Safety and efficacy of commonly used antiemetics

Evidence-based guidelines for the pharmacological treatment of migraine

We here present evidence-based guidelines for the pharmacological treatment of migraine. These guidelines, created by the Italian Society for the Study of Headache and the International Headache Society, aim to offer clear, actionable recommendations to healthcare professionals. They incorporate evidence-based recommendations from randomized controlled trials and expert-based opinions. The guidelines follow the Grading of Recommendations, Assessment, Development and Evaluation approach for assessing the quality of evidence. The guideline development involved a systematic review of literature across multiple databases, adherence to Cochrane review methods, and a structured framework for data extraction and interpretation. Although the guidelines provide a robust foundation for migraine treatment, they also highlight gaps in current research, such as the paucity of head-to-head drug comparisons and the need for long-term outcome studies. These guidelines serve as a resource to standardize migraine treatment and promote high-quality care across different healthcare settings.

Synergistic Antiemetic Effects of Nerolidol on Domperidone, Hyoscine, and Ondansetron: In Vivo and in Silico Investigations on Receptor Binding Affinity

The present study was designed to measure the potential antiemetic properties of nerolidol (NDL) via in vivo and in silico studies. To induce emesis copper sulfate pentahydrate (CuSO4.5H2O) was administered at a dose of 50 mg/kg (orally) to 2-day-old chicks. The test sample (NDL) was given at two doses of 50 and 100 mg/kg. b.w. orally. Additionally, aprepitant (16 mg/kg), domperidone (6 mg/kg), hyoscine (21 mg/kg), ondansetron (5 mg/kg), and diphenhydramine (10 mg/kg) were given also orally as positive controls. To observe the modulatory effects of the test sample, combination therapies with reference drugs were also administered to three different groups of animals. Molecular docking and visualization of ligand-receptor interaction were performed against several emesis-inducing receptors (5HT3, D2, D3, H1, and M1-M5) using diverse computational tools. Pharmacokinetics and drug-likeness of the selected ligands were also calculated. Findings demonstrated that NDL significantly (p <0.05) dose-dependently lessens the mean number of retches and delays the emetic onset in the chicks. The combined drug therapy with ondansetron exposed better antiemetic activity. In addition, in silico analysis, NDL has greater binding affinity (-7.3 kcal/mol) against M2 and M3 receptors. In conclusion, NDL exerted mild antiemetic activity with synergistic properties through muscarinic receptors.

Assessment of antiemetic activity of dihydrocoumarin: In vivo and in silico approaches on receptor binding affinity and modulatory effects

Dihydrocoumarin (DCN) is a natural compound widely used in the flavor industry and has antioxidant and anti-inflammatory properties. However, its potential antiemetic effects on gastrointestinal disturbances remain untested. This study emphasizes assessing the antiemetic properties of the natural aromatic compound DCN using copper sulfate (CuSO4.5H2O)-induced emetic model on chicks, and an in silico approach was also adopted to estimate the possible underlying mechanisms. Two doses (25 and 50 mg/kg b.w.) of DCN and several referral drugs considered positive controls (PCs), including domperidone (6 mg/kg), hyoscine (21 mg/kg), aprepitant (16 mg/kg), diphenhydramine (10 mg/kg), and ondansetron (5 mg/kg), were orally administered to chicks. The vehicle was provided as the control group. Co-treatments of DCN with referral drugs were also provided to chicks to evaluate the modulatory action of the test compound. According to the results, DCN delayed the emetic onset and decreased the frequency of retches in a dose-dependent manner compared to the vehicle group. DCN (50 mg/kg) represented a notable delayed latency period (61.17 ± 4.12 s) and a diminished number of retchings (17.67 ± 1.82 times) compared to the control group. Further, in the co-treatments, DCN increased the latency period and reduced the number of retches, except for domperidone. In the in silico investigation, DCN showed notable binding affinity toward the D2 (-7 kcal/mol), H1 (-7.5 kcal/mol), and M5 (-7 kcal/mol) receptors in the same binding site as the referral ligand. Our research indicates that DCN has mild antiemetic properties by interacting with the D2, H1, and M5 receptors. Therefore, several pre-clinical and clinical studies are necessary to assess the effectiveness and safety profile of this food ingredient.

Antiemetic activity of abietic acid possibly through the 5HT3 and muscarinic receptors interaction pathways

The present study was designed to evaluate the antiemetic activity of abietic acid (AA) using in vivo and in silico studies. To assess the effect, doses of 50 mg/kg b.w. copper sulfate (CuSO4⋅5H2O) were given orally to 2-day-old chicks. The test compound (AA) was given orally at two doses of 20 and 40 mg/kg b.w. On the other hand, aprepitant (16 mg/kg), domperidone (6 mg/kg), diphenhydramine (10 mg/kg), hyoscine (21 mg/kg), and ondansetron (5 mg/kg) were administered orally as positive controls (PCs). The vehicle was used as a control group. Combination therapies with the referral drugs were also given to three separate groups of animals to see the synergistic and antagonizing activity of the test compound. Molecular docking and visualization of ligand-receptor interaction were performed using different computational tools against various emesis-inducing receptors (D2, D3, 5HT3, H1, and M1-M5). Furthermore, the pharmacokinetics and toxicity properties of the selected ligands were predicted by using the SwissADME and Protox-II online servers. Findings indicated that AA dose-dependently enhances the latency of emetic retching and reduces the number of retching compared to the vehicle group. Among the different treatments, animals treated with AA (40 mg/kg) exhibited the highest latency (98 ± 2.44 s) and reduced the number of retching (11.66 ± 2.52 times) compared to the control groups. Additionally, the molecular docking study indicated that AA exhibits the highest binding affinity (- 10.2 kcal/mol) toward the M4 receptors and an elevated binding affinity toward the receptors 5HT3 (- 8.1 kcal/mol), M1 (- 7.7 kcal/mol), M2 (- 8.7 kcal/mol), and H1 (- 8.5 kcal/mol) than the referral ligands. Taken together, our study suggests that AA has potent antiemetic effects by interacting with the 5TH3 and muscarinic receptor interaction pathways. However, additional extensive pre-clinical and clinical studies are required to evaluate the efficacy and toxicity of AA.

Retrospective analysis of real-world prescribing data for managing cisplatin-based chemotherapy-induced nausea and vomiting in China

BACKGROUND

The current utilization of neurokinin-1 receptor antagonists (NK1RAs) and the impact of updated guidelines on prescription patterns of antiemetic drugs among Chinese patients receiving highly emetogenic chemotherapy (HEC) remain undetermined. This study aims to analyze the present situation of Chinese cancer patients using antiemetic drugs and assess the appropriateness of antiemetic regimens.

METHODS

Prescription data were collected between January 2015 and December 2020 from cancer patients receiving cisplatin-based chemotherapy at 76 hospitals in six major cities in China. Trends in the use of antiemetic drugs, prescribing patterns and adherence to antiemetic guidelines were assessed.

RESULTS

Among the 108,611 patients included in this study, 6 classes and 17 antiemetic drugs were identified as monotherapy or combination therapy in 93,872 patients (86.4%), whereas 14,739 patients (13.6%) were administered no antiemetic treatment. 5-hydroxytryptamine 3 receptor antagonists (5-HT3RAs) and glucocorticoids were the two most frequently used classes of antiemetics, followed by metoclopramide. NK1RAs were underused across the six cities, only 9332 (8.6%) and 1655 (1.5%) cisplatin-based treatments were prescribed aprepitant and fosaprepitant, respectively. Prescriptions of olanzapine and lorazepam were very low throughout the study period. In prescribing patterns of antiemetic drugs, dual combination regimens were the most common (40.0%), followed by triple combination therapy and monotherapy (25.8% and 15.1%, respectively). Overall, the adherence to antiemetic guidelines for patients undergoing cisplatin-based regimens was only 8.1% due to inadequate prescription of antiemetic drugs. Finally, our study also revealed that 5-HT3RAs and glucocorticoids were overprescribed in 8.8% and 1.6% of patients, respectively.

CONCLUSIONS

The current study reveals suboptimal utilization of recommended antiemetic drugs for managing cisplatin-based HEC-induced nausea and vomiting in China. Improving the management of CINV is crucial, and these findings provide valuable insights into optimizing antiemetic drug practices.

Antiemetic effects of sclareol, possibly through 5-HT3 and D2 receptor interaction pathways: In-vivo and in-silico studies

BACKGROUND

Emesis is a complex physiological phenomenon that serves as a defense against numerous toxins, stressful situations, adverse medication responses, chemotherapy, and movement. Nevertheless, preventing emesis during chemotherapy or other situations is a significant issue for researchers. Hence, the majority view contends that successfully combining therapy is the best course of action. In-vivo analysis offers a more comprehensive grasp of how compounds behave within a complex biological environment, whereas in-silico evaluation refers to the use of computational models to forecast biological interactions.

OBJECTIVES

The objectives of the present study were to evaluate the effects of Sclareol (SCL) on copper sulphate-induced emetic chicks and to investigate the combined effects of these compounds using a conventional co-treatment approach and in-silico study.

METHODS

SCL (5, 10, and 15 mg/kg) administered orally with or without pre-treatment with anti-emetic drugs (Ondansetron (ODN): 24 mg/kg, Domperidone (DOM): 80 mg/kg, Hyoscine butylbromide (HYS): 100 mg/kg, and Promethazine hydrochloride (PRO): 100 mg/kg) to illustrate the effects and the potential involvement with 5HT3, D2, M3/AChM, H1, or NK1 receptors by SCL. Furthermore, an in-silico analysis was conducted to forecast the role of these receptors in the emetic process.

RESULTS

The results suggest that SCL exerted a dose-dependent anti-emetic effect on the chicks. Pretreatment with SCL-10 significantly minimized the number of retches and lengthened the emesis tendency of the experimental animals. SCL-10 significantly increased the anti-emetic effects of ODN and DOM. However, compared to the ODN-treated group, (SCL-10 + ODN) group considerably (p < 0.0001) extended the latency duration (109.40 ± 1.03 s) and significantly (p < 0.01) decreased the number of retches (20.00 ± 0.70), indicating an anti-emetic effect on the test animals. In in-silico analysis, SCL exhibited promising binding affinities with suggesting receptors.

CONCLUSION

SCL-10 exerted an inhibitory-like effect on emetic chicks, probably through the interaction of the 5HT3 and D2 receptors. Further studies are highly appreciated to validate this study and determine the precise mechanism(s) behind the anti-emetic effects of SCL. We expect that SCL-10 may be utilized as an antiemetic treatment in a single dosage form or that it may function as a synergist with other traditional medicines.

Ondansetron: recommended antiemetics for patients with acute pancreatitis? a population-based study

Objective: Ondansetron administration is a common antemetic of acute pancreatitis therapy in the intensive care unit (ICU), but its actual association with patients' outcomes has not been confirmed. The study is aimed to determine whether the multiple outcomes of ICU patients with acute pancreatitis could benefit from ondansetron. Methods: 1,030 acute pancreatitis patients diagnosed in 2008-2019 were extracted from the Medical Information Mart for Intensive Care (MIMIC)-IV database as our study cohort. The primary outcome we considered is the 90-day prognosis, and secondary outcomes included in-hospital survival and overall prognosis. Results: In MIMIC-IV, 663 acute pancreatitis patients received ondansetron administration (OND group) during their hospitalization, while 367 patients did not (non-OND group). Patients in the OND group presented better in-hospital, 90-day, and overall survival curves than the non-OND group (log-rank test: in-hospital: p < 0.001, 90-day: p = 0.002, overall: p = 0.009). After including covariates, ondansetron was associated with better survival in patients with multiple outcomes (in-hospital: HR = 0.50, 90-day: HR = 0.63, overall: HR = 0.66), and the optimal dose inflection points were 7.8 mg, 4.9 mg, and 4.6 mg, respectively. The survival benefit of ondansetron was unique and stable in the multivariate analyses after consideration of metoclopramide, diphenhydramine, and prochlorperazine, which may also be used as antiemetics. Conclusion: In ICU acute pancreatitis patients, ondansetron administration was associated with better 90-day outcomes, while results were similar in terms of in-hospital and overall outcomes, and the recommended minimum total dose might be suggested to be 4-8 mg.

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

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

Kidney and Mortality Outcomes Associated with Ondansetron in Critically Ill Patients

Background: Ondansetron is a preferred anti-emetic in critical care to treat nausea and vomiting, and has historically been considered a largely safe option. A recent pharmacoepidemiology study reported that ondansetron may be associated with an increased risk for acute kidney injury (AKI). Methods: We interrogated the High-Density Intensive Care (HiDenIC-15) database containing intensive care data for 13 hospitals across Western Pennsylvania between Oct 2008-Dec 2014. AKI was defined using the Kidney Disease, Improving Global Outcomes 2012 guidelines. Ondansetron use was considered as receiving any form of ondansetron within 24 h of admission. The subsequent 48 h (hours 25-72 after admission) were analyzed for outcomes. Primary outcome was development of AKI; secondary outcomes included 90-day mortality and time to AKI. Propensity-matched, multivariate logistic regression was applied for both outcomes. Comparator groups were metoclopramide and prochlorperazine using the same exposure criteria. Results:AKI occurred in 965 (5.6%), 12 (3.0%), and 61 (6.5%) patients receiving ondansetron, prochlorperazine, and metoclopramide, respectively. In the adjusted analysis, no anti-emetic was associated with a significant change in the odds of developing AKI. Ondansetron was associated with a 5.48% decrease (CI -6.17--4.79) in death within 90 days of ICU-admission, which was independent of AKI status; an effect not seen with other anti-emetics. Anti-emetic usage was not associated with a change in the time to first AKI. Conclusion:Anti-emetic usage did not alter AKI risk. Ondansetron was associated with a significant decrease in 90-day mortality that was not seen by other anti-emetics, which requires further exploration.

Endocannabinoid system and cannabis hyperemesis syndrome: a narrative update

Cannabis use has been increasing in the United States and throughout the world. It is derived from one of the earliest plants cultivated by humans - Cannabis sativa. Cannabis (also called marijuana) is the most commonly used psychoactive substance worldwide. The cannabis plant has more than 400 chemicals, of which more than 100 cannabinoids (such as cannabigerol, cannabidiol, and cannabinol) have been identified. The endocannabinoid system (ECS) plays an essential role in the effects of cannabis on end organs. Although cannabis use has been reported for many decades, some of its unique adverse effects of nausea, vomiting, and abdominal pain, termed as cannabis hyperemesis syndrome (CHS), were noted recently. The legal status of cannabis in the United States has been rapidly changing from state to state. The incidence of CHS is expected to rise with rising access to cannabis in the United States. Furthermore, CHS is frequently underdiagnosed due to a lack of uniform criteria, subjective nature of symptoms, and overlap with cyclical vomiting syndrome (CVS). Understanding the ECS and its role in biphasic response (proemetic and antiemetic) of CHS is critical to explain its pathophysiology. As the use of cannabis increases globally, awareness of CHS is warranted for early recognition and prompt treatment to avoid complications. We describe the putative mechanism of CHS with an overview of the clinical features in these patients. Furthermore, we highlight the differences between CHS and CVS with important differentials to consider. We provide a narrative update on the current evidence on CHS pathophysiology, diagnosis, treatment, and identifying research gaps.

Cannabis hyperemesis syndrome: an update on the pathophysiology and management

Cannabis hyperemesis syndrome (CHS) is a form of functional gut-brain axis disorder characterized by bouts of episodic nausea and vomiting worsened by cannabis intake. It is considered as a variant of cyclical vomiting syndrome seen in cannabis users especially characterized by compulsive hot bathing/showers to relieve the symptoms. CHS was reported for the first time in 2004, and since then, an increasing number of cases have been reported. With cannabis use increasing throughout the world as the threshold for legalization becomes lower, its user numbers are expected to rise over time. Despite this trend, a strict criterion for the diagnosis of CHS is lacking. Early recognition of CHS is essential to prevent complications related to severe volume depletion. The recent body of research recognizes that patients with CHS impose a burden on the healthcare systems. Understanding the pathophysiology of the endocannabinoid system (ECS) remains central in explaining the clinical features and potential drug targets for the treatment of CHS. The frequency and prevalence of CHS change in accordance with the doses of tetrahydrocannabinol and other cannabinoids in various formulations of cannabis. CHS is unique in presentation, because of the cannabis’s biphasic effect as anti-emetic at low doses and pro-emetic at higher doses, and the association with pathological hot water bathing. In this narrative review, we elaborate on the role of the ECS, its management, and the identification of gaps in our current knowledge of CHS to further enhance its understanding in the future.

Nausea and Vomiting Not Related to Cancer Therapy: Intractable Problem or Clinical Challenge?

PURPOSE

Unlike therapy-related nausea and vomiting (chemotherapy or radiotherapy induced), nausea and vomiting (N/V) in patients with advanced cancer is often multicausal and thus presents unique challenges. Few professional guidelines address the palliative management of N/V, and those that do are insufficiently detailed to bolster clinical decision-making. Nonetheless, oncology advanced practitioners (APs) are frequently challenged to manage these high-impact symptoms. This requires collaborating with other oncology care providers and cultivating a knowledge base to educate and mentor professional colleagues to optimize N/V unrelated to treatment.

METHODS

Literature reviewed included current and classic articles that address the physiologic bases of N/V related to disease and with malignant bowel obstruction, agents used to alleviate nausea or N/V, and nonpharmacologic adjunctive measures. This information was framed within palliative care and symptom management clinical experience.

RESULTS

This review article summarizes what is known about the neuropharmacology of N/V in advanced disease. Focused assessment, pharmacologic agents (antiemetics, central neuromodulators, and peripheral prokinetic agents), and nondrug adjunctive measures that may be useful for N/V are included.

CONCLUSIONS

Managing N/V in advanced cancer is a quality-of-life imperative that requires persistence and interprofessional collaboration among oncology APs and other clinicians to personalize management. This work can change the perception that N/V related to progressive disease is frequently intractable to one that considers it as a manageable clinical challenge.

Antiemetic drugs: what to prescribe and when

Nausea and vomiting are common symptoms with many possible causes, including the adverse effects of drugs. If a drug is indicated, the cause guides the choice of antiemetic drug The main antiemetic classes include antagonists of the serotonin, dopamine, histamine, muscarinic and neurokinin systems, corticosteroids and benzodiazepines. Some antiemetics appear more effective for specific indications Serotonin and neurokinin antagonists, such as ondansetron and aprepitant, are highly effective in treating chemotherapy-induced nausea and vomiting. Metoclopramide and antihistamines are first-line options for nausea and vomiting in pregnancy Serotonin antagonists and some dopamine antagonists, such as metoclopramide, can prolong the QT interval on the ECG. Dopamine antagonists can cause extrapyramidal adverse effects, particularly in children

Comparison of ramosetron and ondansetron for the prevention of postoperative nausea and vomiting in patients undergoing laparoscopic surgery: a meta-analysis of randomized controlled trials

Objective

We conducted a systematic literature search and meta-analysis to identify randomized controlled trials (RCTs) comparing the efficacy and safety of ramosetron versus ondansetron for the prevention of postoperative nausea and vomiting (PONV; PON and POV, respectively) in patients undergoing laparoscopic surgery.

Methods

The electronic databases PubMed, EMBASE, Web of Science, and Cochrane Library were searched up to March 2019 to identify relevant studies.

Results

The final pooled analysis included 6 RCTs and revealed that postoperative treatment with ramosetron at 24 to 48 hours after surgery significantly reduced the incidence of PON and POV relative to treatment with ondansetron. In a subgroup analysis, ramosetron 0.3 mg tended to reduce PON (0–2 hours) and POV (24–48 hours) more effectively than ondansetron 4 mg. However, no statistical difference was observed between ramosetron 0.3 mg and ondansetron 8 mg in terms of the reduction of PON or POV during any time interval within the first 48 hours after surgery.

Conclusions

Our results indicate that ramosetron 0.3 mg is superior to ondansetron 4 mg and comparable to ondansetron 8 mg for PONV prophylaxis after laparoscopic surgery.

An assay of drug-induced emesis in the squirrel monkey (Saimiri sciureus)

BACKGROUND

Emesis has significant evolutionary value as a defense mechanism against ingested toxins; however, it is also one of the most common adverse symptoms associated with both disease and medical treatments of disease. The development of improved antiemetic pharmacotherapies has been impeded by a shortage of animal models.

METHODS

The present studies characterized the responses of the squirrel monkey to pharmacologically diverse emetic drugs. Subjects were administered nicotine (0.032-0.56 mg/kg), lithium chloride (150-250 mg/kg), arecoline (0.01-0.32 mg/kg), or apomorphine (0.032-0.32 mg/kg) and observed for emesis and prodromal hypersalivation.

RESULTS

Nicotine rapidly produced emesis and hypersalivation. Lithium chloride produced emesis with a longer time course without dose-dependent hypersalivation. Arecoline produced hypersalivation but not emesis. Apomorphine failed to produce emesis or hypersalivation.

CONCLUSIONS

The squirrel monkey is sensitive to drug-induced emesis by a variety of pharmacological mechanisms and is well-positioned to examine antiemetic efficacy and clinically important side effects of candidate antiemetic pharmacotherapies.

Low-dose combined spinal-epidural anesthesia for a patient with a giant hiatal hernia who underwent urological surgery

A hiatal hernia refers to herniation of the abdominal organs through the esophageal hiatus of the diaphragm. A giant hiatal hernia affects digestive and cardiopulmonary function by compressing the organs. We report a patient who had low-dose combined spinal and epidural anesthesia (CSEA) for safe and effective anesthesia for conservative treatment of a giant hiatal hernia. An 84-year-old woman who had a giant hiatal hernia was scheduled for ureteroscopic removal of a ureteral stone. CSEA was performed at the L4 to L5 lumbar interspace and an epidural catheter tip was placed 5 cm cephalad from the inserted level. The T12 block was checked after 10 minutes of intrathecal injection of 6 mg of 0.5% bupivacaine. The T10 block was checked after additional injection of 80 mg of 2% lidocaine through the epidural catheter. During anesthesia and surgery, the patient's vital signs remained stable and the operation was completed within 1 hour without any problems. In conclusion, low-dose CSEA may be safely used without any cardiopulmonary and gastrointestinal problems in patients with a giant hiatal hernia undergoing urological surgery.

Clinical Practice: Nausea and vomiting in acute gastroenteritis: physiopathology and management

Currently recommended management of acute gastroenteritis is supportive. Although the affected children habitually have vomiting, recommendations do not focus on the correction of this symptom. In this condition, elevated ketone bodies and stimuli initiated by gut mucosa damage produced by the enteral pathogen likely underlay nausea and vomiting. As compared to 0.9% saline, intravenous administration of a dextrose-containing bolus of 0.9% saline is associated with a greater reduction of circulating ketones and a shorter duration of nausea and vomiting. Nonetheless, this treatment strategy is not followed by a lower rate of hospitalization.

CONCLUSION

Well-designed investigations suggest that antagonists of the type 3 serotonin receptor, most frequently oral ondansetron, reduce the rate of vomiting, improve the tolerance of oral rehydration, and reduce the need for intravenous rehydration. What is Known: • Although children with gastroenteritis habitually have vomiting, current recommendations do not focus on the correction of this symptom. What is New: • Recently acquired evidence supports the prescription of ondansetron, an antagonist of the type 3 serotonin receptor, to increase the success rate of oral rehydration therapy.