This antiemetic may help kids skip that trip to the hospital

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This antiemetic may help kids skip that trip to the hospital

J Fam Pract. 2009 February;58(2):85-88

By

Thomas Gavagan, MD, MPH

Bernard Ewigman, MD, MSPH

For children with gastroenteritis, a single dose of ondansetron can reduce the vomiting—without IV fluids or serious side effects.

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References

1. DeCamp LS, Byerley JS, Doshi N, et al. Use of antiemetic agents in acute gastroenteritis, a systematic review and meta-analysis. Arch Pediatr Adolesc Med. 2008;162:858-865.

2. King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003;52(RR-16):1-16.

3. Malek MA, Curns AT, Holman RC, et al. Diarrhea- and rotavirus-associated hospitalizations among children less than 5 years of age: United States, 1997 and 2000. Pediatrics. 2006;117:1887-1892.

4. Practice parameter: the management of acute gastroenteritis in young children. American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Pediatrics. 1996;97:424-435.

5. World Health Organization. Clinical management of acute diarrhoea. WHO/Unicef joint statement. Available at http://www.who.int/child_adolescent_health/documents/who_fch_cah_04_7/en/index.html. Accessed January 15, 2009.

6. Szajewska H, Gieruszczak-Bialek D, Dylag M. Meta-analysis: ondansetron for vomiting in acute gastroenteritis in children. Aliment Pharmacol Ther. 2007;25:393-400.

7. Alhashimi D, Alhashimi H, Fedorowicz Z. Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents. Cochrane Database Syst Rev. 2006;(4):CD005506.-

8. Cubeddu LX, Trujillo LM, Talmaciu I, et al. Antiemetic activity of ondansetron in acute gastroenteritis. Aliment Pharmacol Ther. 1997;11:185-191.

9. Roslund G, Hepps TS, McQuillen KK. The role of oral ondansetron in children with vomiting as a result of acute gastritis/gastroenteritis who have failed oral rehydration therapy: a randomized controlled trial. Ann Emerg Med. 2008;52:22-29.

10. Reeves JJ, Shannon MW, Fleisher GR. Ondansetron decreases vomiting associated with acute gastroenteritis; a randomized, controlled trial. Pediatrics. 2002;109:e62.-Available at: http://pediatrics.aappublications.org/cgi/reprint/109/4/e62. Accessed January 12, 2009.

11. Ramsook C, Sahagun-Carreon I, Kozinetz CA, et al. A randomized clinical trial comparing oral ondansetron with placebo in children with vomiting from acute gastroenteritis. Ann Emerg Med. 2002;39:397-403.

12. Freedman SB, Adler M, Seshadri R, et al. Oral ondansetron for gastroenteritis in a pediatric emergency department. N Engl J Med. 2006;354:1698-1705.

13. Stork CM, Brown KM, Reilly TH, et al. Emergency department treatment of viral gastritis using intravenous ondansetron or dexamethasone in children. Acad Emerg Med. 2006;13:1027-1033.

Practice changer

Give oral ondansetron to children with acute gastroenteritis and moderate dehydration who are unable to tolerate oral rehydration to reduce the vomiting and avoid the need for intravenous (IV) hydration or hospitalization.¹

Strength of recommendation

A: Meta-analysis of 6 high-quality studies

DeCamp LS, Byerley JS, Doshi N, et al. Use of antiemetic agents in acute gastroenteritis, a systematic review and meta-analysis. Arch Pediatr Adolesc Med. 2008;162:858-865.

ILLUSTRATIVE CASE

Sarah, a 2-year-old who has been vomiting and had diarrhea for the past 2 days, is brought to your office by her parents. They tell you she’s unable to tolerate oral fluids, and vomited twice after being given small amounts of juice and soup earlier in the day. Sarah has decreased urine output, but she is not febrile and has no blood in her stools. On examination, you find mild tachycardia, dry mucous membranes, delayed capillary refill, and normal mental status.

You try giving Sarah an oral electrolyte solution, but she vomits immediately. Her parents are reluctant to take her to the emergency department for intravenous (IV) hydration, and ask if you can provide a safe and effective alternative.

Each year in the United States, pediatric gastroenteritis and dehydration are responsible for approximately 1.5 million outpatient visits² and 150,000 to 170,000 hospital admissions.³ Oral hydration, recommended by pediatric practice guidelines^2,4 and the World Health Organization,⁵ is safe and generally effective. But, as in Sarah’s case, emesis frequently interferes, leading to hospital admission for IV hydration.

FAST TRACK

Ondansetron does not have the sedating and extrapyramidal effects associated with older antiemetics.

An antiemetic with fewer adverse effects

Older antiemetic medications, such as promethazine, prochlorperazine, and metoclopramide, can cause sedation and extrapyramidal reactions. Ondansetron, a selective 5-hydroxytryptamine (5-HT₃) receptor antagonist that has been used to control postoperative and chemotherapy-associated nausea and vomiting in children and adults, does not cause either problem. In recent studies of ondansetron’s effectiveness in treating children with gastroenteritis, increased diarrhea, lasting up to 48 hours after administration, was the only adverse event.¹

Two earlier systematic reviews—a meta-analysis by Szajewska et al⁶ and a Cochrane review⁷—found clinical benefits of ondansetron for vomiting associated with acute gastroenteritis. But both concluded that the evidence was insufficient to recommend routine use of this drug. The meta-analysis that we review below included additional studies, and the researchers reached a different conclusion.

STUDY SUMMARY: Antiemetic decreases vomiting, hospitalization

DeCamp et al conducted a systematic review and meta-analysis of 11 prospective controlled trials that evaluated antiemetic use in children with vomiting from acute gastroenteritis.¹ Six of the 11 trials focused on ondansetron;^8-13 these 6 were the most recently published and of the highest quality. (The researchers found the remaining 5 trials to be of low methodological quality, with small sample sizes and inconsistent results, and concluded that the antiemetics they assessed should not be used for outpatients with gastroenteritis.) Their meta-analysis of these 6 trials is the focus of this PURL.

The ondansetron studies included a total of 745 children with vomiting and a clinical diagnosis of gastroenteritis. In 5 of the trials, patients received only 1 dose of ondansetron;^8-10,12,13 in the sixth, families received additional doses of ondansetron to use at home.¹¹ In 3 trials, patients were given oral ondansetron—a tablet placed on the tongue that dissolves in minutes. The remaining 3 used an IV formulation.^8,10,13 Five trials were conducted in emergency departments (EDs),^9-13 and 1 in an inpatient setting.⁸

Big reductions. Children who received ondansetron had significantly less vomiting (16.9% vs 37.8%) and IV fluid administration (13.9% vs 33.9%), and fewer hospital admissions (7.5% vs 14.6%) compared with patients who were given a placebo (TABLE). Diarrhea, the only adverse event to be systematically evaluated, was assessed in all but 1 of the trials.^8-12 In 3 of the 5 that reported on this side effect, patients who received ondansetron had an increase in diarrhea for up to 48 hours.^8,11,12

TABLE
Ondansetron reduces vomiting, hospitalization, and IV fluid use

TOTAL NUMBER OF PATIENTS (N=745)	ONDANSETRON	PLACEBO	RR (95% CI)	NNT (95% CI)
Continued vomiting (n=659)	16.9%	37.8%	0.45 (0.33-0.62)	5 (4-7)
IV fluid administration (n=489)	13.9%	33.9%	0.41 (0.28-0.62)	5 (4-8)
Hospital admission (n=662)	7.5%	14.6%	0.52 (0.27-0.95)	14 (9-44)
CI, confidence interval; IV, intravenous; NNT, number needed to treat; RR, relative risk.
Source: DeCamp LS, et al. Arch Pediatr Adolesc Med.¹