Aprepitant for the management of nausea with inpatient IV dihydroergotamine

Abstract

Objective:To assess the efficacy and tolerability of oral aprepitant, a substance P/neurokinin A receptor antagonist, in controlling nausea associated with IV dihydroergotamine (DHE) administered for medically refractory migrainous headache in patients not responding to standard antiemetics or with a history of uncontrolled nausea with DHE.Methods:This was a retrospective chart review of prospectively collected hourly diary data and clinical notes of patients hospitalized between 2011 and 2015 for inpatient treatment with DHE. Patients were classified using the International Classification of Headache Disorders, 3rd edition (beta version). Peak and average daily nausea scores from hourly diaries, or daily entries of notes, and concurrent antiemetic use were collected and tabulated.Results:Seventy-four patients, of whom 24 had daily diaries, with chronic migraine with or without aura, with or without medication overuse, or new daily persistent headache of a migrainous type, were identified. In 36 of 57 cases in which aprepitant was administered during hospitalization, there was a 50% reduction in the average daily number of as-needed antinausea medications. Of 57 patients, 52 reported that the addition of aprepitant improved nausea. Among 21 of 24 patients with hourly diary data, nausea scores were reduced and in all 12 with vomiting there was cessation of emesis after aprepitant was added. Aprepitant was well tolerated with no treatment emergent adverse events.Conclusions:Aprepitant can be effective in the treatment of refractory DHE-induced nausea and emesis. Given the broader issue of troublesome nausea and vomiting in acute presentations of migraine, general neurologists may consider what place aprepitant has in the management of such patients.Classification of evidence:This study provides Class IV evidence that for patients with medically refractory migraine receiving IV DHE, oral aprepitant reduces nausea.

Dihydroergotamine (DHE) – Then and Now: A Narrative Review

“…72 IV DHE is effective for treating migraine with a rapid onset of action, a sustained effect, and independence to time of migraine onset, 61 but high peak plasma concentrations often cause nausea and vomiting that requires pretreatment with an antiemetic. 43,95,96 IV DHE requires establishing IV access and close monitoring for side effects and is not suitable for "at home" administration. A DHE formulation that provides similar plasma exposure to IV DHE but without the high peak plasma concentrations offers a desirable efficacy and safety profile for treating acute migraine with rapid onset and sustained migraine relief with a lower risk of recurrence and good tolerability.…”

Medication-overuse headache: a narrative review

“…The main predictor of poor outcome of DHE is the development of nausea during admission [48]. Protocols including potent antiemetic drugs, such as aprepitant, can tackle this side effect improving the outcomes [50].…”

Pathophysiology and Therapy of Associated Features of Migraine

“…By inhibiting the substance P pathway, NK-1 receptor antagonists, such as aprepitant, have been used in the treatment of nausea generated by intravenous dihydroergotamine in patients with migraine [ 95 ]. NK1 receptor antagonists are potent antiemetics that have been approved for the treatment of severe nausea associated with chemotherapy [ 96 ], and are also recommended for cyclic vomiting syndrome, along with ondansetron or triptans [ 26 ].…”