Review Meta Analysis
Aprepitant (NK1), ramosetron (5HT3), granisetron (5HT3), ondanestron (5HT3) & dexamethasone (steroid) all significantly reduce postoperative nausea & vomiting when used as prophylaxis with a high evidence certainty.pearl
- S Weibel, M S Schaefer, D Raj, G Rücker, N L Pace, T Schlesinger, P Meybohm, P Kienbaum, EberhartL H JLHJDepartment of Anaesthesiology and Intensive Care Medicine, Philipps-University Marburg, Marburg, Germany., and P Kranke.
- Department of Anaesthesia and Critical Care, University of Wuerzburg, Wuerzburg, Germany.
- Anaesthesia. 2021 Jul 1; 76 (7): 962-973.
AbstractPostoperative nausea and vomiting is a common adverse effect of anaesthesia. Although dozens of different anti-emetics are available for clinical practice, there is currently no comparative ranking of efficacy and safety of these drugs to inform clinical practice. We performed a systematic review with network meta-analyses to compare, and rank in terms of efficacy and safety, single anti-emetic drugs and their combinations, including 5-hydroxytryptamine3 , dopamine-2 and neurokinin-1 receptor antagonists; corticosteroids; antihistamines; and anticholinergics used to prevent postoperative nausea and vomiting in adults after general anaesthesia. We systematically searched for placebo-controlled and head-to-head randomised controlled trials up to November 2017 (updated in April 2020). We assessed how trustworthy the evidence was using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and Confidence In Network Meta-Analysis (CINeMA) approaches for vomiting within 24 h postoperatively, serious adverse events, any adverse event and drug class-specific side-effects. We included 585 trials (97,516 participants, 83% women) testing 44 single drugs and 51 drug combinations. The studies' overall risk of bias was assessed as low in only 27% of the studies. In 282 trials, 29 out of 36 drug combinations and 10 out of 28 single drugs lowered the risk of vomiting at least 20% compared with placebo. In the ranking of treatments, combinations of drugs were generally more effective than single drugs. Single neurokinin-1 receptor antagonists were as effective as other drug combinations. Out of the 10 effective single drugs, certainty of evidence was high for aprepitant, with risk ratio (95%CI) 0.26 (0.18-0.38); ramosetron, 0.44 (0.32-0.59); granisetron, 0.45 (0.38-0.54); dexamethasone, 0.51 (0.44-0.57); and ondansetron, 0.55 (0.51-0.60). It was moderate for fosaprepitant, 0.06 (0.02-0.21) and droperidol, 0.61 (0.54-0.69). Granisetron and amisulpride are likely to have little or no increase in any adverse event compared with placebo, while dimenhydrinate and scopolamine may increase the number of patients with any adverse event compared with placebo. So far, there is no convincing evidence that other single drugs effect the incidence of serious, or any, adverse events when compared with placebo. Among drug class specific side-effects, evidence for single drugs is mostly not convincing. There is convincing evidence regarding the prophylactic effect of at least seven single drugs for postoperative vomiting such that future studies investigating these drugs will probably not change the estimated beneficial effect. However, there is still considerable lack of evidence regarding safety aspects that does warrant investigation.© 2020 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.
Interesting Cochrane meta-analysis looking at PONV prophylaxis from German (Weibel et al. 2021) that included almost 100,000 study participants across 585 trials. Interesting not so much because it confirms much of what we already new (or assumed, based on our common PONC prophylaxis drug choices), but because it reassures us that side-effects from commonly used PONV drugs are low to non-existent.
Takeaway: granisetron is probably the best single-agent or in combination with other agents because of it's efficacy (better than ondansetron), low-cost, long duration, and absent side-effects.
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