Drugs for preventing postoperative nausea and vomiting in adults after general anaesthesia: an abridged Cochrane network meta‐analysis

Abstract

Postoperative 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 5hydroxytryptamine 3 , 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 962

Postoperative Vomiting Following Laparoscopic Cholecystectomy Is Associated with Intraoperative Fluid Administration: A Retrospective Cohort Study

“…As PONV or POV involves many different pathological pathways, multimodal approach with combination of pharmacological and nonpharmacological prophylaxis along with interventions is generally employed in patients with high PONV risk to reduce baseline risk [ 22 ]. Although many new antiemetic agents have been introduced and provided considerable beneficial effects, there is still considerable lack of evidence regarding safety aspects that does warrant investigation [ 23 ]. Recently, genetic study for PONV revealed that the CHRM3 polymorphism and the Apfel score independently predict PONV susceptibility and suggested that dexamethasone/acustimulation should be considered in patients with low Apfel score but at high genetic risk [ 24 ].…”

Anti‐emetic drugs for preventing postoperative nausea and vomiting: new evidence from a Cochrane network meta‐analysis

“…1). Figure 2 is a more complex example, taken from the review by Weibel et al [9], although the principles are the same. It shows the network geometry of eligible comparisons for PONV within 24 h of surgery.…”

“…Figure 2 Network geometry of eligible comparisons for postoperative vomiting within 24 h after surgery. Reproduced from [9]. aprepitant, and also argues for the replacement of less effective drugs such as metoclopramide.…”

Amisulpride: A New Drug for Management of Postoperative Nausea and Vomiting

“…However, an abridged Cochrane network meta-analysis of 585 studies that compared various drugs for prevention of PONV was published in November 2020. 30 The RR for incidence of PONV when used as a single agent was reported as the following (in order of highest to lowest efficacy): 0.06 to 0.56 for NK1 receptor antagonists, 0.44 to 0.62 for 5-HT 3 antagonists, 0.51 for dexamethasone, 0.53 to 0.55 for antihistamines, 0.61 for scopolamine, and 0.61 to 0.73 for dopamine antagonists. Among the individual dopamine antagonists, the following RR were found (in order of highest to lowest efficacy): 0.61 for haloperidol, 0.61 for droperidol, 0.71 for amisulpride, and 0.73 for metoclopramide.…”