Kranke Peter, Schuster Frank, Eberhart Leopold H
University Hospitals of Würzburg, Department of Anaesthesiology, D-97080 Würzburg, Germany.
Expert Opin Pharmacother. 2007 Dec;8(18):3217-35. doi: 10.1517/14656566.8.18.3217.
During the last two decades there have been considerable achievements regarding the management of postoperative nausea and vomiting (PONV). Due to the importance of these symptoms in the aim to streamline clinical processes and to improve patient satisfaction, the debate on the best strategies and also research that focuses on PONV continues. This review summarises the recent developments with respect to the management of PONV. Following a brief review on what is already known on the risk assessment, prevention and treatment of PONV, newer trends in the pharmacological prevention (dexamethasone, neurokinin-1 antagonists, multimodal prevention) will be discussed as well as new insights regarding the value of algorithms for the prevention of PONV. Further, pharmacogenetically based algorithms (according to the metaboliser status) as well as new treatment strategies (dexamethasone, multimodal treatment) will be covered. No drug so far can achieve a reduction of PONV of more than one third. Furthermore, all clinical studies consistently demonstrated that a combination treatment has a simple additive effect without any relevant interaction between different drugs or classes of drugs. The relative reduction of approximately 30% can also be expected from dexamethasone and it is likely that the substances presently in development and in an early clinical use (e.g., neurokinin-1 antagonists) will not represent the new panacea. However, they will probably replenish the existing antiemetic portfolio to better cope with high risk patients. Stratified prevention using pharmacogenetic knowledge is still in the early stages. Algorithms need to be customized to the local settings in order to prove efficient. Treatment remains a most important pillar and there is evidence that the principles of combining antiemetics to prolong effects and improve protection can be similarly applied to treatment. Recent developments in the area of PONV are more related to implementing the already existing evidence than based on the introduction of new molecules. New molecules replenish the pharmacological antiemetic portfolio, which is needed due to the limited efficacy of any single agent available so far. The new neurokinin-1 receptor antagonist, aprepitant, and the long lasting 5-HT(3) receptor antagonist palonosetron are the latest developments in this context. Treatment is most important and can also be regarded as a secondary prevention. Due to limited efficacy of single treatment interventions, combination therapy may gain more widespread use in the future.
在过去二十年中，术后恶心呕吐（PONV）的管理取得了显著成就。鉴于这些症状对于简化临床流程和提高患者满意度的重要性，关于最佳策略的争论以及针对PONV的研究仍在继续。本综述总结了PONV管理方面的最新进展。在简要回顾了PONV风险评估、预防和治疗的已知情况后，将讨论药物预防的新趋势（地塞米松、神经激肽-1拮抗剂、多模式预防）以及PONV预防算法价值的新见解。此外，还将涵盖基于药物遗传学的算法（根据代谢状态）以及新的治疗策略（地塞米松、多模式治疗）。到目前为止，尚无药物能将PONV降低超过三分之一。此外，所有临床研究一致表明，联合治疗具有简单的相加效应，不同药物或药物类别之间没有任何相关相互作用。地塞米松也有望实现约30%的相对降低，目前正在研发和早期临床使用的物质（如神经激肽-1拮抗剂）可能不会成为新的万灵药。然而，它们可能会补充现有的止吐药物组合，以更好地应对高风险患者。利用药物遗传学知识进行分层预防仍处于早期阶段。算法需要根据当地情况进行定制，以证明其有效性。治疗仍然是最重要的支柱，有证据表明，联合使用止吐药以延长效果和提高保护作用的原则同样适用于治疗。PONV领域的最新进展更多地与实施现有证据有关，而不是基于新分子的引入。新分子补充了药物止吐药物组合，这是由于目前任何单一药物的疗效有限所需要的。新型神经激肽-1受体拮抗剂阿瑞匹坦和长效5-HT(3)受体拮抗剂帕洛诺司琼是这方面的最新进展。治疗最为重要，也可被视为二级预防。由于单一治疗干预的疗效有限，联合治疗未来可能会得到更广泛的应用。
