LONDON—Metoclopramide significantly reduced the incidence of pneumonia in intubated stroke patients and was associated with improved mortality in a single-center, randomized controlled study. A total of 34 of 60 (57%) patients in the trial developed pneumonia, of whom the majority (87%) received a placebo, while only eight (27%) cases occurred in patients who received the antiemetic therapy. A third of the cohort died by 30 days, but of these 20 deaths, 12 occurred in the placebo group, compared with eight in the metoclopramide arm.
Anushka B. Warusevitane, MD, of the University Hospital of North Staffordshire in Stoke-on-Trent, UK, presented the findings at the 22nd Annual European Stroke Conference and noted that neurologic improvement was also seen in the patients given metoclopramide.
For the whole group, NIH Stroke Scale scores were 19.3 at baseline, indicating moderate to severe stroke, 16.8 at one week, 17.4 at two weeks, and 19.6 at three weeks poststroke. In the trial, adult patients admitted to the acute stroke unit within seven days of having a stroke and who needed a nasogastric tube fitted for more than 24 hours were randomized to receive metoclopramide 10 mg three times a day or the same volume of a similar-looking placebo for a maximum of three weeks. All patients received standard stroke care. The average age of the 60 patients finally recruited was 78 years; 63% were female, and 93% had cerebral infarcts.
Pneumonia was diagnosed according to guidance from the British Thoracic Society, which states that patients need to fulfill the following four criteria: acute lower respiratory tract infection symptoms; new focal chest signs; fever (more than 38° C), chills and rigors, elevated white cell count, or increased inflammatory markers; and new radiologic shadowing.
Dr. Warusevitane reported that all of the episodes of pneumonia seen occurred within 10 days of the initiation of nasogastric feeds. The average time for pneumonia to develop was significantly longer in the metoclopramide group (four days versus two days for placebo). Significantly shorter periods of antibiotic use were noted in the active versus placebo arm, at a mean of two days and eight days, respectively.
Only one patient given metoclopramide had an episode of aspiration, which was witnessed by a health care professional, compared with 14 patients given placebo. There was also evidence that once the nasogastric tube was removed, the actively treated patients had a better swallowing response.
“I’m convinced enough to change practice locally,” said senior study author Christine Roffe, MD, in an interview. Dr. Roffe, Professor of Medicine at Keele University in the UK, conceded that the results of a single-center study of 60 patients might not be enough to convince the wider stroke community.
However, metoclopramide is a standard antiemetic treatment that is already being given to intubated patients, Dr. Roffe observed. Ensuring that it is used more routinely may be a simple strategy that could have a major effect on stroke patients’ outcome, she suggested.
—Sara Freeman
IMNG Medical News