Use of antiemetic agents in acute gastroenteritis - A systematic review and meta-analysis

Pediatric Education Office, Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Campus Box 7593, Chapel Hill, NC 27599, USA.
JAMA Pediatrics (Impact Factor: 5.73). 10/2008; 162(9):858-65. DOI: 10.1001/archpedi.162.9.858
Source: PubMed


To perform a systematic review and meta-analysis to determine whether taking antiemetic drugs reduces vomiting and decreases the need for further intervention in children with gastroenteritis without causing significant adverse effects.
Computerized databases, reference lists, and expert recommendations.
Prospective controlled trials evaluating medication use in children with vomiting from gastroenteritis.
Antiemetic drug therapy.
Emesis cessation, use of intravenous fluid for rehydration, hospital admission, return to care, and medication adverse effects.
The 11 articles that met the inclusion criteria evaluated various antiemetic agents: ondansetron (n = 6), domperidone (n = 2), trimethobenzamide (n = 2), pyrilamine-pentobarbital (n = 2), metoclopramide (n = 2), dexamethasone (n = 1), and promethazine (n = 1). Meta-analysis of 6 randomized, double-masked, placebo-controlled trials of ondansetron demonstrated decreased risk of further vomiting (5 studies; relative risk [RR], 0.45; 95% confidence interval [CI], 0.33-0.62; number needed to treat [NNT] = 5), reduced need for intravenous fluid (4 studies; RR, 0.41; 95% CI, 0.28-0.62; NNT = 5), and decreased risk of immediate hospital admission (5 studies; RR, 0.52; 95% CI, 0.27-0.95; NNT = 14). Diarrheal episodes increased in ondansetron-treated patients in 3 studies. Ondansetron use did not significantly affect return to care (5 studies; RR, 1.34; 95% CI, 0.77-2.35).
Ondansetron therapy decreases the risk of persistent vomiting, the use of intravenous fluid, and hospital admissions in children with vomiting due to gastroenteritis. Future treatment guidelines should incorporate ondansetron therapy for select children with gastroenteritis.

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    • "Systematic reviews and meta-analyses of the subject concluded that there are few studies on the role of ondansetron in the treatment of vomiting in children. While the evidence is not enough to be conclusive, a trend towards positive efficacy is seen [6, 12, 13] However, there are differences in methodology of studies included in these reviews such as route of administration for medication (orally vs. intravenously) [6]. For example, in a study by Ramsook et al [10] showed that oral ondansetron reduces the episodes of vomiting, the need for IVT, and hospitalization. "
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    ABSTRACT: Acute gastroenteritis (AGE) is a common condition among children that is frequently accompanied by vomiting. Symptomatic control of vomiting is important as it improves patient's general condition and reduces the need for intravenous therapy and hospitalization. Antiemetic agents including ondansetron and domperidone are used to provide symptomatic relief but the existing studies do not provide enough evidence of better efficacy for one over another. Seventy-six Thai children under the age of 15 with AGE were randomized to receive either ondansetron or domperidone. The primary outcome of the study was the proportion of the patients in each group who had no episode of vomiting 24 hours after the start of treatment. Primary outcome was met in 62% of patients in ondansetron group and 44% of patients in domperidone group (P = 0.16). Patients in domperidone group received more doses of the drug within 24 hours after the start of the treatment compared to ondansetron group (P = 0.01). No adverse effect was observed in any of the two groups. Ondansetron can be considered a safe comparable alternative to commonly-used domperidone in Thai children who suffer from symptoms of gastroenteritis. Larger clinical trials are needed to further explore the effectiveness of the two medications.
    Journal of Clinical Medicine Research 12/2013; 5(6):460-6. DOI:10.4021/jocmr1500w
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    • "The findings in this systematic review are to a large extent in agreement with those reported by the Cochrane reviews [26] and previously done meta-analysis on the same subject [27-31]. Although we differ from the previously carried out reviews as we have only included studies looking at children aged 0 to 12 years and we have evaluated the quality of the studies and the outcomes based on the LiST model as suggested by CHERG intervention review process. "
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    ABSTRACT: Diarrheal diseases are the second leading cause of childhood morbidity and mortality in developing countries and an important cause of malnutrition. An estimated 0.75 million children below 5 years of age die from diarrhea. Vomiting associated with acute gastroenteritis (AGE) is a distressing symptom and limits the success of oral rehydration in AGE leading to an increased use of intravenous rehydration, prolonged emergency department stay and hospitalization. In this review we estimate the effect of antiemetics in gastroenteritis in children. We conducted a systematic review of all the efficacy and effectiveness studies. We used a standardized abstraction and grading format and performed meta-analyses for all outcomes with more than two studies. The estimated effect of antiemetics was determined by applying the standard Child Health Epidemiology Reference Group (CHERG) rules. We included seven studies in the review. Antiemetics significantly reduced the incidence of vomiting and hospitalization by 54%. Antiemetics also significantly reduced the intravenous fluid requirements by 60%, while it had a non-significant effect on the ORT tolerance and revisit rates. Antiemetics are effective for the management of gastroenteritis in children and have the potential to decrease morbidity and mortality burden due to diarrhea, when introduced and scaled up.
    BMC Public Health 09/2013; 13 Suppl 3(Suppl 3):S9. DOI:10.1186/1471-2458-13-S3-S9 · 2.26 Impact Factor
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    • "All these studies compared ondansetron versus placebo. Furthermore two RCTs included the comparison of ondansetron to metoclopramide and dexamethasone [16]. In three studies ondansetron was administrated per os and in the other three intravenous administration was preferred. "
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    ABSTRACT: Vomiting in children with acute gastroenteritis (AG) is not only a direct cause of fluid loss but it is also a major factor of failure of oral rehydration therapy (ORT). Physicians who provide care to paediatric patients in the emergency department (ED) usually prescribe intravenous fluid therapy (IVT) for mild or moderate dehydration when vomiting is the major symptom. Thus, effective symptomatic treatment of vomiting would lead to an important reduction in the use of IVT and, consequently, of the duration of hospital stay and of frequency of hospital admission. Available evidence on symptomatic treatment of vomiting shows the efficacy of the most recently registered molecule (ondansetron) but a proper evaluation of antiemetics drugs largely used in clinical practice, such as domperidone, is lacking. To compare the efficacy of ondansetron and domperidone for the symptomatic treatment of vomiting in children with AG who have failed ORT. Multicentre, double-blind randomized controlled trial conducted in paediatric EDs. Children aged from 1 to 6 years who vomiting, with a presumptive clinical diagnosis of AG, and without severe dehydration will be included. After the failure of a initial ORS administration in ED, eligible children will be randomized to receive: 1) ondansetron syrup (0,15 mg/Kg of body weight); 2) domperidone syrup (0,5 mg/Kg of body weight); 3) placebo. The main study outcome will be the percentage of patients needing nasogastric or IVT after symptomatic oral treatment failure, defined as vomiting or fluid refusal after a second attempt of ORT. Data relative to study outcomes will be collected at 30 minute intervals for a minimum of 6 hours. A telephone follow up call will be made 48 hours after discharge. A total number of 540 children (i.e. 180 patients in each arm) will be enrolled. The trial results would provide evidence on the efficacy of domperidone, which is largely used in clinical practice despite the lack of proper evaluation and a controversial safety profile, as compared to ondansetron, which is not yet authorized in Italy despite evidence supporting its efficacy in treating vomiting. The trial results would contribute to a reduction in the use of IVT and, consequently, in hospital admissions in children with AG. The design of this RCT, which closely reflect current clinical practice in EDs, will allow immediate transferability of results. NCT01257672.
    BMC Pediatrics 02/2011; 11(1):15. DOI:10.1186/1471-2431-11-15 · 1.93 Impact Factor
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