September 20, 2023
Given Medicare’s addition of several orthopedic procedures to its fee schedule, an increasingly graying population and a post-COVID effect that has predisposed...
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By: Tricia Meyer
Published: 7/14/2008
So long as post-operative nausea and vomiting (PONV) continues to have negative clinical and economic consequences, you can expect that pharmaceutical companies and researchers will continue to develop new agents, therapeutic options and antiemetic regimens. Here's a quick review of what's available to help anesthesia providers tailor antiemetic regimens for every patient.
Aprepitant has very few adverse effects, but it can interfere with oral contraceptives. Instruct patients taking such contraceptives to use another form of contraception for a month after taking aprepitant because the co-administration could disrupt the efficacy of hormonal contraceptives. It's difficult to determine the degree of this interaction because this problem is associated with the higher doses given for chemotherapy-induced nausea and vomiting, not the much smaller doses used to prevent PONV. However, the warning in the package insert is given for both the CINV and PONV doses and it is best to inform the patients of the need for alternate forms of birth control prior to administration.
Put together a winning combination
The true etiology of PONV remains a mystery. We're still unclear on exactly why some receptors stimulate nausea and vomiting and others do not. Prevention through combination therapy is showing greater efficacy in recent trials, as this lets us use multiple agents from different pharmacological classes to cover different receptor sites.
Studies conducted over the past five years make it clear that this is sound both in theory and in practice when treating patients at a moderate to high risk of PONV. Combination therapy may be particularly beneficial not only for the higher risk patients but also for cases where vomiting poses a particular medical risk. That may include patients undergoing procedures involving wired jaws or surgeries where we want to avoid intracranial pressure as much as possible.
The multimodal approach lets you combine the benefits of agents from different classes. For example, a combination of ondansetron and droperidol would give you the anti-vomiting properties of a 5-HT3 receptor antagonist with the anti-nausea properties of droperidol. This combination has been widely studied and the research shows that it is very effective.
But when planning a combination, bear in mind that that there is an increased potential for adverse effects when you use more drugs. Many of the older antiemetics, such as promethazine and antihistamine antiemetic drugs, could cause sedation, so combining these two could lead to a delay in discharge.
Dexamethasone is frequently given as combination therapy because it's so useful. Studies have shown similar efficacy in lower doses (4mg or 5mg) as it does for larger doses (8mg or 10mg) when used as an adjunct therapy, and at least one study noted it could also help to reduce the patient's pain, fatigue and time for coalescence.
But there are concerns about dexamethasone elevating blood glucose levels. Although many physicians may not be worried about using dexamethasone as a single agent and at a lower dose, there has been some conflicting data about this adverse effect, so further investigation is needed.
Plan for post-discharge illness
Post-discharge nausea and vomiting can occur after the patient leaves your facility. If you don't give these patients antiemetic prescriptions to take home for their PDNV, they may have difficulty managing their symptoms. We still need more research on PDNV risk factors and the optimal treatment for this problem. For now, consider using antiemetics with a longer duration of action, writing prescriptions for antiemetics when the patient is discharged and providing patient education for PDNV.
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