Simultaneous quantification of sumatriptan succinate and prochlorperazine maleate in orodispersible films using two validated UV-spectroscopic methods

The study aimed at simultaneous quantification of sumatriptan succinate (SUM) and prochlorperazine maleate (PCP) in an orodispersible film using two validated spectroscopic methods viz. simultaneous equation (Method I) and the Q-absorption ratio (Method II). The Method I involved measurement of absorbances at λ_max of both drugs while in Method II, absorbances were measured at isosbestic wavelength and λ_max of one of the two components. Method validation were accomplished as per the ICH guidelines. A 1:1 mixture of the drugs and an orodispersible film (ODF) containing these drugs were assayed by both methods. The absorbance data of SUM and PCP in both methods were linear at respective wavelengths with correlation coefficient values >0.995. Both methods were precise as % RSD in repeatability, interday and intraday precision was less than 2. The estimation of SUM and PCP from the film dosage form by method I was104.74% and 98.34% and by method II was 103.45% and 98.85%, respectively, with a standard deviation <2. The study concluded that both the methods were simple, reliable and robust and can be applied successfully for the simultaneous quantification of SUM and PCP in mixture and orodispersible film dosage form.

Real-world insights on the management of migraine patients: an Italian nationwide study

Objectives: Understanding migraine management using data from a sample of patients representative of the Italian general adult population.Methods: Retrospective analysis on IQVIA Italian Longitudinal Patient Database. Two cohorts were created. (a) The triptan user cohort included patients with triptan prescriptions between November 2015 and October 2016. Migraine days were estimated counting triptan and indometacin/caffeine/prochlorperazine (ICP) pills prescribed during the 6 months following first triptan prescription. Patients were categorized as having episodic (EM) or chronic (CM) migraine based on the number of migraine days following International Classification of Headache Disorders criteria. (b) The migraine preventive treatment (MPT) user cohort included patients with MPT prescriptions during the period June 2016-May 2017. MPTs considered included beta-blockers, calcium-channel blockers, antiepileptics, antidepressants and antiserotoninergics. Migraine days experienced by MPTs users were estimated counting triptan and ICP pills prescribed during the 6 months following the most recent MPT prescription, while the number of MPT switches was estimated based on MPT prescriptions during the previous two years.Results: There were 9461 patients with triptan prescriptions to treat migraine acute attacks, which accounted yearly for 0.8% of general adult population. CM patients accounted for 3% of triptan users. There were 2004 patients prescribed with MPTs, which accounted for 0.16% of general adult population. Overall, among MPT users, 291 (15%) were still experiencing at least four migraine days/month, with this proportion increasing with the increase in the number of MPT switches.Conclusions: Results from this study suggest an unmet need in the management of migraine: too many patients did not receive MPTs, with this potentially due to several reasons requiring further investigations. Furthermore, even among patients receiving MPTs, disease control level with now available drugs seems to be sub-optimal.

Efficacy of Prophylactic Treatment for Oxycodone-Induced Nausea and Vomiting Among Patients with Cancer Pain (POINT): A Randomized, Placebo-Controlled, Double-Blind Trial

BACKGROUND

Although opioid-induced nausea and vomiting (OINV) often result in analgesic undertreatment in patients with cancer, no randomized controlled trials have evaluated the efficacy of prophylactic antiemetics for preventing OINV. We conducted this randomized, placebo-controlled, double-blind trial to evaluate the efficacy and safety of prophylactic treatment with prochlorperazine for preventing OINV.

MATERIALS AND METHODS

Cancer patients who started to receive oral oxycodone were randomly assigned in a 1:1 ratio to receive either prochlorperazine 5 mg or placebo prophylactically, given three times daily for 5 days. The primary endpoint was the proportion of patients who had a complete response (CR) during the 120 hours of oxycodone treatment. CR was defined as no emetic episode and no use of rescue medication for nausea and vomiting during 5 days. Key secondary endpoints were the proportion of patients with emetic episodes, proportion of patients with moderate or severe nausea, quality of life, and proportion of treatment withdrawal.

RESULTS

From November 2013 through February 2016, a total of 120 patients were assigned to receive prochlorperazine (n = 60) or placebo (n = 60). There was no significant difference in CR rates (69.5% vs. 63.3%; p = .47) or any secondary endpoint between the groups. Patients who received prochlorperazine were more likely to experience severe somnolence (p = .048).

CONCLUSION

Routine use of prochlorperazine as a prophylactic antiemetic at the initiation of treatment with opioids is not recommended. Further research is needed to evaluate whether other antiemetics would be effective in preventing OINV in specific patient populations.

IMPLICATIONS FOR PRACTICE

Prophylactic prochlorperazine seems to be ineffective in preventing opioid-induced nausea and vomiting (OINV) and may cause adverse events such as somnolence. Routine use of prophylactic prochlorperazine at the initiation of treatment with opioids is not recommended. Further research is needed to evaluate whether other antiemetics would be effective in preventing OINV in specific patient populations.

Bioavailability and Metabolism of Prochlorperazine Administered via the Buccal and Oral Delivery Route

Prochlorperazine has been accepted as an effective antiemetic for more than 50 years; however, its therapeutic success has been limited by its low and variable absorption and high first-pass metabolism. A buccal dosage form of prochlorperazine has been developed. This article discusses 2 clinical studies conducted to characterize the single-dose and multiple-dose pharmacokinetics of prochlorperazine and its metabolites after buccal administration. The results of these studies demonstrate that buccal administration of prochlorperazine produces plasma concentrations more than twice as high as an oral tablet, with less than half the variability. In addition to the metabolites, N-desmethyl prochlorperazine and prochlorperazine sulfoxide, 2 new metabolites, prochlorperazine 7-hydroxide and prochlorperazine sulfoxide 4'-N-oxide, were identified and quantitated. Exposure to metabolites after the buccal prochlorperazine formulation was approximately half that observed after the oral tablet. Buccal administration of prochlorperazine, twice daily, should enhance the therapeutic role of prochlorperazine in preventing and treating nausea and vomiting.

Sedation and analgesia for transvaginal oocyte retrieval: an audit resulting in a change of clinical practice

The aim was to audit the standard of care at oocyte retrieval with respect to the analgesia used. Before June 1999, a combination of intramuscular pethidine and prochlorperazine was given as a single dose. Many women found this to be unsatisfactory and requested general anaesthesia for subsequent oocyte retrievals. An intravenous sedation and analgesia regimen was introduced using a combination of midazolam and fentanyl. The introduction of this regimen was audited and compared with the established regimen. This study describes the experience with this technique, its patient acceptability, safety and cost implications.

Efficacy of dosing and re-dosing of two oral fixed combinations of indomethacin, prochlorperazine and caffeine compared with oral sumatriptan in the acute treatment of multiple migraine attacks: a double-blind, double-dummy, randomised, parallel group, multicentre study

AIMS AND METHODS

In this double-blind, double-dummy, randomised, parallel group, multicentre study, the efficacy of dosing and re-dosing of a fixed combination of indomethacin, prochlorperazine and caffeine (Indoprocaf) was compared with encapsulated sumatriptan in the acute treatment of two migraine attacks. Additionally, in the group taking Indoprocaf, two different oral formulations were tested: effervescent tablets and encapsulated coated tablets.

RESULTS

Of 297 patients randomised (150 assigned to Indoprocaf and 147 to sumatriptan), 281 were included in the intention-to-treat efficacy analysis. The initial dosing of Indoprocaf and sumatriptan was similarly effective with pain-free rates higher than 30% (95% CI of odds-ratio: 0.57-1.28) and headache relief rates of about 60% (95% CI of odds-ratio: 0.82-1.84) with both the drugs. The efficacy of re-dosing of Indoprocaf as rescue medication was more effective than that of sumatriptan with pain-free values of 47% vs. 27% in the total attacks with a statistically significant difference in the first migraine attack in favour of Indoprocaf. The efficacy of re-dosing to treat a recurrence/relapse was very high without differences between the drugs (pain-free: 60% with Indoprocaf and 50% with sumatriptan in the total attacks). Indoprocaf and sumatriptan were well-tolerated.

CONCLUSION

The study demonstrated that the efficacy of the initial dosing of Indoprocaf was not higher than that of sumatriptan, but that the strategy to use the lowest effective dose as soon as the headache occurred, followed by a second dose if the headache has not relieved or to treat a relapse, was very effective, especially with Indoprocaf.

Ultra-fast absorption of amorphous pure drug aerosols via deep lung inhalation

A deficiency of most current drug products for treatment of acute conditions is slow onset of action. A promising means of accelerating drug action is through rapid systemic drug administration via deep lung inhalation. The speed of pulmonary drug absorption depends on the site of aerosol deposition within the lung and the dissolution rate and drug content of the deposited particles. Alveolar delivery of fast-dissolving, pure drug particles should in theory enable very rapid absorption. We have previously shown that heating of thin drug films generates vapor-phase drug that subsequently cools and condenses into pure drug particles of optimal size for alveolar delivery. Here we present a hand held, disposable, breath-actuated device incorporating this thermal aerosol technology, and its application to the delivery of alprazolam, an anti-panic agent, and prochlorperazine, an anti-emetic with recently discovered anti-migraine properties. Thermal aerosol particles of these drugs exist in an amorphous state, which results in remarkably rapid drug absorption from the lung into the systemic circulation, with peak left ventricular concentrations achieved within 20 s, even quicker than following rapid (5 s) intravenous infusion. Absorption of the thermal aerosol is nearly complete, with >80% absolute bioavailability found in both dogs and human normal volunteers.

Recirculatory Pharmacokinetic Model of the Uptake, Distribution, and Bioavailability of Prochlorperazine Administered as a Thermally Generated Aerosol in a Single Breath to Dogs

A thermal aerosol generation process is capable of delivering pure drug reliably to the alveoli where it is absorbed systemically. Although deep lung absorption of drugs administered as an aerosol has been shown to be rapid, detailed characterization of their absorption and distribution has not been reported. The present study describes the pharmacokinetics of prochlorperazine from the moment of administration as either a rapid intravenous infusion or a thermally generated aerosol and determines the bioavailability of the aerosol by two independent methods. Prochlorperazine disposition was determined in four anesthetized dogs after a 5-s intravenous infusion and after thermally generated aerosol administration in one breath. Venous blood samples were collected frequently from the time of drug administration to 24 h and left ventricular blood samples were drawn more often until 10 min after drug administration. Prochlorperazine disposition after intravenous and aerosol administration was characterized by fitting a recirculatory model to left ventricular and venous drug concentration data simultaneously. Prochlorperazine aerosol administration produced plasma drug concentrations similar to those after rapid intravenous administration of the same nominal dose, with peak left ventricular concentrations achieved in less than 30 s. Plasma concentration profiles of prochlorperazine administered by both routes were well described by the recirculatory model. Bioavailability of the thermally generated aerosol was consistent and averaged more than 80% of emitted dose. Pulmonary administration of a thermally generated drug aerosol in one breath may be a viable alternative to rapid intravenous administration of drugs requiring rapid and predictable production of effective plasma concentrations.

Antiemetic-related dystonic reaction unmasked by removal of a scopolamine transdermal patch

A case of a dystonic reaction is presented that occurred after the use of prochlorperazine, metoclopramide and ondansetron for the treatment of post-operative nausea and vomiting. The onset of dystonia coincided temporally with the removal of a transdermal scopolamine patch used as adjunctive antiemetic therapy. Withdrawal of concurrently administered anticholinergic medication, after recent use of antiemetic medications with dopamine receptor (D2) inhibition, can unmask a dystonic reaction. This case also suggests that transdermal scopolamine may offer an innovative therapy for the treatment of acute dystonic reactions.

5-Hydroxytryptamine-receptor antagonists versus prochlorperazine for control of delayed nausea caused by doxorubicin: a URCC CCOP randomised controlled trial

BACKGROUND

Despite widespread use of short-acting antagonists for the 5-hydroxytryptamine (5-HT) receptor, about 50% of patients given moderately emetogenic chemotherapy have delayed nausea. We aimed to assess whether a 5-HT-receptor antagonist was more effective than was prochlorperazine for control of delayed nausea and delayed vomiting caused by doxorubicin.

METHODS

691 patients who previously had not had chemotherapy and who were scheduled to receive doxorubicin were given a short-acting 5-HT-receptor antagonist and dexamethasone before doxorubicin (day 1), and were randomly assigned to one of three regimens for days 2 and 3: 10 mg prochlorperazine taken orally every 8 h; any first-generation 5-HT-receptor antagonist (except palonosetron) taken as standard dose intravenously or orally; or 10 mg prochlorperazine taken as needed. Nausea and vomiting were assessed by use of a home record. The primary endpoint was mean severity of delayed nausea. The secondary endpoint was quality of life. Analyses were done by intention to treat.

FINDINGS

519 (77%) of the 671 evaluable patients had delayed nausea, with a mean severity of 3.33 (95% CI 3.22-3.44). 161 (71%) of 226 patients assigned prochlorperazine every 8 h reported delayed nausea (mean severity 3.37 [3.16-3.58]), as did 179 (79%) of 226 patients assigned 5-HT-receptor antagonists (3.29 [3.09-3.48]) and 179 (82%) of 219 patients assigned prochlorperazine as needed (3.33 [3.15-3.50]); groups did not differ in mean severity (p=0.853, one-way ANOVA). Patients allocated prochlorperazine every 8 h had less delayed nausea than did those allocated 5-HT-receptor antagonists (p=0.05, t test) and those allocated prochlorperazine as needed (p=0.009, t test).

INTERPRETATION

Short-acting 5-HT-receptor antagonists are no better than is prochlorperazine in control of delayed nausea caused by doxorubicin. Although fewer patients taking prochlorperazine report delayed nausea, the proportion was unacceptably high.

Indomethacin, alone and combined with prochlorperazine and caffeine, but not sumatriptan, abolishes peripheral and central sensitization in in vivo models of migraine

Recently it has been proposed that the throbbing pain of migraine is mediated by sensitization of peripheral trigeminovascular neurons, and that cutaneous allodynia of migraine is mediated by sensitization of central trigeminovascular neurons, and, moreover, that the triptans are less effective in aborting a migraine attack if the central sensitization is already established. The combination of indomethacin, prochlorperazine, and caffeine (IndoProCaf) is a drug of well-established use in the acute treatment of migraine. The aim of this study was to investigate whether the 3 active principles of IndoProCaf, alone and combined, compared to sumatriptan, were able to abolish the peripheral sensitization induced by kainic acid and the central sensitization induced by N-methyl-D-aspartate (NMDA) in in vivo models of hyperalgesia. The study showed that indomethacin or IndoProCaf is able to abolish both the kainic acid-induced and the NMDA-induced hyperalgesia. If administered at different times, IndoProCaf was always effective in reversing the kainic acid-induced hyperalgesia. Sumatriptan was not able to reverse either the kainic acid-induced or the NMDA-induced hyperalgesia. The efficacy of indomethacin, alone and combined with prochlorperazine and caffeine, in abolishing peripheral and central sensitization in in vivo models of hyperalgesia is a further explanation of the clinical efficacy of IndoProCaf in the treatment of migraine.

PERSPECTIVE

This study suggests that, although triptans were shown to be able to abort migraine attacks only if given before the establishment of cutaneous allodynia and central sensitization, IndoProCaf should be able to abort migraine attacks independently from the time of administration, because it is able to abolish an already established peripheral and central sensitization.

Droperidol vs. prochlorperazine for the treatment of acute headache

To determine if droperidol i.v. is as effective as prochlorperazine i.v. in the emergency department (ED) treatment of uncomplicated headache, a randomized, controlled, blinded study was conducted in the Emergency Departments of two urban teaching hospitals. Patients >or= 18 years old with crescendo-onset headache were eligible for inclusion. Ninety-six patients (48 in each group) were randomized to receive droperidol 2.5 mg i.v. or prochlorperazine 10 mg i.v. Baseline characteristics were similar between the two study groups. For the main study outcome, 83.3% in the droperidol group and 72.3% in the prochlorperazine group reported 50% pain reduction at 30 min (p <.01; one-sided test of equivalence). The mean decrease in headache intensity was 79.1% (SD 28.5%) in the droperidol group and 72.1% (SD 28.0%) in the prochlorperazine group (p =.23). It is concluded that droperidol i.v. provided a similar reduction of headache as achieved with prochlorperazine i.v. with a similar incidence of akathisia.

Comparison of three outpatient regimens in the management of nausea and vomiting in pregnancy

OBJECTIVE

This study compares pyridoxine-metoclopramide combination therapy to prochlorperazine and promethazine monotherapies in the outpatient treatment of nausea and vomiting in pregnancy.

STUDY DESIGN

In total, 174 first trimester, singleton pregnancies were evaluated for nausea and vomiting. Patients were prospectively randomized into three treatment groups: pyridoxine-metoclopramide, prochlorperazine, or promethazine. Prior to, and on the third day, patients recorded their subjective responses to the given treatment and their number of emesis episodes. The three treatment groups were compared for therapy response.

RESULTS

There were no differences in the number of emesis episodes prior to treatment. Both subjective and objective responses to treatment differed among the three groups when comparing the combination therapy to the monotherapies (p<0.05).

CONCLUSION

Combination therapy with pyridoxine and metoclopramide appears to be superior to either monotherapy in the treatment of nausea and vomiting in pregnancy.

Variations among emergency departments in the treatment of benign headache

STUDY OBJECTIVE

The practice patterns of US emergency departments in the treatment of patients with isolated benign headache have been recently described. How treatment varies among EDs has not been reported. To assess institutional variability in the pharmacotherapy of patients with benign headache, we describe and analyze the practice patterns of 3 US EDs.

METHODS

This health records survey included a cohort sample of consecutive adult patients aged 16 to 65 years treated with parenteral medication for isolated benign headache at 3 nonaffiliated US EDs: a large, group-model health maintenance organization, a tertiary-care academic center, and a rural community hospital. Patients who underwent a diagnostic search for intracranial pathology, who had any nonheadache secondary diagnosis, or who had coexistent trauma, fever (temperature of > or =38.0 degrees C [100.4 degrees F]), or known pregnancy were excluded from study analysis. Demographic, clinical, and pharmacotherapeutic variables were collected for each ED visit. Descriptive analyses were performed; comparisons were made with t tests.

RESULTS

Of the 490 eligible patients treated during the 4-month study period, the mean age was 36.4 years, and 374 (76%) were women. During their 629 visits, 364 (58%) received a migraine diagnosis, and 258 (41%) received a nonspecific headache diagnosis. Polypharmacy was common: 515 (82%) received 2 or more medications, and 154 (25%) received 3 or more medications. Pharmacotherapy varied greatly among the EDs. Use of opioid agonists showed the widest variation (16% to 72%), although use of dihydroergotamine (5% to 16%), prochlorperazine (32% to 59%), and adjunct diphenhydramine with prochlorperazine (42% versus 88%) also varied.

CONCLUSION

Great institutional variability exists among US EDs in the parenteral treatment of patients with isolated benign headache.

Efficacy and tolerability of prochlorperazine buccal tablets in treatment of acute migraine

OBJECTIVES

To study the efficacy and tolerability of prochlorperazine (PCZ) management of acute migraine.

DESIGN AND METHODS

A double blind comparative study was conducted to assess the efficacy of buccal PCZ 3 mg compared with oral ergotamine tartarate 1 mg plus caffeine 100 mg (ERG) or placebo (buccal or oral) for treatment of acute migraine. In all, 114 episodes of acute migraine were evaluated. Patients graded symptoms on a four-point scale before and up to 4 hours after treatment. The primary efficacy parameters included headache resolution within 2 hours (grade 3 or 2 to grade 0) and alleviation of other accompanying symptoms of migraine. The supplementary endpoints included improvement in quality of life (QOL).

RESULTS

The percentage of patients reporting resolution of headache (to grade 0) was 51.4% for buccal PCZ and 21.7% for buccal placebo, 23.1% for oral ERG and 28.6% for oral placebo, headache tended to recur in both the placebo and ERG groups after initial improvement. Buccal PCZ was well tolerated; no signs of local irritation were evident, and patients found the formulation easy to use. Mild but transient sedation and drowsiness were observed in 41%.

CONCLUSIONS

In the present study, PCZ 3 mg via the buccal route produced faster improvement and greater efficacy than placebo (oral as well as buccal) or oral ERG. The global QOL score 2 hours after treatment scores was higher in the PCZ group. Buccal PCZ may represent a particularly effective alternative for acute migraine treatment.

Medical management of Meniere's disease

Medical therapy of Meniere's disease is geared not only toward the differential diagnosis that has led to Meniere's disease and the supportive therapy for the physical manifestations of the disease but also for the psychologic sequelae of the disease such as mild-to-moderate situational depression and even chronic depression. Overall, with adequate medical therapy, allergy workup, and immunotherapy for patients with known diagnoses of allergies, the author's clinic has been able to help more than 85% of its patients who present with symptoms of Meniere's disease. For intractable cases where autoimmune phenomena can be suspected with a strong degree of suspicion, the author's clinic has also treated patients with immunosuppressive medications such as azathioprine and/or methotrexate in a low dose.

Intravenous administration of prochlorperazine by 15-minute infusion versus 2-minute bolus does not affect the incidence of akathisia: a prospective, randomized, controlled trial

STUDY OBJECTIVE

We sought to compare the rate of akathisia after administration of intravenous prochlorperazine as a 2-minute bolus or 15-minute infusion.

METHODS

We conducted a prospective, randomized, double-blind study in the emergency department of a central-city teaching hospital. Patients aged 18 years or older treated with prochlorperazine for headache, nausea, or vomiting were eligible for inclusion. Study participants were randomized to receive 10 mg of prochlorperazine administered intravenously by means of 2-minute push (bolus group) or 10 mg diluted in 50 mL of normal saline solution administered by means of intravenous infusion during a 15-minute period (infusion group). The main outcome was the number of study participants experiencing akathisia within 60 minutes of administration. Akathisia was defined as either a spontaneous report of restlessness or agitation or a change of 2 or more in the patient-reported akathisia rating scale and a change of at least 1 in the investigator-observed akathisia rating scale. The intensity of headache and nausea was measured with a 100-mm visual analog scale.

RESULTS

One hundred patients were enrolled. One study participant was excluded after protocol violation. Seventy-three percent (73/99) of the study participants were treated for headache and 70% (70/99) for nausea. In the bolus group, 26.0% (13/50) had akathisia compared with 32.7% (16/49) in the infusion group (Delta=-6.7%; 95% confidence interval [CI] -24.6% to 11.2%). The difference between the bolus and infusion groups in the percentage of participants who saw a 50% reduction in their headache intensity within 30 minutes was 11.8% (95% CI -9.6% to 33.3%). The difference in the percentage of patients with a 50% reduction in their nausea was 12.6% (95% CI -4.6% to 29.8%).

CONCLUSION

A 50% reduction in the incidence of akathisia when prochlorperazine was administered by means of 15-minute intravenous infusion versus a 2-minute intravenous push was not detected. The efficacy of prochlorperazine in the treatment of headache and nausea likewise did not appear to be affected by the rate of administration, although no formal statistical comparisons were made.

Droperidol vs. prochlorperazine for benign headaches in the emergency department

OBJECTIVE

To compare the efficacy of droperidol with that of prochlorperazine for the treatment of benign headaches in emergency department (ED) patients.

METHODS

Prospective, randomized clinical trial in an urban ED. Patients were given either droperidol, 5 mg intramuscular (IM) or 2.5 mg intravenous (IV), or prochlorperazine, 10 mg IM or 10 mg IV. Measurements included side effects and the patient's pain perception as measured on a 100-mm visual analog scale (VAS) at baseline, 30, and 60 minutes after the medication was given. Data were analyzed using chi-square, two-tailed t-tests, and two-way analysis of variance (ANOVA) when appropriate.

RESULTS

During an eight-month period, 168 patients were enrolled. Eighty-two (48.8%) of the patients received droperidol; 86 (51.2%) received prochlorperazine. In the droperidol group, 49 (59.6%) received IM administration and 33 (40.4%) IV. In the prochlorperazine group, 57 (66.3%) received IM administration and 29 (33.7%) IV. Sixty minutes after the medication, the mean decrease in the VAS scores was 81.4% for droperidol and 66.9% for prochlorperazine (p = 0.001). At 30 minutes, 60.9% of the patients receiving droperidol and 44.2% of the patients receiving prochlorperazine had obtained at least a 50% reduction in their VAS scores (p = 0.09). At 60 minutes, 90.2% of the patients receiving droperidol and 68.6% of the patients receiving prochlorperazine had at least a 50% reduction in their VAS scores (p = 0.017). No difference between IM dosing and IV dosing was detected. Side effects, including dystonia, akathisia, and decreased level of consciousness, were seen in 15.2% of the patients receiving droperidol and 9.61% of the patients receiving prochlorperazine. No significant or persisting morbidity was detected.

CONCLUSIONS

Droperidol was more effective than prochlorperazine in relieving pain associated with benign headaches.

Pegylated liposomal doxorubicin: tolerability and toxicity

We evaluated the tolerability and toxicity attributed to pegylated liposomal doxorubicin (PL-DOX) in women with recurrent or refractory ovarian cancer, and reviewed procedures to prevent or treat toxicity induced by the agent. Medical records of 13 women who received PL-DOX between October 1997 and December 2000 were reviewed. Patients 1-8 received PL-DOX once it was added to the hospital formulary in 1997. Patients 9-13 received it after medical staff education. Data on premedications, number of cycles, dosage, length of infusion, tolerability, side effects, and indicators for response were collected. The median number of cycles and cumulative dose/patient of PL-DOX were higher (6 and 420 mg) in the second group than in the first group (2 and 240 mg). Patient factors such as duration of disease and number of chemotherapy cycles influenced tolerability. One patient experienced a life-threatening adverse reaction within minutes of receiving the first dose. Treatment was discontinued, and she was resuscitated successfully. Other dose- or treatment-limiting complications (neutropenia, stomatitis, plantar-palmar erythrodysesthesia) were documented. Toxicity management consisted of dosage reduction or treatment delay; treatment often was discontinued. Patients with recent disease tolerated more cycles of PL-DOX when given early in recurrence compared with heavily pretreated women with long-standing disease. Tolerability was not necessarily indicative of response. The agent is simple to administer, but its tolerability and lack of uniform toxicity management remain concerns.

Continuous infusion prochlorperazine: pharmacokinetics, antiemetic efficacy, and feasibility of high-dose therapy

PURPOSE

The purpose of these sequential phase I studies was to evaluate the antiemetic efficacy and pharmacokinetics of high-dose continuous infusion prochlorperazine.

METHODS

A total of 52 patients with advanced cancer were treated in two sequential phase I studies utilizing high-dose prochlorperazine. In study 1, designed to investigate the antiemetic effects of dose-intensive prochlorperazine, various cisplatin-based multiagent chemotherapeutic regimens were administered in combination with escalating doses of prochlorperazine. In study 2, a fixed dose of cisplatin (60 mg/m2) was administered over 24 h as a continuous intravenous infusion in combination with infusional high-dose prochlorperazine. Antiemetic efficacy in the first trial was assessed in terms of the number of episodes of nausea, retching, and/or emesis during the 24 h following cisplatin administration. The pharmacokinetics of high-dose prochlorperazine were evaluated in eight patients treated in study 2 at the two dose levels below those at which dose-limiting toxicity was noted.

RESULTS

The maximally tolerated dose of prochlorperazine in combination with cisplatin (60 mg/m2 administered as a continuous infusion over 24 h) was 24 mg/h. The dose-limiting toxicity was grade 4 agitation and confusion noted in one patient treated at 26 mg/h. This patient died 3 days following cessation of chemotherapy due to the toxicity of the regimen in combination with the debilitating pulmonary effects of the disease. The mean end of infusion prochlorperazine level at the 24 mg/h dose level was 1.1 microM, a concentration previously reported to be consistent with the reversal of the multidrug resistance phenotype. Two partial responses were observed in study 2.

CONCLUSIONS

We conclude that the antiemetic efficacy of high-dose infusional prochlorperazine does not appear to be improved over more convenient bolus administration. However, prochlorperazine levels consistent with those required in vitro for drug resistance reversal are attainable within the dose range having a tolerable toxicity profile.

Tolerability and effectiveness of prochlorperazine for intractable migraine in children

OBJECTIVE

To study the effectiveness of prochlorperazine in aborting severe, intractable migraines in children.

STUDY DESIGN

Patients for this study were drawn from the population seen and evaluated in the Headache Center at Cincinnati Children's Hospital Medical Center. All patients were diagnosed with migraine headache by both clinical and International Headache Society criteria. The effectiveness of intravenous prochlorperazine in 20 consecutive patients referred to the emergency department for severe, prolonged migraines was retrospectively reviewed.

RESULTS

Patients evaluated in this study presented with a mean headache severity of 8.4 on a 0- to 10-point scale and an average duration of 54 hours. At 1 hour, 90% of the patients reported feeling better with 50% becoming pain-free. A 50% or greater reduction in severity occurred in 75% of patients at 1 hour and in 95% at 3 hours. At 3 hours, 95% of the patients reported feeling better, and 60% were pain-free. Only 1 patient failed to respond to prochlorperazine.

CONCLUSION

Prochlorperzaine was shown to be highly effective in aborting intractable migraines in children. It was well tolerated with no significant side effects. Additional large, double-blinded, randomized, placebo-controlled studies are needed to further investigate its effectiveness.

A phase I study of carboplatin and etoposide administered in conjunction with dipyridamole, prochlorperazine and cyclosporine A

PURPOSE

In recognition of the variety of available chemotherapeutic modulating agents and their potential to enhance the efficacy of platinum-based therapy, we embarked upon a phase I study to investigate the feasibility of combining fixed doses of carboplatinum (CBDCA) and etoposide (VP-16) with 24-h concurrent infusions of dipyridamole (DP), prochlorperazine (PCZ) and cyclosporine A (CSA) administered in escalating doses.

METHODS

Patients received intravenous VP-16 (200 mg/m2) and CBDCA (300 mg/m2), each over 30 min, starting at hour 6 of the modulator infusions. Resistance modulators were escalated sequentially to determine their respective maximally tolerated doses (MTDs). The pharmacokinetics (PK) of VP-16, CBDCA, and the three drug resistance (DR) modifiers were studied in eight patients.

RESULTS

A total of 59 patients were entered on study. The MTD was established at DP 5 mg/kg per day, PCZ 24 mg/h, and CSA 9.5 mg/kg per day. Dose-limiting toxicities included hypotension and severe sedation, presumably related to PCZ. No objective responses were seen. PK studies were performed when PCZ and DP doses were 24 mg/h and 3.3 mg/kg, and the CSA dose was either 8.5 mg/kg (five patients) or 9.5 mg/kg (three patients). The median clearance of VP-16 was 0.96 l/h per m2 (range 0.8-1.5 l/h per m2), which is lower than for VP-16 alone and similar to previously reported effects of CSA on VP-16 elimination. The median measured CBDCA AUC was 3.0 mg/ml x min (range 2.4-4.8 mg/ml x min). CBDCA AUC predicted by the Calvert formula using measured creatinine clearance underestimated the actual AUC in seven of the eight patients, in one case by as much as twofold. The median end of infusion PCZ and total DP plasma concentrations were 1.2 microM (range 0.5-2.2 microM) and 4.4 microM (range 1.3-5.9 microM), respectively, consistent with in vitro resistance modulatory levels. However, free DP was only 0.02 microM (range 0.004-0.04 microM). The median CSA level at 24 h of 1450 microg/l (range 1075-1640 microg/l) is in agreement with concentrations required for partial DR reversal in vitro, although it is much lower than levels achieved in our previous phase I study of CBDCA + CSA alone using similar doses of CSA. The CSA dose on the current trial was escalated beyond the MTD for the previous phase I study, suggesting that there may be an interaction between CSA and one of the other modulators.

CONCLUSION

These results demonstrate that in vitro DR-reversing levels of two of the three agents used in this study can be achieved in vivo, and that this combination of DR modulators has significant effects on the pharmacokinetics of VP-16.

Slow infusion for the prevention of akathisia induced by prochlorperazine: a randomized controlled trial

The utility of intravenous prochlorperazine (PCZ) in the treatment of nausea, vomiting, and headache may be limited by the akathisia that occurs frequently with the recommended 2-min infusion rate. We tested the hypothesis that decreasing the rate of PCZ infusion to 15 min reduces the incidence of akathisia at 1 hour. This double-blinded, randomized, controlled trial was conducted in the Emergency Department of an academic tertiary-care medical center with an annual census of 95,000 emergency patient visits. We enrolled a convenience sample of adult patients who received 10 mg i.v. PCZ for the treatment of nausea, vomiting, or headache. Subjects were randomized to receive either a 2-min infusion of PCZ (10 mg) followed by a 15-min infusion of saline, or a 2-min infusion of saline followed by a 15-min infusion of prochlorperazine. The incidence of akathisia at 1 hour was measured by using explicit diagnostic criteria. One hundred sixty patients were randomly enrolled into two groups, which were comparable with respect to age, gender, weight, and complaint. Akathisia developed in 31 of 84 patients (36.9%) who received the 2-min infusion of PCZ and in 18 of 76 patients (23.7%) who received the 15-min infusion of PCZ (p = 0.07), a 36% (95% CI, -5% to 61%) relative reduction. The delta from pre-infusion to postinfusion scores between the two groups was not significant (p = 0.19). We conclude that slowing the rate of PCZ infusion does not decrease akathisia.

[Diagnostic image (17). Acute dystonia induced by prochlorperazine]

An 11-year-old girl had a one-day history of nausea and vomiting for which her family physician prescribed 4 suppositories of prochlorperazine 25 mg. Five hours after the last dose she developed dystonic posturing; she recovered rapidly after intramuscular injection of 40 mg orphenadrine.

Intensive medical management of ureteral calculi

OBJECTIVES

To compare two treatment regimens in patients with ureteral calculi. One regimen (control arm) used routine drugs, and the second regimen (treatment arm) used the same routine drugs plus uncommonly used drugs.

METHODS

Between February and October 1998, 70 consecutive patients were evaluated for symptomatic ureteral calculi. Thirty-five patients were randomized to a control arm and received ketorolac, oxycodone, and acetaminophen combination tablets and prochlorperazine suppositories. Thirty-five patients were randomized to the treatment arm and received the same medications plus nifedipine XL, prednisone, and trimethoprim/sulfa combination tablets and plain acetaminophen. Stone passage rates, work days lost, emergency room visits, surgical interventions, and possible side effects of the drugs were recorded.

RESULTS

The treatment arm (addition of nifedipine XL, prednisone, trimethoprim/sulfa, and plain acetaminophen) had higher (86% versus 56%) stone passage rates and fewer lost work days (mean 1.76 versus 4.9), emergency room visits (1 versus 4), and surgical interventions (2 versus 15). Both arms exhibited similar potential drug side effects.

CONCLUSIONS

The addition of a calcium channel blocking agent, steroids, antibiotics, and more acetaminophen effected a higher stone passage rate and fewer lost work days, emergency room visits, and surgical interventions.

Prochlorperazine versus promethazine for uncomplicated nausea and vomiting in the emergency department: a randomized, double-blind clinical trial

STUDY OBJECTIVE

Nausea and vomiting related to gastritis or gastroenteritis are common complaints in the emergency department. The most effective antiemetic agent is yet undetermined. This study was conducted to compare the efficacy of prochlorperazine versus promethazine for uncomplicated nausea and vomiting in the ED.

METHODS

The study was a randomized, double-blind comparison of prochlorperazine (Compazine) and promethazine (Phenergan) for acute ED treatment of gastritis or gastroenteritis. We studied patients 18 years or older with presumed uncomplicated gastritis or gastroenteritis who presented to 2 academic EDs. Patients were randomly assigned to receive either prochlorperazine, 10 mg intravenously, or promethazine, 25 mg intravenously. Visual analog scale readings of patient comfort were obtained at baseline and at 30- and 60-minute intervals. The primary endpoint was degree of relief at 30 and 60 minutes. Secondary endpoints were time to complete relief, need for further antiemetic medication (treatment failures), and side effects. Statistical analysis was performed using the Mann-Whitney U test for nonparametric analysis and repeated-measures analysis of variance (ANOVA).

RESULTS

Eighty-four patients were enrolled in the study; 42 received prochlorperazine and 42 received promethazine. There were no differences in demographics in the 2 groups. At baseline (time 0), there was no difference in symptoms (P =.23). At 30 and 60 minutes after receiving medication, prochlorperazine worked significantly better than promethazine (P =.004 and P <.001 using nonparametric analysis). Using repeated-measures ANOVA, there was a significant difference in symptoms over time for both groups (P <.001) and a significant difference in prochlorperazine versus promethazine (P =.002). Time to complete relief was significantly shorter with prochlorperazine (P =.021). There were significantly fewer treatment failures with prochlorperazine (P =.03, 9.5% versus 31%; difference 21%, 95% confidence interval 5 to 38). There was no difference in incidence of extrapyramidal effects. Prochlorperazine caused significantly fewer complaints of sleepiness (P =.002, 38% versus 71%; difference 33%, 95% confidence interval 13 to 53; P =.002).

CONCLUSION

Prochlorperazine works significantly better than promethazine for relieving symptoms of nausea and vomiting more quickly and completely in ED patients with uncomplicated nausea and vomiting.

Oral granisetron for the prevention of acute late onset nausea and vomiting in patients treated with moderately emetogenic chemotherapy

PURPOSE

To demonstrate the efficacy of oral granisetron 1 mg twice daily for the prevention of late onset nausea and vomiting after moderately emetogenic chemotherapy that includes cyclophosphamide, carboplatin, or doxorubicin.

METHODS

Prior to chemotherapy, patients were stratified by gender and randomized to receive oral granisetron (1 mg tablet twice daily) or prochlorperazine (10 mg sustained release capsule twice daily). Study agents were administered 1 h prior to and 12 h after chemotherapy. Antiemetics were administered for seven consecutive days. Efficacy variables were assessed 48 and 72 h after administration of chemotherapy, and included no emesis, no nausea, no moderate or severe nausea, and no antiemetic rescue. Safety analysis included all patients who received medication.

RESULTS

A total of 230 patients were included in the intent-to-treat analysis; 119 patients received granisetron and 111 patients received prochlorperazine. Females, and all patients combined, who received granisetron had significantly higher no-emesis rates at 48 h (p =.010 and p =.016, respectively) than patients who received prochlorperazine. No-nausea rates at 48 h were numerically higher for all patients combined and females who received granisetron rather than prochlorperazine. Response rates for no nausea or mild nausea were also numerically higher in females treated with granisetron, compared to prochlorperazine, at 48 h. Significantly more patients (p <.001) and females (p <.001) in the granisetron group than in the prochlorperazine group did not require rescue antiemetics at 48 h. At 72 h, efficacy results were comparable for granisetron and prochlorperazine.

CONCLUSION

Oral granisetron is well tolerated and more effective than prochlorperazine in preventing nausea and vomiting for up to 48 h following treatment with moderately emetogenic chemotherapy.

A prospective study of i.v. magnesium and i.v. prochlorperazine in the treatment of headaches

Previous uncontrolled, nonrandomized trials suggest that magnesium sulfate (MgSO(4)) is effective in the treatment of headache. The objective of this study was to determine the efficacy of MgSO(4) vs. prochlorperazine in emergency department (ED) patients with acute headache. Patients presenting to the ED with a chief complaint of headache who met study criteria were enrolled. Each patient rated pain on a visual analog scale before and 30 min after a randomized study drug infusion. Thirty-six similar patients were enrolled. There was complete or partial pain relief in 90% of the prochlorperazine group and 56% of the MgSO(4) group, a statistically significant difference. Prochlorperazine caused significantly fewer side effects, and none of the patients required additional medication during the study period. It was determined that intravenous prochlorperazine is highly effective in the treatment of headache and magnesium is moderately effective. Response to MgSO(4) was unrelated to serum Mg level.

Control of high-dose-cisplatin-induced emesis with an all-oral three-drug antiemetic regimen

In this pilot trial, the antiemetic efficacy and tolerability of an all-oral antiemetic combination in the prevention of both acute and delayed nausea and vomiting following high-dose cisplatin was evaluated. Fifty-two patients receiving cisplatin (median dose 100 mg/m2) were entered. Patients received (1) 60 min prior to cisplatin: prochlorperazine spansule 15 mg, dexamethasone 20 mg, granisetron 2 mg; (2) 12 h after cisplatin: prochlorperazine spansule 15 mg, dexamethasone 10 mg; (3) on days 2 and 3: prochlorperazine spansule 15 mg b.i.d., dexamethasone 8 mg b.i.d.; (4) on days 4 and 5: dexamethasone 4 mg b.i.d. All antiemetics were administered orally. The study period was the 120 h after cisplatin administration. The primary efficacy end-point was complete control (no vomiting, retching or antiemetic rescue) of delayed emesis (24-120 h after cisplatin). Complete control of delayed emesis was achieved in 26 patients (53%). Nineteen patients (39%) noted no delayed nausea. Complete control of acute emesis (24 h after cisplatin) was attained in 44 patients (86%). The no nausea rate during the first 24 h was 74%. Overall, 39 patients (80%) were satisfied or very satisfied with their outcome. Treatment was well tolerated with infrequent and minor adverse events. In conclusion, an all-oral combination of granisetron, dexamethasone and prochlorperazine is a highly effective and well-tolerated regimen for preventing acute cisplatin-induced emesis. Control of delayed emesis was not better than with current standard treatment, and more effective approaches are needed.

Prochlorperazine induces akathisia in emergency patients

STUDY OBJECTIVE

Prochlorperazine (PCZ), a commonly used antiemetic and analgesic agent, is known to cause akathisia. The incidence of akathisia after a single 10-mg dose of intravenous PCZ has not been prospectively evaluated. We determined the incidence and severity of PCZ-induced akathisia at 1 hour and the incidence of delayed akathisic symptoms at 48 hours.

METHODS

This prospective controlled study evaluated a convenience sample of 140 adult patients at a 400-bed, academic, tertiary-care medical center with an annual emergency department census of 95,000 patient visits. One hundred patients who received intravenous PCZ for the treatment of severe headache or vomiting constituted the PCZ group. Forty patients receiving nonakathisic intravenous therapy (eg, saline solution or antibiotics) served as control subjects. Patients were excluded if they had preexisting motor disorders (eg, restless-leg syndrome or Parkinson's disease) or if they recently had received any medication with extrapyramidal, anticholinergic, sedative, or antiakathisic properties. All patients underwent an akathisia assessment before and 1 hour after receiving their respective intravenous medications. An established scale was used to detect the presence of akathisia and grade its severity as mild, moderate, or severe. The delayed development of akathisic symptoms within 48 hours also was measured in the PCZ group.

RESULTS

Akathisia developed in 44 (44%) of the patients receiving PCZ within 1 hour (95% confidence interval, 34% to 54%). The akathisia was graded as mild, moderate, and severe in 14, 22, and 8 subjects, respectively. Delayed symptoms suggestive of akathisia developed in 3 other patients within 48 hours. None of the 40 control subjects developed akathisia.

CONCLUSION

Single-dose intravenous PCZ frequently induced akathisia within 1 hour of administration. Acute akathisia was not observed in patients receiving intravenous saline solution or antibiotics. The delayed development of akathisia symptoms 48 hours after a single dose of intravenous PCZ was uncommon.

An assessment of prochlorperazine buccal for the prevention of nausea and vomiting during intravenous patient-controlled analgesia with morphine following abdominal hysterectomy

The effectiveness of prochlorperazine buccal as an anti-emetic for the prevention of post-operative nausea and vomiting in patients using intravenous patient-controlled analgesia with morphine following abdominal hysterectomy has been assessed in a randomized, double-blind, placebo-controlled study. Forty-nine female patients participated with 26 allocated to the prochlorperazine buccal group and the remainder to the placebo group. Each received either placebo or prochlorperazine buccal 6 mg, in each case by the buccal route, 1 h prior to anaesthesia with further doses at 6, 18, 30 and 42 h, respectively. Symptom scores in respect of nausea, pain and sedation, the number without nausea, the number without vomiting and the requirement for rescue anti-emetic therapy were noted for each 4-h period during the 48-h study. Morphine utilization and taste associated with the study material were recorded. Data for 21 patients in the placebo group and 25 patients in the prochlorperazine buccal group were available for analysis. Patients in the prochlorperazine buccal group showed significantly lower mean nausea scores at 4-8 h (placebo group: mean nausea score 0.95; prochlorperazine buccal group: mean nausea score 0.36; P < 0.05) and at 16-20 h (placebo group: mean nausea score 1.24; prochlorperazine buccal group: mean nausea score 0.48; P < 0.05). Furthermore, the prochlorperazine buccal group showed significantly more patients without nausea at 4-8 h (placebo group: 11 patients out of 21; prochlorperazine buccal group: 20 patients out of 25; P < 0.05) and at 16-20 h (placebo group: nine patients out of 21; prochlorperazine buccal group: 18 patients out of 25; P < 0.05). The prochlorperazine buccal group showed a significantly higher number of patients rating the taste as unsatisfactory (placebo group: two patients out of 21; prochlorperazine buccal group: nine patients out of 25; P < 0.05). Intravenous droperidol is the current gold standard prophylactic anti-emetic in post-operative nausea and vomiting associated with intravenous patient controlled analgesia with morphine usage. This study has demonstrated a peri-operative prochlorperazine buccal regimen to be effective in post-operative nausea and vomiting prophylaxis in the use of intravenous patient controlled analgesia with morphine. Prochlorperazine buccal should be considered as an effective, inexpensive option for the prevention of post-operative nausea and vomiting in post-operative intravenous patient controlled analgesia with morphine administration.

Evaluation of prochlorperazine buccal tablets (Bukatel) and metoclopramide oral tablets in the treatment of acute emesis

The dizziness associated with vertiginous disorders is often accompanied with nausea and/or vomiting. Antiemetic effect of prochlorperazine (PCZ) is diminished by its low bioavailability owing to a significant gastric and hepatic first pass effect. This effect could be further diminished by likelihood of regurgitation of nauseating patients further limiting the therapeutic effect of oral PCZ. A buccal preparation achieves higher plasma concentrations through direct systemic absorption. In this study buccal prochlorperazine (Bukatel) was compared for its efficacy and tolerability with commonly used metoclopramide. Bukatel was well tolerated and well rated by both patients and investigators with no adverse effects on buccal mucosa and causing less drowsiness and sedation. Results indicate that Bukatel is safe and effective for the treatment of nausea and/or vomiting in patients suffering from vertiginous disorders and could be safely and strongly recommended as an alternative to less bioavailable and indiscriminately used oral metoclopramide tablets.

Peripheral nerve injection injury with antiemetic agents

Antiemetics are widely used drugs, frequently administered to alleviate postoperative and postchemotherapeutic nausea and vomiting. While antiemetics do not induce peripheral neurotoxicity when administered systemically, it is not known whether peripheral nerve injury can occur as a result of inadvertent intraneural injection during intramuscular administration. The purpose of this study was to characterize the neurotoxic effect of three commonly used antiemetic agents (promethazine, dimenhydrinate, and prochlorperazine) as compared to saline in the rat sciatic nerve model. Intrafascicular and extrafascicular injection as well as direct application of the antiemetic drugs were performed. Nerves were harvested at 2 weeks postoperatively for histology and morphometry, with an additional sacrifice point at 8 weeks for the intrafascicular injection group. Injection injuries caused by antiemetic drugs differed depending on the agent injected and the location of injection. Extrafascicular injection and direct application caused no damage. Intrafascicular injection caused diffuse axonal injury in the promethazine and dimenhydrinate groups, while prochlorperazine caused only focal injury. Regeneration was prominent at 8 weeks in all intrafascicular injection groups in this rat model. Prochlorperazine thus appears to be less neurotoxic when injected intraneurally and should preferentially be used for intramuscular injections.

Intravenous ketorolac vs intravenous prochlorperazine for the treatment of migraine headaches

OBJECTIVE

To compare i.v. ketorolac with i.v. prochlorperazine as the initial treatment of migraine headaches in the ED.

METHODS

A prospective, double-blind comparison study was performed, using a convenience sample of 64 patients suffering from migraine headaches presenting to the ED at a tertiary care university teaching hospital. Patients were randomly assigned to receive either 10 mg of prochlorperazine i.v. or 30 mg of ketorolac i.v.. Patients scored the severity of their headaches using a 10-cm visual analog pain scale. An initial mark was made on the scale at the time of entry into the study and later another mark was made on a new unmarked pain scale 1 hour after medication administration. Changes in pain scores within each treatment group and between groups were analyzed using the Wilcoxon rank sum test.

RESULTS

Prior to treatment, the patients assigned to receive prochlorperazine had a median score of 9.2 cm (mean +/- SD pain score of 8.3 cm +/- 2.1 cm), while the patients receiving ketorolac had a median score of 9.0 (mean pain score of 8.4 cm +/- 1.7 cm). There was no significant difference between the pain scores of the participants in the 2 groups prior to treatment (p = 0.80). One hour after medication administration, the patients in the prochlorperazine group had a median score of 0.5 cm (mean 2.1 +/- 3.2 cm), while those patients receiving ketorolac had a median pain score of 3.9 (mean 4.0 +/- 3.3 cm). The decrease in pain score was significant for both groups of patients (p = 0.0001). The change in pain score for the patients in the prochlorperazine group (median 7.1) was significantly greater than the change in pain score for the patients in the ketorolac group (median 4.0; p = 0.04).

CONCLUSION

Although both drugs were associated with a significant reduction in pain scores, benefit over a placebo agent was not tested. Furthermore, the patients who received prochlorperazine i.v. for migraine headaches had a statistically significant greater decrease in their pain scores than did those receiving ketorolac i.v.

Comparison of buccal and oral prochlorperazine in the treatment of dizziness associated with nausea and/or vomiting

The dizziness inherent in vertiginous disorders is often accompanied by nausea and/or vomiting. While prochlorperazine is effective in relieving nausea and vomiting, its low bioavailability following first pass metabolism in the liver and metabolism in the intestinal wall, compounded by the likelihood of regurgitation in the nauseous patient, may limit the therapeutic value of the oral preparation. A buccal preparation achieves higher plasma concentrations by direct absorption into the systemic circulation. In this randomised, double-blind, double-dummy trial in patients with vestibular disorders, in keeping with previous pharmacokinetic studies, buccal prochlorperazine achieved a significantly faster onset of effect compared with oral prochlorperazine (p = 0.04), and was significantly better in reducing the frequency of nausea (p = 0.02) and severity of vomiting (p = 0.05) at 24-36 hours. The frequency of vomiting was also reduced by buccal prochlorperazine compared with oral prochlorperazine, but this difference was only of borderline significance (p = 0.07). Buccal prochlorperazine was well tolerated and well rated by both patients and investigators, having no more adverse effects on the buccal mucosa than placebo and causing less drowsiness and sedation compared with the oral preparation. No advantages were reported for the oral preparation over buccal prochlorperazine. Buccal prochlorperazine is therefore safe and effective, and suitable for the treatment of dizziness associated with nausea and/or vomiting in patients suffering from vertiginous disorders.

Simultaneous quantitation of plasma doxorubicin and prochlorperazine content by high-performance liquid chromatography

A high-performance liquid chromatographic method has been developed and tested for simultaneous extraction, elution and determination of doxorubicin and prochlorperazine content in human plasma samples. The procedure consists of extraction through a conditioned C18 solid-phase extraction cartridge, elution from a Spherisorb C8 reversed-phase column by an isocratic mobile phase (60% acetonitrile, 15% methanol and 25% buffer) followed by detection with electrochemical and fluorescence detectors. Recovery of doxorubicin and prochlorperazine from pooled human plasma samples (n=3) containing 100 ng/ml of the two drugs was 77.8+/-3.5% and 89.1+/-6.0%, respectively. The lower limits of quantitation for doxorubicin and prochlorperazine in plasma samples were 6.25 ng/ml and 10 ng/ml, respectively. A linear calibration curve was obtained for up to 2 microg/ml of doxorubicin and prochlorperazine. This combination method may be of particular value in clinical studies where phenothiazines such as prochlorperazine are used to enhance retention of doxorubicin in drug resistant tumor cells.

An all oral antiemetic regimen for patients undergoing high-dose chemotherapy with peripheral blood stem cell transplant

The purpose of the study was to assess the toxicity and efficacy of an oral, combination antiemetic regimen including granisetron (Kytril; SmithKline Beecham Pharmaceuticals, Philadelphia, PA, USA) in the setting of highly emetogenic conditioning chemotherapy for stem cell transplantation. Antiemetic prophylaxis consisted of oral granisetron 2 mg once daily, oral prochlorperazine 10 mg q 6 h and oral dexamethasone 4 mg q 6 h, beginning 1 h prior to chemotherapy on each of the 4 days of chemotherapy and continuing until 24 h after the completion of high-dose chemotherapy (HDC). Patients received either CVP (cyclophosphamide 6 g/m2, VP-16 1800 mg/m2 and carboplatin 1200 mg/m2) or CTP (thiotepa 500 mg/m2 in place of VP-16) in four daily doses given over 4 h from days -4 to -1. Previously mobilized and cryopreserved peripheral blood stem cells (PBSC) were reinfused on day +1. Evaluation of nausea, emetic episodes (EE), adverse events, and rescue medications were recorded on a daily patient diary. Thirty-six patients were entered. Fifty-three percent (95% CI = 37-75%) of patients achieved complete response for emesis (CR = 0 EE/24 h) and 75% (95% CI = 58-90%) had combined complete and major response (CR+MR = 0-3 EE/24 h) during all 5 of the treatment days. During the 5 study days, the average number of patient-days with no emesis was 3.7 (74%) and with 1-3 EE was 4.3 (86%). On days -4, -3, -2, -1 and 0, the combined CR+MR rate for emesis was 97, 92, 86, 78 and 75%, respectively. Nausea was absent or mild on all 5 study days in 57% (95% CI = 37-75%). Eight patients had severe late-onset emesis occurring on days +1 to +3 after reinfusion of stem cells. No clinically significant toxicities attributable to the antiemetic regimen were observed. An all oral antiemetic regimen of granisetron, prochlorperazine and dexamethasone appears to be safe and highly effective in patients receiving multiple, daily, high-dose chemotherapy regimens. This regimen offers the advantage of cost-savings, a low side-effect profile and ease of administration in the predominately outpatient setting of HDC with peripheral blood stem cell transplant (PBSCT).

The prophylactic antiemetic efficacy of prochlorperazine and ondansetron in nasal septal surgery: a randomized double-blind comparison

A prospective, randomized placebo-controlled study was undertaken to compare the effects on heart rate and blood pressure during surgery and on the incidence of nausea, vomiting and headache after surgery of i.m. prochlorperazine 0.2 mg.kg-1, i.v. prochlorperazine 0.1 mg.kg-1 and i.v. ondansetron 0.06 mg.kg-1 given at induction of general anaesthesia to patients undergoing septorhinoplasty. The effects of the test drugs after administration on heart rate and blood pressure were similar, as were the incidences of retching and vomiting in the recovery ward after each test drug. Postoperatively, compared with placebo (7%), nausea per se was most frequent in those given i.v. prochlorperazine (25%, P < 0.01), and less frequent in those given i.m. prochlorperazine (2%) and i.v. ondansetron (15%). Vomiting per se was reduced from 24% to 7% (P < 0.025) by i.v. prochlorperazine and to 4% (P < 0.0005) by i.v. ondansetron. The incidence of nausea with vomiting was reduced from 35% to 15% (P < 0.025). 16% (P < 0.05) and 11% (P < 0.005) by i.m. prochlorperazine, i.v. prochlorperazine and i.v. ondansetron respectively. I.m. prochlorperazine and i.v. ondansetron increased the frequency (from 35% to 64%, P < 0.0005 and to 71%, P < 0.0005, respectively) of those experiencing no PONV and delayed the onset of PONV, but only i.m. prochlorperazine reduced the severity of postoperative vomiting. Headache was frequent in the control (69%), i.v. prochlorperazine (62%) and i.v. ondansetron (69%) groups, and least frequent after i.m. prochlorperazine (53%; P < 0.05 versus i.v. ondansetron). It is concluded that these drugs have no adverse cardiovascular effects within 10 minutes of administration, i.m. prochlorperazine and i.v. ondansetron reduce PONV more effectively than i.v. prochlorperazine and postoperative headache after septorhinoplasty occurs less frequently in those given i.m. prochlorperazine than in those given i.v. ondansetron.