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Review
, 2015 (9), CD010106

Drugs for the Treatment of Nausea and Vomiting in Adults in the Emergency Department Setting

Affiliations
Review

Drugs for the Treatment of Nausea and Vomiting in Adults in the Emergency Department Setting

Jeremy S Furyk et al. Cochrane Database Syst Rev.

Abstract

Background: Nausea and vomiting is a common and distressing presenting complaint in emergency departments (ED). The aetiology of nausea and vomiting in EDs is diverse and drugs are commonly prescribed. There is currently no consensus as to the optimum drug treatment of nausea and vomiting in the adult ED setting.

Objectives: To provide evidence of the efficacy and safety of antiemetic medications in the management of nausea and vomiting in the adult ED setting.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 8), MEDLINE (OvidSP) (January 1966 to August 2014), EMBASE (OvidSP) (January 1980 to August 2014) and ISI Web of Science (January 1955 to August 2014). We also searched relevant clinical trial registries and conference proceedings.

Selection criteria: We included randomized controlled trials (RCTs) of any drug in the treatment of nausea and vomiting in the treatment of adults in the ED. Study eligibility was not restricted by language or publication status.

Data collection and analysis: Two review authors independently performed study selection, data extraction and assessment of risk of bias in included studies. We contacted authors of studies to obtain missing information if required.

Main results: We included eight trials, involving 952 participants, of which 64% were women. Included trials were generally of adequate quality, with six trials at low risk of bias, and two trials at high risk of bias. Three trials with 518 participants compared five different drugs with placebo; all reported the primary outcome as mean change in visual analogue scale (VAS) (0 to 100) for nausea severity from baseline to 30 minutes. Trials did not routinely report other primary outcomes of the change in nausea VAS at 60 minutes or number of vomiting episodes. Differences in mean VAS change from baseline to 30 minutes between placebo and the drugs evaluated were: metoclopramide (three trials, 301 participants; mean difference (MD) -5.27, 95% confidence interval (CI) -11.33 to 0.80), ondansetron (two trials, 250 participants; MD -4.32, 95% CI -11.20 to 2.56), prochlorperazine (one trial, 50 participants; MD -1.80, 95% CI -14.40 to 10.80), promethazine (one trial, 82 participants; MD -8.47, 95% CI -19.79 to 2.85) and droperidol (one trial, 48 participants; MD -15.8, 95% CI -26.98 to -4.62). The only statistically significant change in baseline VAS to 30 minutes was for droperidol, in a single trial of 48 participants. No other drug was statistically significantly superior to placebo. Other included trials evaluated a drug compared to "active controls" (alternative antiemetic). There was no convincing evidence of superiority of any particular drug compared to active control. All trials included in this review reported adverse events, but they were variably reported precluding meaningful pooling of results. Adverse events were generally mild, there were no reported serious adverse events. Overall, the quality of the evidence was low, mainly because there were not enough data.

Authors' conclusions: In an ED population, there is no definite evidence to support the superiority of any one drug over any other drug, or the superiority of any drug over placebo. Participants receiving placebo often reported clinically significant improvement in nausea, implying general supportive treatment such as intravenous fluids may be sufficient for the majority of people. If a drug is considered necessary, choice of drug may be dictated by other considerations such as a person's preference, adverse-effect profile and cost. The review was limited by the paucity of clinical trials in this setting. Future research should include the use of placebo and consider focusing on specific diagnostic groups and controlling for factors such as intravenous fluid administered.

Conflict of interest statement

Jeremy S Furyk: none known.

Robert Meek and Diana Egerton‐Warburton are authors of one of the trials included in this review (Egerton‐Warburton 2014).

JF and RM independently appraised the study for inclusion, risk of bias and data extraction.

There were no disagreements in this process, or need for independent arbiter.

Figures

Figure 1
Figure 1
Study flow diagram.
Figure 2
Figure 2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figure 3
Figure 3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figure 4
Figure 4
Forest plot of comparison: 1 Metoclopramide versus placebo, outcome: 1.1 Change in nausea severity at 30 minutes.
Figure 5
Figure 5
Forest plot of comparison: 3 5HT‐3 Antagonists versus active control, outcome: 6.1 Change in nausea severity at 30 minutes.
Analysis 1.1
Analysis 1.1
Comparison 1 Metoclopramide versus placebo, Outcome 1 Change in nausea severity at 30 minutes.
Analysis 1.2
Analysis 1.2
Comparison 1 Metoclopramide versus placebo, Outcome 2 Proportion of participants requiring rescue medication.
Analysis 1.3
Analysis 1.3
Comparison 1 Metoclopramide versus placebo, Outcome 3 Participant satisfaction.
Analysis 2.1
Analysis 2.1
Comparison 2 Ondansetron versus placebo, Outcome 1 Change in nausea severity at 30 minutes.
Analysis 2.2
Analysis 2.2
Comparison 2 Ondansetron versus placebo, Outcome 2 Proportion of participants requiring rescue medication.
Analysis 3.1
Analysis 3.1
Comparison 3 Metoclopramide versus active control, Outcome 1 Change in nausea severity at 30 minutes.
Analysis 3.2
Analysis 3.2
Comparison 3 Metoclopramide versus active control, Outcome 2 Proportion of participants requiring rescue medication.
Analysis 3.3
Analysis 3.3
Comparison 3 Metoclopramide versus active control, Outcome 3 Participant satisfaction.
Analysis 4.1
Analysis 4.1
Comparison 4 Metoclopramide versus 5HT3 antagonist, Outcome 1 Change in nausea severity at 30 minutes.
Analysis 4.2
Analysis 4.2
Comparison 4 Metoclopramide versus 5HT3 antagonist, Outcome 2 Proportion of participants requiring rescue medication.
Analysis 5.1
Analysis 5.1
Comparison 5 Metoclopramide versus ondansetron, Outcome 1 Change in nausea severity at 30 minutes.
Analysis 5.2
Analysis 5.2
Comparison 5 Metoclopramide versus ondansetron, Outcome 2 Proportion of participants requiring rescue medication.
Analysis 6.1
Analysis 6.1
Comparison 6 5HT3 Antagonists versus active control, Outcome 1 Change in nausea severity at 30 minutes.
Analysis 6.2
Analysis 6.2
Comparison 6 5HT3 Antagonists versus active control, Outcome 2 Proportion of participants requiring rescue medication.
Analysis 6.3
Analysis 6.3
Comparison 6 5HT3 Antagonists versus active control, Outcome 3 Proportion of participants who required hospital admission.
Analysis 7.1
Analysis 7.1
Comparison 7 Ondansetron versus active control, Outcome 1 Change in nausea severity at 30 minutes.
Analysis 7.2
Analysis 7.2
Comparison 7 Ondansetron versus active control, Outcome 2 Proportion of participants requiring rescue medication.
Analysis 7.3
Analysis 7.3
Comparison 7 Ondansetron versus active control, Outcome 3 Participant satisfaction.
Analysis 8.1
Analysis 8.1
Comparison 8 Ondansetron versus promethazine, Outcome 1 Change in nausea severity at 30 minutes.
Analysis 8.2
Analysis 8.2
Comparison 8 Ondansetron versus promethazine, Outcome 2 Proportion of participants requiring rescue medication.
Analysis 9.1
Analysis 9.1
Comparison 9 Prochlorperazine versus active control, Outcome 1 Change in nausea severity at 30 minutes.
Analysis 9.2
Analysis 9.2
Comparison 9 Prochlorperazine versus active control, Outcome 2 Proportion of participants requiring rescue medication.
Analysis 9.3
Analysis 9.3
Comparison 9 Prochlorperazine versus active control, Outcome 3 Proportion of participants who required hospital admission.
Analysis 10.1
Analysis 10.1
Comparison 10 Promethazine versus active control, Outcome 1 Change in nausea severity at 30 minutes.
Analysis 10.2
Analysis 10.2
Comparison 10 Promethazine versus active control, Outcome 2 Proportion of participants requiring rescue medication.
Analysis 10.3
Analysis 10.3
Comparison 10 Promethazine versus active control, Outcome 3 Proportion of participants who required hospital admission.

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