesarean delivery performed under regional anesthesia. Subhypnotic-dose propofol 1.0 mg/kg per hour has been used to reduce the incidence of these emetic symptoms. Dexamethasone has been shown to reduce chemotherapy-induced emesis when added to an antiemetic regimen.

OBJECTIVE

The aim of this study was to examine the difference in efficacy and tolerability between subhypnoticdose propofol 1.0 mg/kg per hour alone and combined with dexamethasone 8 mg for reducing postdelivery emetic episodes in parturients undergoing cesarean delivery.

METHODS

In a randomized, double-blind trial, parturients received IV placebo (saline) or dexamethasone 8 mg followed by a continuous infusion of propofol at subhypnotic dose (1.0 mg/kg per hour) immediately after clamping of the umbilical cord. Intraoperative, postdelivery emetic episodes and safety assessments were performed by an investigator.

RESULTS

One hundred twenty parturients (mean [SD] age, 29 [5] years; age range, 21-38 years; mean [SD] height, 158 [7] cm; height range, 145-172 cm; mean [SD] body weight, 72 [8] kg; weight range, 54-90 kg) were enrolled in the study, 60 in each treatment group. The treatment groups were comparable with respect to maternal demographics and operative management. The rate of emetic symptoms (nausea, retching, and vomiting) in an intraoperative, postdelivery period was lower in patients who received the combination regimen than in those who received subhypnotic-dose propofol 1.0 mg/kg per hour alone (5% [3/60] vs 20% [12/60], respectively; P = 0.012). No clinically important adverse events attributable to the study drug were observed in either group.

CONCLUSION

In the parturients undergoing cesarean delivery performed under spinal anesthesia in this study, the combination of subhypnotic-dose propofol 1.0 mg/kg per hour and dexamethasone 8 mg was more effective than propofol alone for reducing the incidence of postdelivery emetic symptoms.

Comparison of Prophylactic Anti-Emetic Effects of Ondansetron and Dexamethasone in Women Undergoing Day-Case Gynaecological Laparoscopic Surgery

We aimed to determine the effect of ondansetron and dexamethasone on preventing post-operative nausea and vomiting (PONV). Sixty women undergoing laparoscopic gynaecological surgery were randomized to receive ondansetron 4 mg, dexamethasone 8 mg or saline. Drugs were administered 2 min before induction of anaesthesia, and anaesthesia and post-operative analgesic regimens were standardized. The incidence of PONV in the first 24 h after the operation was 35% in the ondansetron group, 55% in dexamethasone group and 85% in the control group. A significant difference between the groups was only seen in the first 3 h post-operatively. In this period, ondansetron was significantly more effective than dexamethasone and saline, but no differences were seen between dexamethasone and saline. In all treatment groups, post-operative visual analogue scale scores, sedation scores and usage of analgesics were similar. In conclusion, ondansetron, but not dexamethasone, prevented PONV in the first 3 h after gynaecological laparoscopic surgery.

A randomized, double-blind comparison of granisetron alone and combined with dexamethasone for post-laparoscopic cholecystectomy emetic symptoms

BACKGROUND

Granisetron hydrochloride, a selective serotonin receptor antagonist, has been used to treat established postoperative nausea and vomiting (PONV). Dexamethasone has been shown to reduce the incidence of chemotherapy-induced emesis when added to an antiemetic regimen.

OBJECTIVE

The aim of this study was to examine the differences in efficacy and tolerability between the combination of granisetron plus dexamethasone and granisetron alone for the treatment of PONV.

METHODS

This study was a randomized, double-blind trial conducted at Toride Kyodo General Hospital (Toride, Ibaraki, Japan). Men and women aged 25 to 65 years and experiencing emetic symptoms after laparoscopic cholecystectomy were eligible for the study. Patients received IV therapy with either granisetron 40 μg/kg alone or with dexamethasone 8 mg. Patients were observed for 24 hours. Emetic episodes and the need for a rescue antiemetic were recorded by nursing staff, who were blinded to treatment assignment.

RESULTS

One hundred patients (63 women, 37 men; mean [SD] age, 47 [10] years; range, 25-65 years) were enrolled; 50 patients were randomized to each treatment group. No significant differences in baseline demographic or clinical characteristics were observed between the groups. Complete control of established PONV, defined as no emetic symptoms and no need for another rescue antiemetic medication, occurred in significantly more patients who received the combination (49/50 [98%]) than in those who received granisetron alone (41/50 [82%]) (P = 0.008). No clinically important adverse effects due to the study drugs were observed in either group.

CONCLUSION

In this study population of patients experiencing post-cholecystectomy emesis, the combination of granisetron plus dexamethasone was more efficacious than granisetron alone for the treatment of PONV. Tolerability between the 2 treatments was similar.

Low-dose dexamethasone reduces nausea and vomiting after tympanomastoid surgery: a comparison of tropisetron with saline

PURPOSE

The aim of the study was to evaluate the efficacy of low-dose dexamethasone sodium phosphate (5 mg) on the prophylaxis of nausea and vomiting after tympanomastoid surgery. Tropisetron hydrochloride (2 mg) and saline were used as controls.

MATERIALS AND METHODS

One hundred twenty patients (n = 40 in each of 3 groups) undergoing general anesthesia for tympanomastoid surgery were enrolled in this randomized, double-blind, placebo-controlled study. Following endotracheal intubation, group 1 received intravenous dexamethasone 5 mg, whereas groups 2 and 3 received intravenous 2 mg tropisetron and saline, respectively. Several parameters connected with the occurrence of postoperative nausea and vomiting were evaluated.

RESULTS

Dexamethasone 5 mg significantly reduced the total incidence of nausea and vomiting by 40% (P =.002). Dexamethasone also reduced the incidence of vomiting episodes by more than 4-fold (P =.03) and the incidence of patients requiring rescue antiemetics (P =.02). Tropisetron at a 2-mg dose did not exhibit any significant antiemetic effect.

CONCLUSIONS

Dexamethasone sodium phosphate 5 mg was more effective than 2 mg tropisetron hydrochloride and saline in the prevention of nausea and vomiting after tympanomastoid surgery.

Small-dose dexamethasone reduces nausea and vomiting after laparoscopic cholecystectomy: a comparison of tropisetron with saline

Dexamethasone is an effective antiemetic drug, but the efficacy of small-dose dexamethasone 5 mg on the prophylaxis of postoperative nausea and vomiting (PONV) in patients undergoing laparoscopic cholecystectomy has not been evaluated. We, therefore, evaluated the prophylactic effect of small-dose dexamethasone (5 mg) on PONV in patients undergoing laparoscopic cholecystectomy. Tropisetron and saline served as controls. One-hundred-twenty patients scheduled for laparoscopic cholecystectomy were enrolled in a randomized, double-blinded, placebo-controlled study. At the induction of anesthesia, the Dexamethasone group received IV dexamethasone 5 mg, the Tropisetron group received IV tropisetron 2 mg, and the Placebo group received IV saline. We found that both dexamethasone and tropisetron significantly decreased the following variables: the total incidence of PONV (P < 0.01), more than four vomiting episodes (P < 0.05), and the proportions of patients requiring rescue antiemetics (P < 0.05). The differences between the Dexamethasone and Tropisetron groups were not significant. We conclude that prophylactic IV dexamethasone 5 mg significantly reduces the incidence of PONV in patients undergoing laparoscopic cholecystectomy. At this dose, dexamethasone is as effective as tropisetron 2 mg and is more effective than placebo.

IMPLICATIONS

We evaluated the prophylactic effect of small-dose dexamethasone (5 mg) on postoperative nausea and vomiting (PONV) in patients undergoing laparoscopic cholecystectomy. Tropisetron (2 mg) and saline served as controls. We found that dexamethasone 5 mg (IV) significantly reduced the incidence of PONV in these patients, and, at this dose, dexamethasone was as effective as tropisetron and was more effective than placebo.

The effect of dexamethasone upon patient-controlled analgesia-related nausea and vomiting

Ninety female patients were enrolled in this randomised, double-blind, placebo-controlled study to compare the anti-emetic effect of intravenous dexamethasone 8 mg with saline control in preventing patient-controlled analgesia-related nausea and vomiting following major orthopaedic surgery. The prophylactic administration of dexamethasone 8 mg significantly reduced the overall incidence of patient-controlled analgesia-related nausea and vomiting (p<0.001) and the need for rescue anti-emetics (p<0.01). Furthermore, patients who received dexamethasone showed a higher incidence of complete responses (no vomiting or need for rescue anti-emetic for a 24-h postoperative period) than those who received saline (p<0.05). We conclude that dexamethasone 8 mg may be valuable for preventing patient-controlled analgesia-related nausea and vomiting in women undergoing major orthopaedic surgery.

The effect of dexamethasone on postoperative pain and emesis after intrathecal neostigmine

We evaluated the effect of a single dose of dexamethasone on the incidence and severity of postoperative nausea and vomiting (PONV) after intrathecal injection of tetracaine plus neostigmine. Sixty ASA physical status I patients scheduled for inguinal herniorrhaphy were studied with a randomized, double-blinded, placebo-controlled protocol. The dexamethasone group (Group D) received 10 mg of dexamethasone IV before performance of spinal anesthesia, whereas the placebo group (Group P) received saline. Spinal anesthesia was performed with intrathecal injection of 15 mg tetracaine plus neostigmine 100 microg in both groups. Pain, PONV, and other side effects were evaluated 24 h after surgery. The duration and severity of analgesia and the incidence of PONV were not significantly different between the two groups. Our results demonstrate that a single dose of dexamethasone (10 mg) did not potentiate the analgesic effect or reduce the incidence of PONV after intrathecal injection of tetracaine and neostigmine.

IMPLICATIONS

The results of our evaluation of the effect of IV dexamethasone versus saline control on analgesia and nausea and vomiting after intrathecal neostigmine and tetracaine suggest that IV dexamethasone did not enhance the analgesic effect of neostigmine or reduce the incidence of emesis after intrathecal administration.

Nausea and vomiting in patients with cancer

Nausea and vomiting in advanced cancer, occurring as a manifestation of the disease process or as a complication of drugs used for symptom control, can be controlled rapidly in most instances using the protocol described. This involves an informed appraisal of the cause or causes of nausea and vomiting, combined with application of knowledge of the mechanisms of emesis and the action of antiemetics. Different mechanisms appear to responsible for emesis after chemotherapy and irradiation and for anticipatory vomiting. Ondansetron combined with dexamethasone appears to be the most effective regimen for post-cisplatin emesis. For less emetogenic agents, dexamethasone alone, or in combination with ondansetron for refractory cases, gives good control. For the control of vomiting induced by single-fraction radiotherapy to the upper abdomen, ondansetron is very effective. Management of anticipatory vomiting should concentrate on prevention, but once vomiting is established, behavioral therapy and the amnesic properties of lorazepam may be used.

Insulin syringes: dangers of dead space

To assess the accuracy and reproducibility of various U100 insulin syringes in the hands of diabetics, we devised a method to measure individual insulins injected from the syringe. We found alarming inaccuracies with dead-space-containing syringes when two insulins were mixed in the syringe before injection; these errors exceeded 100% with low doses. Reproducibility of dose was also poor with dead-space syringes. Syringes with minimal dead space overcome these problems and we recommend that all diabetics who mix insulins should use these syringes.