Genetic variability in postoperative nausea and vomiting: A systematic review

Genomic Study in Opioid-Treated Cancer Patients Identifies Variants Associated With Nausea-Vomiting

CONTEXT

Opioids are the mainstay therapy for patients affected by cancer pain. However, about 10%-20% of patients do not benefit from the received analgesic treatment or experience side effects. Genetic variability might account for the variation in individual responses to opioids, both in terms of efficacy and toxicity.

OBJECTIVES

The aim of this genome-wide association study (GWAS) was to identify genetic markers of opioid toxicity, in terms of nausea-vomiting.

METHODS

Cancer patients receiving morphine, oxycodone, buprenorphine, and fentanyl were recruited from different European countries. Data about toxicity (nausea-vomiting score, NVS) and other relevant clinical information were collected, as well as genotyping data. Regression analysis between genotypes of 2052 patients and NVS was performed, using appropriate covariates, with REGENIE software.

RESULTS

We found 65 variants associated with NVS (P-value < 1.0×10-5). Of note, 14 intronic variants on chromosome 2 were in NPAS2 gene, encoding a circadian transcription factor reported to play a role in another opioid side effect, the alteration of sleep. Some of these variants were previously identified as splicing quantitative trait loci of the NPAS2 gene.

CONCLUSIONS

This is the first GWAS, performed in more than two thousand individually genotyped patients treated with opioids for cancer pain, that investigated the genetic bases of opioid-induced nausea-vomiting. Although further studies are needed to confirm our findings and to characterize the functional role of the identified variants, our results emphasize the importance of performing large pharmacogenomic studies to identify germline variants associated with opioid response, with the ultimate goal of tailoring cancer pain therapies.

Polygenic Score for the Prediction of Postoperative Nausea and Vomiting: A Retrospective Derivation and Validation Cohort Study

BACKGROUND

Postoperative nausea and vomiting (PONV) is a key driver of unplanned admission and patient satisfaction after surgery. Because traditional risk factors do not completely explain variability in risk, this study hypothesized that genetics may contribute to the overall risk for this complication. The objective of this research is to perform a genome-wide association study of PONV, derive a polygenic risk score for PONV, assess associations between the risk score and PONV in a validation cohort, and compare any genetic contributions to known clinical risks for PONV.

METHODS

Surgeries with integrated genetic and perioperative data performed under general anesthesia at Michigan Medicine (Ann Arbor, Michigan) and Vanderbilt University Medical Center (Nashville, Tennessee) were studied. PONV was defined as nausea or emesis occurring and documented in the postanesthesia care unit. In the discovery phase, genome-wide association studies were performed on each genetic cohort, and the results were meta-analyzed. Next, the polygenic phase assessed whether a polygenic score, derived from genome-wide association study in a derivation cohort from Vanderbilt University Medical Center, improved prediction within a validation cohort from Michigan Medicine, as quantified by discrimination (c-statistic) and net reclassification index.

RESULTS

Of 64,523 total patients, 5,703 developed PONV (8.8%). The study identified 46 genetic variants exceeding the threshold of P < 1 × 10-5, occurring with minor allele frequency greater than 1%, and demonstrating concordant effects in both cohorts. Standardized polygenic score was associated with PONV in a basic model, controlling for age and sex (adjusted odds ratio, 1.027 per SD increase in overall genetic risk; 95% CI, 1.001 to 1.053; P = 0.044), a model based on known clinical risks (adjusted odds ratio, 1.029; 95% CI, 1.003 to 1.055; P = 0.030), and a full clinical regression, controlling for 21 demographic, surgical, and anesthetic factors, (adjusted odds ratio, 1.029; 95% CI, 1.002 to 1.056; P = 0.033). The addition of polygenic score improved overall discrimination in models based on known clinical risk factors (c-statistic, 0.616 compared to 0.613; P = 0.028) and improved net reclassification of 4.6% of cases.

CONCLUSIONS

Standardized polygenic risk was associated with PONV in all three of the study's models, but the genetic influence was smaller than exerted by clinical risk factors. Specifically, a patient with a polygenic risk score greater than 1 SD above the mean has 2 to 3% greater odds of developing PONV when compared to the baseline population, which is at least an order of magnitude smaller than the increase associated with having prior PONV or motion sickness (55%), having a history of migraines (17%), or being female (83%) and is not clinically significant. Furthermore, the use of a polygenic risk score does not meaningfully improve discrimination compared to clinical risk factors and is not clinically useful.

EDITOR’S PERSPECTIVE

TMEM132C rs7296262 Single-Nucleotide Polymorphism Is Significantly Associated with Nausea Induced by Opioids Administered for Cancer Pain and Postoperative Pain

Opioids are almost mandatorily used for analgesia for cancer pain and postoperative pain. Opioid analgesics commonly induce nausea as a side effect. However, the genetic factors involved are still mostly unknown. To clarify the genetic background of individual differences in the occurrence of nausea during opioid administration, the incidence of nausea was investigated in 331 patients (Higashi-Sapporo Hospital [HS] group) who received morphine chronically for cancer pain treatment and in 2021 patients (Cancer Institute Hospital [CIH] group) who underwent elective surgery under general anesthesia. We conducted a genome-wide association study of nausea in HS samples. Among the top 20 candidate single-nucleotide polymorphisms (SNPs), we focused on the TMEM132C rs7296262 SNP, which has been reportedly associated with psychiatric disorders. The rs7296262 SNP was significantly associated with nausea in both the HS and CIH groups (TT+TC vs. CC; HS group, p = 0.0001; CIH group, p = 0.0064). The distribution of nausea-prone genotypes for the rs7296262 SNP was reversed between HS and CIH groups. These results suggest that the TMEM132C rs7296262 SNP is significantly associated with nausea during opioid use, and the effect of the SNP genotype on nausea is reversed between chronic and acute phases of opioid use.

Association of the dopamine D2 receptor gene SNP rs1800497 with postoperative nausea and vomiting: A prospective cohort study

BACKGROUND

Postoperative nausea and vomiting (PONV) are the most frequent complications in the context of anaesthesia. Several studies suggest a contribution of genetic traits to PONV disposition. Single nucleotide polymorphisms (SNPs) located in the cholinergic receptor muscarinic 3 gene CHRM3 (rs2165870) and the potassium voltage-gated channel subfamily B member 2 KCNB2 (rs349358) have been described as independent risk factors for the occurrence of PONV. In addition, further SNPs might be associated with an increased PONV risk, for example a dopamine D2 receptor (DRD2) SNP (rs1800497).

OBJECTIVE

The primary aim of our study was the development of a new PONV prediction score which includes genetic information of SNPs in the genes CHRM3 and KCNB2, which have been already associated with PONV. The secondary aim of our study was to investigate the association of five additional SNPs with PONV.

DESIGN

Prospective cohort study.

SETTING

Single centre study in Germany.

RESULTS

We could not establish a new PONV prediction score that includes genetic information, due to limited association of the KCNB2 SNP and CHRM3 SNP with PONV. Interestingly, the GA and AA genotypes of the DRD2 rs1800497 in the dopamine D2 receptor gene were associated with PONV 24 h postoperatively, with a relative risk (RR) of GA/AA genotype vs. GG genotype of 1.5 [95% confidence interval (CI) 1.06 to 2.01, P = 0.02]. This association was independent from the Apfel score in a multivariate logistic regression analysis (RR 1.4, 95% CI 1.03 to 1.90, P = 0.03).

CONCLUSION

The construction of a new PONV prediction score including genetic information was not possible due to limited association of the CHRM3 and KCNB2 SNPs. However, the DRD2 GA and AA genotypes (rs1800497) were associated with PONV and this SNP might be a future candidate for further validation studies aiming for molecular-derived PONV prediction models.

TRIAL REGISTRATION

German Clinical Study Register - DRKS00021051.

CYP2D6 isoenzyme and ABCB1 gene polymorphisms associated with postoperative nausea and vomiting in women undergoing laparoscopic cholecystectomy: a randomized trial

INTRODUCTION

Postoperative nausea and vomiting is still a common complication. Serotonin receptor antagonists are commonly used in clinical practice for antiemetic prophylaxis. Interindividual variations in drug response, including single nucleotide polymorphisms, are related to pharmacokinetic and pharmacodynamic changes in these drugs and may lead to a poor therapeutic response. This study aimed to evaluate the influence of CYP2D6 isoenzyme and ABCB1 gene polymorphisms on the frequency of postoperative nausea and vomiting with the use of ondansetron or palonosetron.

METHODS

A randomized, double-blind clinical trial including 82 women aged 60 years or over undergoing laparoscopic cholecystectomy was conducted. Patients were randomized to receive either ondansetron or palonosetron for postoperative nausea and vomiting prophylaxis. DNA was extracted from saliva. Genetic polymorphisms were analyzed by real-time polymerase chain reaction. The following polymorphisms were analyzed: rs3892097 C/T, rs1128503 A/G, rs16947 A/G, rs1065852 A/G, rs1045642 A/G, rs2032582 C/A, and rs20325821 C/A.

RESULTS

Overall, vomiting, and severe nausea occurred in 22.5% and 57.5% of patients, respectively. In the palonosetron group, patients with the GG genotype (rs16947 A/G) experienced more severe nausea (p = 0.043). In the ondansetron group, patients with the AA genotype (rs16947 A/G) presented mild nausea (p = 0.034), and those with the AA genotype (rs1065852 A/G) experienced more vomiting (p = 0.034).

CONCLUSION

A low antiemetic response was observed with ondansetron in the presence of the AA genotype (rs16947 A/G) and the AA genotype (rs1065852 A/G), and a low therapeutic response was found with palonosetron in the presence of the GG genotype (rs16947 A/G) in laparoscopic cholecystectomy.

REGISTER

ClinicalTrials.gov.

Genome-Wide Association Study Identifies Novel Candidate Variants Associated with Postoperative Nausea and Vomiting

Considerable individual differences are widely observed in the incidence of postoperative nausea and vomiting (PONV). We conducted a genome-wide association study (GWAS) to identify potential candidate single-nucleotide polymorphisms (SNPs) that contribute to PONV by utilizing whole-genome genotyping arrays with more than 950,000 markers. The subjects were 806 patients who provided written informed consent and underwent elective surgery under general anesthesia with propofol or desflurane. The GWAS showed that two SNPs, rs2776262 and rs140703637, in the LOC100506403 and CNTN5 gene regions, respectively, were significantly associated with the frequency of nausea. In another GWAS conducted only on patients who received propofol, rs7212072 and rs12444143 SNPs in the SHISA6 and RBFOX1 gene regions, respectively, were significantly associated with the frequency of nausea as well as the rs2776262 SNP, and the rs45574836 and rs1752136 SNPs in the ATP8B3 and LOC105370198 gene regions, respectively, were significantly associated with vomiting. Among these SNPs, clinical and SNP data were available for the rs45574836 SNP in independent subjects who underwent laparoscopic gynecological surgery, and the association was replicated in these subjects. These results indicate that these SNPs could serve as markers that predict the vulnerability to PONV. Our findings may provide valuable information for achieving satisfactory prophylactic treatment for PONV.

Postoperative nausea and vomiting: risk factors, prediction tools, and algorithms

PURPOSE OF REVIEW

Postoperative/postdischarge nausea and vomiting (PONV/PDNV) remain relevant issues in perioperative care. Especially in ambulatory surgery, PONV can prevent discharge or lead to unplanned readmission.

RECENT FINDINGS

The evidence for the management of PONV is now quite good but is still inadequately implemented. A universal, multimodal rather than risk-adapted approach for PONV prophylaxis is now recommended. The evidence on PDNV is insufficient.

SUMMARY

PDNV management is based primarily on consequent prophylaxis and therapy of PONV.

Association of intraocular pressure and postoperative nausea and vomiting after microvascular decompression - a prospective cohort study

BACKGROUND

Postoperative nausea and vomiting is common in patients receiving microvascular decompression. In the current study, we examined whether postoperative nausea and vomiting is associated with reduced intraocular pressure (IOP) after microvascular decompression, a measure that reflects intracranial pressure.

METHODS

This is a prospective cohort study. Adult patients scheduled for microvascular decompression surgery for hemifacial spasm between January 2020 and August 2020 were eligible. IOP was measured immediately before anesthesia induction and 30 min after patients regained complete consciousness using non-contact tonometry. IOP reduction was defined by at least 1 mmHg decrease vs. preoperative baseline. The primary outcome was vomiting on postoperative day 1.

RESULTS

A total of 103 subjects were enrolled. IOP was reduced in 56 (54.4%) subjects. A significantly greater proportion of patients with IOP reduction had vomiting on postoperative day 1 (51.8% (29/56) vs. 23.4% (11/47) in those without IOP reduction; p = 0.003). In the multivariate regression analysis, vomiting on postoperative day 1 was associated with female sex [odds ratio = 7.87, 95% CI: 2.35-26.32, p = 0.001] and IOP reduction [odds ratio = 2.93, 95% CI: 1.13-7.58, p = 0.027].

CONCLUSIONS

In patients undergoing microvascular decompression surgery, postoperative IOP reduction is associated with postoperative vomiting.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR2000029083 . Registered 13 January 2020.

Effects of Ramosetron on Nausea and Vomiting Following Spinal Surgery: A Meta-Analysis

BACKGROUND

Spinal surgery is associated with severe pain within the first few days after surgery. Opioids are commonly used to control postoperative pain, but these can lead to postoperative nausea and vomiting (PONV). Therefore, use of more effective and better-tolerated agents would be beneficial for these patients. Serotonin receptor antagonists, such as ramosetron, have been used to reduce PONV in patients receiving anesthesia.

OBJECTIVE

We conducted a meta-analysis of published randomized controlled trials (RCTs) to compare the efficacy and tolerance of ramosetron to prevent PONV after spinal surgery.

METHODS

Medline, Embase, Cochrane Library, and Science Citation Index databases were systematically searched for relevant RCT articles published between January 1979 and November 2020. Full text articles restricted to English language that described RCTs comparing the use of ramosetron with other serotonin antagonists to treat PONV following spinal surgery in adult patients were considered for meta-analysis. Two reviewers independently performed study selection, quality assessment, and data extraction of all articles. Differences were resolved by a third reviewer.

RESULTS

The search identified 88 potentially relevant articles, of which only 3 met our selection criteria. Study drugs were administered at the end of spinal surgery in all 3 included articles. The meta-analysis revealed that ramosetron (0.3 mg) reduced the pain score (mean difference = -0.66; 95% CI -1.02 to -0.30), lowered the risk of PONV (risk ratio = 0.86; 95% CI, 0.76-0.97), and postoperative vomiting (risk ratio = 0.32; 95% CI, 0.17-0.60), and limited the use of rescue antiemetics (risk ratio = 0.66; 95% CI, 0.45-0.96) after spinal surgery. However, there were no significant differences in the incidence of postoperative nausea, the use of rescue pain medications, the number of rescue analgesics required, and the risk of discontinuation of patient-controlled analgesia between ramosetron and palonosetron (0.075 mg) or ondansetron (4 mg). There were no statistically significant differences in the risk of adverse events among the 3 medications.

CONCLUSIONS

This meta-analysis of 3 RCTs showed that ramosetron reduced the risk of PONV and POV, limited the use of rescue antiemetics, reduced the postoperative pain score, and did not increase the risk of discontinuing patient-controlled analgesia compared with palonosetron or ondansetron after spinal surgery in 3 RCTs. Therefore, this meta-analysis indicates that ramosetron is an effective and well tolerated antiemetic that can be used to prevent PONV following spinal surgery in adult patients. PROSPERO identifier: CRD42020223596 (Curr Ther Res Clin Exp. 2022; 83:XXX-XXX)© 2022 Elsevier HS Journals, Inc.

Auricular nerve stimulation using the NSS-2 BRIDGE device to reduce opioid requirement following laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Evidence supports the use of complementary techniques to reduce pain and opioid use after surgery. The NSS-2 BRIDGE device (NBD; Innovative Health Solutions, Inc., Versailles, Indiana) modulates pain via stimulation of the nucleus of the auricular branch of the cranial nerves at the level of the brainstem and the limbic system.

OBJECTIVE

To investigate the role of auricular nerve field stimulation for pain control following gastric bypass surgery.

SETTINGS

U.S. academic medical center.

METHODS

A total of 18 subjects were included. Subjects were divided in 2 groups: NBD group (n = 8) and a control group (n = 10). The NBD was placed following laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery in the recovery room. The effectiveness of NBD was assessed comparing the relative use of opioid consumption (oral morphine equivalents) and pain (0 = no pain to 10= worst possible pain) at 24 and 48 hours after surgery. In addition, the device tolerability (1-10) was assessed, with 8-10 considered excellent. Data were analyzed using unpaired t tests and presented as mean ± standard deviation. Alpha was set up at .1.

RESULTS

Compared with the control group, the use of NBD was associated with a 60.2% reduction in oral morphine equivalents (38.15 vs 15.2 mg; P < .1) and a 28% reduction in pain (5.0 vs 3.6; P = .1) at 24 hours after surgery. The tolerability of NBD was reported to be excellent.

CONCLUSIONS

This report suggests that NBD may represent an interesting alternative to control perioperative pain and limit opioid use following bariatric surgery. This needs to be confirmed by a placebo-controlled, randomized study.