Aprepitant vs. multimodal prophylaxis in the prevention of nausea and vomiting following extended-release epidural morphine.
BACKGROUND
Extended-release epidural morphine (EREM) is an effective option for postoperative analgesia following major orthopedic surgery; however, postoperative nausea/vomiting (PONV) is a recognized limitation. The incidence of PONV following prophylactic aprepitant, a neurokinin-1 antagonist, was compared with prophylactic multimodal antiemetic therapy in patients receiving EREM for postoperative analgesia following unilateral primary total knee arthroplasty (TKA).


METHODS
Prospectively collected quality assurance data were examined with Institutional Review Board approval. A sequential, open-label, active matched case-control study compared PONV following EREM in patients receiving ondansetron and dexamethasone, and either metoclopramide, diphenhydramine, or prochlorperazine every 6 hours for the 48-hour study period, to patients receiving aprepitant 40 mg given as a single oral dose in the preoperative holding area. Cases were matched for procedure (TKA), age, epidural morphine dose, and known major risk factors for PONV (sex, smoking, previous PONV/motion sickness).


RESULTS
Twelve consecutive patients (3 male; 9 female) receiving aprepitant prior to EREM were matched to 12 patients of the same sex of similar age (range 51 to 84 years.) and EREM dose (range 5 to 12.5 mg) receiving the multimodal regime. The incidence of PONV was significantly less for the aprepitant group where 3 of 12 (25%) had PONV compared with 9 of 12 (75%) in the multimodal group (P = 0.039, Fisher's Exact Test; odds ratio = 0.11; 95% CI: 0.018 to 0.706, P = 0.03).


CONCLUSIONS
While aprepitant significantly reduced the incidence of PONV compared with a multimodal antiemetic regime, used alone it did not eliminate PONV.
Department of Anesthesiology, William Beaumont Hospital-Troy, Troy, Michigan 48085, USA. chartrick@beaumont.edu
Craig T
CT
Hartrick
Yeong-Shiuh
YS
Tang
David
D
Hunstad
John
J
Pappas
Kathy
K
Muir
Cecile
C
Pestano
Daniel
D
Silvasi
D000368:Aged; D000369:Aged, 80 and over; D000767:Anesthesia, Epidural / Q000009:adverse effects*; D000932:Antiemetics / Q000627:therapeutic use*; D000077608:Aprepitant; D016022:Case-Control Studies; D016503:Drug Delivery Systems; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009020:Morphine / Q000009:adverse effects*; D009025:Morpholines / Q000627:therapeutic use*; D009325:Nausea / Q000139:chemically induced / Q000517:prevention & control*; D016017:Odds Ratio; D010146:Pain / Q000150:complications / Q000188:drug therapy / Q000209:etiology; D011183:Postoperative Complications / Q000503:physiopathology; D011446:Prospective Studies; D012189:Retrospective Studies; D014839:Vomiting / Q000139:chemically induced / Q000517:prevention & control*
D000932:Antiemetics; D009025:Morpholines; D000077608:Aprepitant; D009020:Morphine