Intravenous dolasetron for the prevention of postoperative nausea and vomiting after outpatient laparoscopic gynecologic surgery

The effectiveness of ramosetron and ondansetron for preventing postoperative nausea and vomiting after arthroscopic rotator cuff repair: a randomized controlled trial

Background

Arthroscopic rotator cuff repair is a painful procedure, and treatment of emetic events associated with drugs used in the current multimodal pain management remains challenging. This study aimed to evaluate the effectiveness of ramosetron or ondansetron to relieve postoperative nausea and vomiting (PONV) and pain after arthroscopic rotator cuff repair.

Methods

In total, 122 consecutive patients undergoing arthroscopic rotator cuff repair were randomly allocated into three groups: ramosetron group (n = 39), ondansetron group (n = 43), and control group (n = 40). Then, 0.3 mg of ramosetron or 8 mg of ondansetron was administered intravenously at the end of surgery according to group. All patients received general anesthesia and multimodal pain management protocol including preemptive analgesic medication, fentanyl-based intravenous patient-controlled analgesia, and postoperative analgesic medication. Incidence of emetic events, rescue antiemetic requirements (10 mg of metoclopramide, IV), complete response, pain level, and side effects were recorded in three periods: 0–6, 6–24, and 24–48 h postoperatively. The severity of nausea and pain was evaluated using a visual analog scale.

Results

The ramosetron group tended to have a lower incidence and severity of nausea during the 6- to 24-h postoperative period and fewer rescue antiemetic drug requirements during the 0- to 48-h period than the control group, showing statistical significance. Additionally, the frequency of complete response of the ramosetron and ondansetron groups was significantly higher than that of the control group. No difference was found among the groups in the pain level except during the 0- to 6-h period. The two groups have a higher complete response during the 6- to 24-h period than the control group.

Conclusions

Ramosetron use led to a lower incidence, mild severity of nausea, and reduced use of rescue antiemetic drug after arthroscopic rotator cuff repair during the 6- to 24-h postoperative period than the control.

Level of evidence

Level I, randomized controlled trials, treatment study

Comparison of palonosetron, granisetron, and ramosetron for the prevention of postoperative nausea and vomiting after laparoscopic gynecologic surgery: a prospective randomized trial

BACKGROUND

Selective 5-hydroxytryptamine type 3 (5-HT3) receptor antagonists are reported to have potent antiemetic effects for postoperative nausea and vomiting (PONV). The purpose of this study was to prospectively evaluate the efficacy of palonosetron, granisetron, and ramosetron for the prevention of PONV in patients undergoing laparoscopic gynecologic surgery.

METHODS

In this prospective, randomized observational study, 105 healthy female patients who were undergoing laparocopic hystectomy under general anaesthesia were enrolled (clinical trial number: NCT01752374, www.clinicaltrials.gov ). Patients were divided into three groups: the palonostron (0.075 mg i.v.; n = 35), the granisetron group (3 mg i.v.; n = 35), and the ramosetron group (0.3 mg i.v.; n = 35). The treatments were given before the end of surgery. The incidence of PONV, severity of nausea/vomiting, and the use of rescue antiemetic requirements during the first 48 h after surgery were evaluated.

RESULTS

The overall incidence of PONV was 33.3 % for this series. The number of complete responders at 48 h after the surgery was 21 (60.0 %) for palonosetron, 24 (68.6 %) for granisetron, and 26 (71.4 %) for ramosetron, representing no statistical difference (P = 0.086).

CONCLUSIONS

There were no significant differences in the overall incidence of postoperative nausea and vomiting and complete responders for palonosetron, granisetron and ramosetron group.

TRIAL REGISTRATION

CLINICAL TRIAL NUMBER

NCT01752374 , www.clinicaltrials.gov .

Comparative safety of serotonin (5-HT3) receptor antagonists in patients undergoing surgery: a systematic review and network meta-analysis

BACKGROUND

Serotonin (5-HT3) receptor antagonists are commonly used to decrease nausea and vomiting for surgery patients, but these agents may be harmful. We conducted a systematic review on the comparative safety of 5-HT3 receptor antagonists.

METHODS

Searches were done in MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials to identify studies comparing 5-HT3 receptor antagonists with each other, placebo, and/or other antiemetic agents for patients undergoing surgical procedures. Screening search results, data abstraction, and risk of bias assessment were conducted by two reviewers independently. Random-effects pairwise meta-analysis and network meta-analysis (NMA) were conducted. PROSPERO registry number: CRD42013003564.

RESULTS

Overall, 120 studies and 27,787 patients were included after screening of 7,608 citations and 1,014 full-text articles. Significantly more patients receiving granisetron plus dexamethasone experienced an arrhythmia relative to placebo (odds ratio (OR) 2.96, 95 % confidence interval (CI) 1.11-7.94), ondansetron (OR 3.23, 95 % CI 1.17-8.95), dolasetron (OR 4.37, 95 % CI 1.51-12.62), tropisetron (OR 3.27, 95 % CI 1.02-10.43), and ondansetron plus dexamethasone (OR 5.75, 95 % CI 1.71-19.34) in a NMA including 31 randomized clinical trials (RCTs) and 6,623 patients of all ages. No statistically significant differences in delirium frequency were observed across all treatment comparisons in a NMA including 18 RCTs and 3,652 patients.

CONCLUSION

Granisetron plus dexamethasone increases the risk of arrhythmia.

Does ramosetron reduce postoperative emesis and pain after TKA?

BACKGROUND

Current pain management protocols involving many anesthetic and analgesic drugs reportedly provide adequate analgesia after TKA. However, control of emetic events associated with the drugs used in current multimodal pain management remains challenging.

QUESTIONS/PURPOSES

We determined (1) whether ramosetron prophylaxis reduces postoperative emetic events; and (2) whether it influences pain levels and opioid consumption in patients managed with a current multimodal pain management protocol after TKA.

METHODS

We randomized 119 patients undergoing TKA to receive either ramosetron (experimental group, n = 60) or no prophylaxis (control group, n = 59). All patients received regional anesthesia, preemptive analgesic medication, continuous femoral nerve block, periarticular injection, and fentanyl-based intravenous patient-controlled analgesia. We recorded the incidence of emetic events, rescue antiemetic requirements, complete response, pain level, and opioid consumption during three periods (0-6, 6-24, and 24-48 hours postoperatively). The severity of nausea was evaluated using a 0 to 10 VAS.

RESULTS

The ramosetron group tended to have a lower incidence of nausea with a higher complete response and tended to have less severe nausea and fewer rescue antiemetic requirements during the 6- to 24-hour period. However, the overall incidences of emetic events, rescue antiemetic requirements, and complete response were similar in both groups. We found no differences in pain level or opioid consumption between the two groups.

CONCLUSIONS

Ramosetron reduced postoperative emetic events only during the 6- to 24-hour postoperative period and did not affect pain relief. More efficient measures to reduce emetic events after TKA should be explored.

LEVEL OF EVIDENCE

Level I, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Selective serotonin 5-HT3 receptor antagonists for postoperative nausea and vomiting: are they all the same?

Selective serotonin 5-HT(3) receptor antagonists have proven safe and effective for the management of postoperative nausea and vomiting. Dolasetron, granisetron, ondansetron and tropisetron selectively and competitively bind to 5-HT(3) receptors, blocking serotonin binding at vagal afferents in the gut and in the regions of the CNS involved in emesis, including the chemoreceptor trigger zone and the nucleus tractus solitarii. Despite their shared mechanism of action, 5-HT(3) receptor antagonists have different chemical structures and exhibit differences in receptor binding affinity, dose response and duration of effect. Furthermore, although dolasetron, granisetron, ondansetron and tropisetron are all extensively metabolised by the cytochrome P450 (CYP) system, different components of this system predominate in the metabolism of each of these agents. Hence, although these agents are considered equally effective in the overall population, their pharmacokinetic and pharmacodynamic differences may explain the variability in individual responses to these drugs. This review discusses the pharmacological profiles of dolasetron, granisetron, ondansetron and tropisetron, and the clinical implications of differences in their profiles.

Benefits and risks of newer treatments for chemotherapy-induced and postoperative nausea and vomiting

Nausea and vomiting are common adverse effects of chemotherapy, radiation therapy, anaesthesia and surgery. The incidence of chemotherapy-induced nausea and vomiting (CINV) is estimated to vary from 30 to 90%, depending on the type of chemotherapeutic agent used. Radiation-induced emesis varies with anatomical site radiated but is estimated to have an overall incidence of approximately 40%. The incidence of postoperative nausea and vomiting (PONV) depends on the type of anaesthesia and surgery, but overall is estimated to be 20-30%. Evidence-based medicine and meta-analysis have been used to direct medical therapy to help determine equivalence, optimal dose, timing, safety and efficacy of antiemetic medications. Concepts such as the number needed to treat and number needed to harm are helpful to guide the clinician regarding the benefits and risks of a particular treatment. The serotonin 5-HT(3) receptor antagonists ondansetron, granisetron, tropisetron and dolasetron have been important additions to the antiemetic armamentarium. The 5-HT(3) receptor antagonists are similar in chemical structure, efficacy and adverse effect profile. They appear to have no important differences among themselves in clinical outcomes for CINV and PONV. Headache, dizziness, constipation and diarrhoea are their most common adverse effects, and when they occur they are usually mild and easily managed. Haemodynamic changes and extrapyramidal adverse effects are uncommon. ECG changes such as prolonged corrected QT (QTc) interval are infrequent, dose-related and overall judged to be clinically insignificant. As most studies with the 5-HT(3) antagonists have been conducted on relatively healthy patients, caution should be exercised when these drugs are used in susceptible patients with co-morbidities. The clinician must weigh the benefit of administering an antiemetic for CINV or PONV against the risk of occurrence of an adverse event.

Impact of antiemetic selection on postoperative nausea and vomiting and patient satisfaction

STUDY OBJECTIVE

To determine the impact of antiemetic selection on postoperative nausea and vomiting (PONV) and patient satisfaction after ambulatory surgery.

DESIGN

Prospective, observational study.

SETTING

Ambulatory surgery center in an academic medical center.

PATIENTS

Five hundred fifty-four consecutive patients undergoing ambulatory surgical procedures of any kind.

INTERVENTION

Data on antiemetic utilization, occurrence of PONV, and patient satisfaction were collected perioperatively. Multiple regression analyses for antiemetic choice were performed.

MEASUREMENTS AND MAIN RESULTS

Prophylactic antiemetic therapy was administered to 292 (52.7%) patients, most often with droperidol (200 patients), metoclopramide (134), or dexamethasone (55). Forty-one (7.4%) patients had an episode of emesis in the postanesthesia care unit. Choice of antiemetic was not a significant predictor of PONV. Patient satisfaction for all patients was 9.5 on a 10-point scale, with no agent more or less successful than any other.

CONCLUSION

As choice of antiemetic drug given for prophylaxis had little impact on clinical outcome or patient satisfaction, traditional agents should form the core of antiemetics used for PONV prophylaxis in ambulatory surgery patients.

Antiemetics for obstetric and gynecological procedures

Nausea and vomiting is a troublesome side-effect that occurs more frequently during obstetric and gynecological procedures than during most other surgical procedures. Recent research has focused on the efficacy and safety of new antiemetic medications, primarily 5-hydroxytryptamine subtype 3 receptor antagonists, as well as clinical comparisons of these new drugs with older, established antiemetics. In the current healthcare environment, the cost-effectiveness of available antiemetic therapies has also become increasingly important, and this has been addressed in some of the recent literature.