Consensus Guidelines for the Prevention of Postoperative Nausea and Vomiting

Pharmacologic Prophylaxis for PONV Based on Consensus Guidelines for the Management of PONV

CGM-PONV were developed under the auspices of the Society for Ambulatory Anesthesiology and published in January 2014.¹³ Compiled by a multidisciplinary international panel of experts, the guidelines provide evidence-based recommendations for PONV prophylaxis consisting of the most effective single-treatment and combination-treatment regimens. 

CGM-PONV state that current evidence does not support a universal administration of PONV prophylaxis to all patients undergoing surgical procedures.¹³ Rather, the guidelines provide an overview of prophylactic options for patients at moderate or high risk for PONV and advise a wait-and-see approach in patients at low risk for PONV.¹³

Prophylaxis in Adults at Moderate Risk for PONV

CGM-PONV recommend the use of 1 to 2 prophylaxis interventions in adults at moderate risk for PONV.¹³ The guidelines provide an overview of the latest clinical research on several classes of antiemetic agents including 5-hydroxytryptamine receptor antagonists (5-HT₃), neurokinin-1 (NK-1) receptor antagonists, butyrophenones, antihistamines, corticosteroids, and anticholinergics.¹³ Not all the drugs from these categories have been indicated for use in PONV by the Food and Drug Administration (FDA), and not all of them have been approved for use in the United States (US).¹³

5-HT₃ receptor antagonists evaluated for PONV include ondansetron, dolasetron, granisetron, tropisetron, ramosetron, and palonosetron of which ondansetron has been studied the most and is considered the “gold standard” of antiemetics.¹³ According to CGM-PONV, ramosetron and tropisetron are not approved in the United States, and dolasteron is no longer marketed in the United States. ¹³ Granisetron, dolasetron, ondansetron, and palonosetron had been approved for prevention of nausea and vomiting in the period from 1994 and 2003 and, presently, all except palonosetron are available in generic form.¹⁴ Due to the potential for serious cardiac risks, the FDA discontinued the marketing of the 32-mg single intravenous dose of ondansetron in 2012.¹⁵

NK-1 receptor antagonists mentioned in the guidelines include aprepitant, casopitant, and rolapitant. Aprepitant has been approved for use in PONV and has shown a significant antiemetic effect compared with ondansetron in clinical trials.^16,17 Casopitant and rolapitant have not been approved for use in PONV,¹³ while intravenous rolapitant has been approved in combination with other antiemetic agents for the prevention of delayed chemotherapy-induced nausea and vomiting (CINV) in adults.¹⁸

Corticosteroids evaluated for PONV prophylaxis include dexamethasone and methylprednisolone. According to CGM-PONV, dexamethasone is typically administered at anesthesia induction while methylprednisolone is effective for prevention of late-onset PONV.¹³ A recent study found that intraoperative dexamethasone at doses between 4 mg and 8 mg may carry a greater risk of postoperative infection.¹⁹

Butyrophenones evaluated in CGM-PONV include droperidol and haloperidol, as well as transdermal scopolamine, an anticholinergic.¹³

Other antiemetics discussed in the guidelines, with varying degrees of clinical evidence for use in PONV, include antihistamines (dimenhydrinate and meclizine), phenothiazines (perphenazine, metoclopramide), alpha₂ antagonists (clonidine and dexmedetomidine), as well as propofol, mirtazapine, gabapentin, and midazolam.¹³