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Duke University Medical Center, Durham, NC, gan00001{at}mc.duke.edu, Roche Laboratories, Nutley, NJ, Brigham & Women’s Hospital, Boston, MA
In Response:
We appreciate Dr. Neustein’s letter (1) in response to our recent study comparing granisetron plus dexamethasone to ondansetron plus dexamethasone (2). The use of combination antiemetics to prevent postoperative nausea and vomiting (PONV) in high-risk patients is well established (3,4). A recent large, multicenter study found that combining various antiemetics, for example ondansetron, dexamethasone, and droperidol, with propofol as the maintenance anesthetic was an effective prophylactic strategy. Each antiemetic reduces the relative risk of PONV by 20% to 25%; the effect is additive when these antiemetics are used in combination (5).
When a patient does not respond to an adequate dose of a 5-HT3 antagonist, evidence suggests that using an antiemetic from a different class is more appropriate than repeating the same dose (4). Kovac et al. (6), in a large multicenter study, found no advantage to administering ondansetron 4 mg again, after failure of an identical prophylactic dose. In turn, if a 5-HT3 antagonist plus dexamethasone fails, then one should treat the patient with a drug from another class, for instance droperidol or promethazine (7).
In a pilot multicenter, randomized, placebo-controlled study, D’Angelo et al. (8) compared granisetron 0.1 mg, granisetron 0.2 mg, granisetron 0.3 mg, and placebo—each administered as a single IV injection approximately 15 min before the end of surgery. The investigators demonstrated that all three granisetron doses were more effective than a placebo in preventing PONV in the first 6 h after abdominal hysterectomy. However, this pilot study was not specifically designed to have adequate sample size to identify a dose-response relationship.
In summary, for patients at high-risk for PONV, one should combine antiemetics from different classes.
References
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