BMJ  2006;333:313-314 (12 August), doi:10.1136/bmj.333.7563.313

Editorial

Postoperative nausea and vomiting

Metaclopramide with dexamethasone works and has few side effects

Fifteen years ago Kapur described postoperative nausea and vomiting as the "big, little problem,"¹ a description that still applies despite the best efforts of doctors and drug companies. In this issue of the BMJ, Wallenborn and colleagues revisit the use of metoclopramide to prevent postoperative nausea and vomiting.² In the United Kingdom, metoclopramide is no longer a popular choice for prophylaxis or treatment. This is because the standard 10 mg dose is not very effective³; metoclopramide has unpleasant side effects such as extrapyramidal symptoms, especially with repeated doses; and it has been supplanted by newer agents that are more expensive but have fewer complications.

The likelihood of postoperative nausea and vomiting is increased by several factors including the type of surgery (for example, laparoscopic, gynaecological, and ophthalmic surgery), certain anaesthetic drugs including volatiles and opioids, patient factors including female sex, a history of postoperative nausea and vomiting, and non-smoking status.⁴ The most effective treatment is usually a combination of agents that target different pathways or receptors.⁵ These include antihistamines, anticholinergics, antidopaminergics, 5-hydroxytryptamine receptor (5-HT₃) antagonists, and drugs with poorly understood modes of action such as dexamethasone.⁶ A popular combination in the UK at present is a 5-HT₃ antagonist such as ondansetron or tropisetron combined with dexamethasone, with the addition of agents from another class such as promethazine or cyclizine for rescue or for resistant cases.⁷

Wallenborn and colleagues have taken the innovative step of revisiting the effects of metoclopramide in a randomised trial using the standard 10 mg dose and also doses of 25 mg and 50 mg (doses that will be unfamiliar to most doctors in the UK). Metoclopramide was added to dexamethasone in more than 3000 patients having elective surgery. Both the 25 mg and 50 mg combinations were strikingly effective in reducing early postoperative nausea and vomiting, and 50 mg also prevented late nausea and vomiting. Side effects, mostly hypotension and tachycardia, were few. The incidence of dyskinesia and extrapyramidal side effects was also surprisingly low—0.4% in the 25 mg group and 0.8% in the 50 mg group (number needed to harm 156 for both doses).

Newer drugs such as 5-HT₃ antagonists have undoubtedly improved outcomes; a neurokinin receptor antagonist (aprepitant) has also been introduced in the UK for the treatment of chemotherapy induced nausea and vomiting.⁸ However, the mechanism underlying postoperative nausea and vomiting is so complex that a universal panacea is unlikely, and a multimodal approach is best for both prevention and treatment. In this regard, the optimum dose of metoclopramide combined with dexamethasone offers another option for prevention of nausea and vomiting or as an adjunct or alternative to existing treatment.

A head to head trial of metoclopramide and dexamethasone versus a 5-HT₃ antagonist combined with dexamethasone would be the next logical step. In the meantime, the trial by Wallenburg et al supports metoclopramide as an option for the prevention and treatment of postoperative nausea and vomiting. This use of metoclopramide would probably result in considerable cost saving compared with the newer 5-HT₃ antagonists, such as palonosetron, despite their longer duration of action.

Finally, Wallenborn and colleagues also found that regular consumption of alcohol protects against postoperative nausea and vomiting. This finding adds to the debate about why certain factors, such as smoking, protect against postoperative nausea and vomiting.⁵

Poole and Royal Bournemouth Hospital, Bournemouth BH7 7DW
(bpsween{at}aol.com)

---

Research p 324

References

1. Kapur PA. The big, little problem. Anaesth Analg 1991;72: 243-5.
2. Wallenborn J, Gelbrich G, Bulst D, Behrends K, Wallenborn H, Rohrbach A, et al. Prevention of postoperative nausea and vomiting by metoclopramide combined with dexamethasone: randomised double blind multicentre trial. BMJ 2006;333: 324-7.[Abstract/Free Full Text]
3. Henzi I, Walder B, Tramer MR. Metoclopramide in the prevention of postoperative nausea and vomiting: a quantitative systematic review of randomised, placebo-controlled studies. Br J Anaesth 1999;83: 761-71.[Abstract/Free Full Text]
4. Apfel CC, Greim CA, Haubitz I, Goepfert C, Usadel J, Sefrin P, et al. A risk score to predict the probability of postoperative vomiting in adults. Acta Anaesth Scand 1998;42: 495-501.[ISI][Medline]
5. Habib AS, Gan TJ. Combination therapy for postoperative nausea and vomiting: a more effective prophylaxis? Ambulatory Surg 2001;9: 59-71.
6. Gan TJ, Meyer T, Apfel CC, Chung F, Davis PJ, Eubanks S, et al. Consensus guidelines for managing postoperative nausea and vomiting. Anesth Analg 2003;97: 62-71.[Abstract/Free Full Text]
7. Apfel CC, Kortilla K, Abdalla M, Kerger H, Turan A, Vedder I, et al. A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. N Engl J Med 2004;350: 2441-51.[Abstract/Free Full Text]
8. Aapro M, Johnson J. Chemotherapy-induced emesis in elderly cancer patients: the role of 5-HT3-receptor antagonists in the first 24 hours. Gerontology 2005;51: 287-96.[Medline]
9. Sweeney BP. Why are smokers protected against PONV [editorial]? Br J Anaesth 2002;89: 1-4.[Free Full Text]

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Related Articles

Preventing postoperative nausea and vomiting: Prevention in context

John B Carlisle
BMJ 2006 333: 448. [Extract] [Full Text]

Prevention of postoperative nausea and vomiting by metoclopramide combined with dexamethasone: randomised double blind multicentre trial

Jan Wallenborn, Götz Gelbrich, Detlef Bulst, Katrin Behrends, Hasso Wallenborn, Andrea Rohrbach, Uwe Krause, Thomas Kühnast, Martin Wiegel, and Derk Olthoff
BMJ 2006 333: 324. [Abstract] [Full Text] [PDF]

This article has been cited by other articles:

• Carlisle, J. B (2006). Preventing postoperative nausea and vomiting: prevention in context.. BMJ 333: 448-448 [Full text]  

Rapid Responses:

Read all Rapid Responses

Metoclpramide for nausea and vomiting

Giles W Stevenson
bmj.com, 14 Aug 2006 [Full text]