Post Operative Nausea and Vomiting

1. Post Operative Nausea and Vomiting Robert Ferrante Pharmacy Candidate

2. Objectives • Discuss the prevalence of Post Operative Nausea and Vomiting (PONV) and why reducing PONV is so important to hospitals • Review the evolution of PONV treatment • Examine the current medications used for PONV

3. Post Operative Nausea and Vomiting(PONV)1 • Up to 35% of ambulatory patients affected • 70% of high risk patients • Number one concern of patients • … above pain, death, and MI • Patients often classified by risk

4. Risk Factors • Younger • Female • “Large body habitus” • History of: • PONV • Motion Sickness • Anxiety • Procedures: • Head/Neck • Intraabdominal • Larparoscopic • Gynecologic • Medications: • Opiods

5. Why So Important? • Medical Consequences • Patient satisfaction • Shorter PACU stays • More patients • MORE MONEY • Mo’ Problems?

6. http://www.frca.co.uk/article.aspx?articleid=354#faq

7. https://www.inkling.com/read/pharmacology-brenner-stevens-4th/chapter-28/figure-28-3https://www.inkling.com/read/pharmacology-brenner-stevens-4th/chapter-28/figure-28-3 Antiemetics

8. Droperidol3 • Potent D2 Receptor antagonist • PONV: 0.625-1.25 mg IM/IV Q3-4h • Adjust for renal, hepatic, and age-related factors. • 75% renal elimination • Extensive liver metabolism • T ½ - 135 mins

9. Droperidol Brief History1,2,3 • Droperidol was the foundation for PONV • Effective and inexpensive • December 2001: FDA issue BBW • Arrhythmic-Effects • Heavily disputed. • Should be reserved for resistant patients • Requires excessive monitoring • ECG • Cost increase

10. Droperidol3 • Contraindications • First line treatment for anything but PONV • Known or suspected QT interval • Major drug interactions • Drugs that may cause QT prolongation • Including antiarrhythmics, opiods antipsychotics, and, diuretics

11. Reglan (Metoclopramide)4 • MOA: • Peripheral dopamine receptor inhibiton • Sensitizes tissues to acetylcholine (does not stimulate). • Postoperative nausea and vomiting: 10 to 20 mg IV/IM every 4 to 6 hours as needed • CrCl < 40mL/min: 50% dose • Geriatric: Initiate at 50% dose • Adverse Effects: • Asthenia • Headache, Fatigue, Somnolence • N/V

12. Reglan (Metoclopramide) • BBW – Tardive dyskinesia • Contraindications: • Concomitant use with drugs likely to cause extrapyramidal reactions  • Epilepsy • Gastrointestinal hemorrhage, mechanical obstruction, or perforation. • REMS program required for other Indications

13. Reglan Efficacy5 • Metoclopramide vs Ondansetron • According to a meta-analysis of 54 studies, metoclopramide is as effective as ondansetron in preventing postoperative nausea (59% vs 48%, respectively; p = 0.125) • Metoclopramide prevented postoperative vomiting in only 35% of patients compared with 50% of those using ondansetron (p < 0.001) • Metoclopramide vs Droperidol • Metoclopramide was inferior to droperidol in preventing both postoperative nausea and vomiting. • The incidence of nausea was 41% for droperidol and 52% for metoclopramide (p < 0.008); • The incidence of vomiting was 26% for droperidol versus 34% for metoclopramide (p < 0.001)

14. Aloxi (Palonosetron)6 • PONV; Prophylaxis: 0.075 mg IV as a single dose immediately before induction of anesthesia Major side effects • No Dose adjustments! • Contraindications?... Not really • Pregnancy Category B • Major drug interactions?... Not really… • Apomorphine

15. Aloxi (Palonosetron) • Adverse Effects: • Bradyarrhythmia (1-4%) • Constipation (5%) • Headache (9%) • One vial = about $400

16. Aloxi Vs. Ondansetron7 • A Randomized, Double-blind Trial of Palonosetron Compared with Ondansetron in Preventing Postoperative Nausea and Vomiting after GynaecologicalLaparoscopic Surgery. • Study design: • Induced with propofol • Intubated with rocuronium • NM blockade reversed with pyridostigmine and glycopyrolate

17. Aloxi Vs. Ondansetron7 • 0.075 mg Palonosetron , n = 45 • 8 mg Ondansetron, n = 45 • Results: • Over 24 hours, overall PONV in 30 ondansetron patients, 19 in palonosetron • Rescue antiemetics were used in an equal number of patients • Adverse Events: • Headache, Dizziness, Constipation, Myalgia • Basically the same • Patient Satisfaction: • 21 in ondansetron • 30 in palonosetron

18. References • 1.) Ting, P. Post-operative Nausea and Vomiting (PONV): An Overview. Available from http://anesthesiologyinfo.com/articles/04252004.php • 2.) Brenner GM, Stevens CW. Pharmacology. 4th Edition. Tulsa, OK. 2013 • 3.) Cherry W. Jackson, Amy Heck Sheehan, Jennifer G. Reddan. Evidence-Based Review of the Black-box Warning for Droperidol. Am J Health Syst Pharm. 2007;64(11):1174-1186.  • 4.) Metoclopramide. In: DRUGDEX Evaluations [database on the Internet]. Greenwood Village (CO): Thompson Micromedex; 1974-2014 [cited 18 Sep 2014]. • 5.) Domino KB, Anderson EA, Polissar NL, Posner KL. Comparative efficacy and safety of ondansetron, droperidol, and metoclopramide for preventing postoperative nausea and vomiting: a meta-analysis. Anesth Analg 1999;88:1370-9. • 6.) Palonosetron. In: DRUGDEX Evaluations [database on the Internet]. Greenwood Village (CO): Thompson Micromedex; 1974-2014 [cited 18 Sep 2014]. • 7.)Park SK, Cho EJ. A Randomized, Double-blind Trial of Palonsetron Compared with Ondansetron in Preventing Postoperative Nausea and Vomiting after GynaecologicalLapaoscopic Surgery. J Int Med Res. 2011 39: 399

19. Questions?