Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA.
Emergency Department, Allegheny Health Network, Erie, Pennsylvania, USA.
Cochrane Database Syst Rev. 2022 May 19;5(5):CD013860. doi: 10.1002/14651858.CD013860.pub2.
Physicians often prescribe opioids for pain in the acute care setting. Nausea and vomiting are well-described adverse events, occurring in over one-third of patients. Prophylactic antiemetics may be one option to reduce opioid-associated nausea and vomiting. However, these medications also have their own adverse effects, so it is important to understand their efficacy and safety prior to routine use. This is a review of randomized controlled trials comparing prophylactic antiemetics versus placebo or standard care for preventing opioid-associated nausea and vomiting.
To assess the effects of prophylactic antiemetics for nausea and vomiting in adults (aged 16 years or older) receiving intravenous opioids in the acute care setting.
We searched CENTRAL (the Cochrane Library), MEDLINE (OVID), Embase (OVID) from inception to January 2022, and Google Scholar (17 January 2022). We also searched the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and screened reference lists.
We included randomized controlled trials of prophylactic antiemetics versus placebo or standard care in adults prior to receiving an intravenous opioid.
Two review authors (MG, JNC) independently determined the eligibility of each study according to the inclusion criteria. Two review authors (MG, GDP) then independently extracted data, assessed risk of bias, and determined the certainty of evidence using GRADE. Our primary outcomes were the occurrence of nausea, vomiting, and adverse events. Secondary outcomes included nausea severity, number of vomiting episodes, and number of participants requiring antiemetic rescue therapy. We presented outcomes as risk ratios (RR) for dichotomous data (e.g. presence of vomiting, presence of nausea, number of participants requiring rescue medication, adverse events) and mean difference (MD) or standardized mean difference for continuous data (e.g. number of vomiting episodes, nausea severity) with 95% confidence intervals (CI).
We included three studies involving 527 participants (187 women and 340 men) with a mean age of 42 years. All studies used intravenous metoclopramide (10 mg) as the intervention and a placebo for the comparator. No studies assessed any other antiemetic or compared the intervention to standard care. Compared to placebo, metoclopramide did not reduce vomiting (RR 1.18, 95% CI 0.26 to 5.32; low-certainty evidence) or nausea (RR 0.55; 95% CI 0.15 to 2.03; low-certainty evidence) and there was no difference in adverse events (RR 2.34, 95% CI 0.47 to 11.61; low-certainty evidence). No data were available regarding the number of vomiting episodes. Metoclopramide did reduce the severity of nausea compared with placebo (MD -0.49, 95% CI -0.75 to -0.23; low-certainty evidence) but did not reduce the need for rescue medication (RR 1.86, 95% CI 0.17 to 20.16; low-certainty evidence). Two studies were at unclear risk of bias for random sequence generation, one for blinding of outcome assessors, one for incomplete outcome data, and two for selective reporting. The studies were at low risk of bias for all remaining components.
AUTHORS' CONCLUSIONS: There was no evidence that prophylactic metoclopramide affected the risk of vomiting, nausea, or the need for rescue medication when provided prior to intravenous opioids in the acute care setting. There was a clinically insignificant difference in nausea severity when comparing prophylactic metoclopramide with placebo. Overall, the evidence was of low certainty. Future research could better delineate the effects of prophylactic antiemetics on specific populations, and new studies are needed to evaluate the use of other prophylactic antiemetic agents, for which there were no data.
医生经常在急性护理环境中开具阿片类药物治疗疼痛。恶心和呕吐是描述明确的不良反应，发生在超过三分之一的患者中。预防用止吐药可能是减少阿片类药物相关恶心和呕吐的一种选择。然而，这些药物也有自己的不良反应，因此在常规使用之前了解它们的疗效和安全性非常重要。这是一篇对比较预防用止吐药与安慰剂或标准护理预防阿片类药物相关恶心和呕吐的随机对照试验的综述。
评估在急性护理环境中接受静脉内阿片类药物的成年人中使用预防用止吐药预防恶心和呕吐的效果。
我们检索了 Cochrane 图书馆的 CENTRAL、OVID 中的 MEDLINE、OVID 中的 Embase、2022 年 1 月前的 Google Scholar，以及世界卫生组织（WHO）国际临床试验注册平台（ICTRP）并筛选了参考文献列表。
我们纳入了在接受静脉内阿片类药物之前使用预防用止吐药与安慰剂或标准护理的成年人的随机对照试验。
两名综述作者（MG、JNC）根据纳入标准独立确定每项研究的资格。然后，两名综述作者（MG、GDP）独立提取数据，评估偏倚风险，并使用 GRADE 确定证据的确定性。我们的主要结局是恶心、呕吐和不良事件的发生。次要结局包括恶心严重程度、呕吐发作次数和需要止吐药解救治疗的参与者人数。我们以二分类数据（例如呕吐、恶心、需要解救药物的参与者人数、不良事件）的风险比（RR）和连续数据（例如呕吐发作次数、恶心严重程度）的均数差（MD）或标准化均数差表示结果，并给出 95%置信区间（CI）。
我们纳入了三项涉及 527 名参与者（187 名女性和 340 名男性）的研究，平均年龄为 42 岁。所有研究均使用静脉内甲氧氯普胺（10mg）作为干预措施，以安慰剂作为对照。没有研究评估任何其他预防用止吐药或比较干预措施与标准护理。与安慰剂相比，甲氧氯普胺并未减少呕吐（RR 1.18，95%CI 0.26 至 5.32；低确定性证据）或恶心（RR 0.55；95%CI 0.15 至 2.03；低确定性证据），并且不良事件发生率无差异（RR 2.34，95%CI 0.47 至 11.61；低确定性证据）。没有关于呕吐发作次数的数据。与安慰剂相比，甲氧氯普胺可降低恶心的严重程度（MD -0.49，95%CI -0.75 至 -0.23；低确定性证据），但不能降低对解救药物的需求（RR 1.86，95%CI 0.17 至 20.16；低确定性证据）。两项研究在随机序列生成、结局评估者盲法、结局数据不完整和选择性报告方面存在偏倚风险不确定，两项研究在所有其他组成部分中存在低偏倚风险。
在急性护理环境中，在给予静脉内阿片类药物之前使用预防用甲氧氯普胺并不能影响呕吐、恶心或需要解救药物的风险。与安慰剂相比，预防用甲氧氯普胺对恶心严重程度的影响无统计学意义。总体而言，证据确定性为低。未来的研究可以更好地描述预防用止吐药对特定人群的影响，并且需要新的研究来评估其他预防用止吐药的使用情况，因为这些药物的数据尚不可用。
