Fosaprepitant for PONV
Postoperative nausea and vomiting (PONV) is a major challenge following surgery. Estimates are that PONV affects 30–50% of patients undergoing general anesthesia, and 70–80% of patients who are at high risk of PONV 1. Even with double prophylactic therapy including dexamethasone and a 5-hydroxytryptamine-3 receptor antagonist, the incidence remains high, leading to significant discomfort and in some cases causing complications. Recently, fosaprepitant, a neurokinin-1 (NK1) receptor antagonist, has emerged as an effective antiemetic for PONV.
In the last decade, studies have begun to investigate the effectiveness of fosaprepitant in comparison to alternatives medications. A study from 2014, for example, sought to compare fosaprepitant to ondansetron, a selective 5-hydroxytryptamine type 3 (5-HT3) receptor antagonist that is commonly used for PONV. To this end, more than 60 patients undergoing craniotomy were randomly allocated to receive fosaprepitant 150 mg intravenously or ondansetron 4 mg intravenously prior to anesthesia. Overall, the incidence of vomiting was significantly less in the fosaprepitant group. On top of that, the incidence of a complete response, i.e. no vomiting and no rescue antiemetic use, was significantly higher in the fosaprepitant group than in the ondansetron group. The researchers concluded that in patients undergoing craniotomy, fosaprepitant is more effective than ondansetron at increasing the rate of complete response and decreasing the incidence of vomiting 24 to 48 hours postoperatively 2.
In a similar fashion, a study from 2017 also investigated the efficacy of fosaprepitant compared to ondansetronin moderate to high PONV risk patients from a number of previously carried out randomized controlled trials. On investigation, no significant differences in PONV, complete response, rescue antiemetic use, or nausea score were identified across groups 0–48 hours postoperatively. However, in moderate to high PONV risk patients, fosaprepitant decreased the incidence of vomiting and outperformed ondansetron in preventing postoperative vomiting 1.
Later on, in 2022, a Brazilian research team compared single use fosaprepitant to the use of palonosetron, a second-generation 5-HT3 antagonist, for antiemetic prophylaxis in women undergoing laparoscopic cholecystectomy. Close to 90 nonsmoking women (rated American Society of Anesthesiologists physical status I or II) between 18 and 60 years of age were enrolled and received 150 mg of fosaprepitant intravenously or 75 μg of palonosetron intravenously following the induction of general anesthesia. Overall data revealed that the administration of a single dose of fosaprepitant following the induction of anesthesia was as effective as the administration of a single dose of palonosetron for the prophylaxis of vomiting in the first 48 hours postoperatively 3.
Finally, in 2023, a randomized, controlled, double-blind trial sought to probe the general efficacy and safety of fosaprepitant in combination antiemetic therapy for preventing PONV 4. To this end over 1,000 participants at high risk of PONV and undergoing laparoscopic gastrointestinal surgery were randomly assigned to either a fosaprepitant group receiving fosaprepitant 150 mg intravenously dissolved in 0.9% saline 150 ml, or a placebo group receiving 0.9% saline 150 ml prior to anesthesia induction. Dexamethasone 5 mg intravenously and palonosetron 0.075 mg intravenously were also administered in both groups. Results revealed that fosaprepitant added to dexamethasone and palonosetron reduced the incidence of PONV in patients at high risk of PONV undergoing laparoscopic gastrointestinal surgery.
References
1. Murakami, C. et al. A Comparison of Fosaprepitant and Ondansetron for Preventing Postoperative Nausea and Vomiting in Moderate to High Risk Patients: A Retrospective Database Analysis. Biomed Res. Int. 2017, (2017). doi: 10.1155/2017/5703528
2. Tsutsumi, Y. M. et al. The Effects of intravenous fosaprepitant and ondansetron for the prevention of postoperative nausea and vomiting in neurosurgery patients: A prospective, randomized, double-blinded study. Biomed Res. Int. 2014, (2014). doi: 10.1155/2014/307025
3. Braga, E. L. C., Verçosa, N. & Cavalcanti, I. L. Comparative Study Between Fosaprepitant and Palonosetron in the Prophylaxis of Postoperative Nausea and Vomiting in Women Undergoing Laparoscopic Cholecystectomy: Prospective, Randomized and Double-Blind Study. Front. Pharmacol. 13, 915347 (2022). doi: 10.3389/fphar.2022.915347
4. Huang, Q. et al. Fosaprepitant for postoperative nausea and vomiting in patients undergoing laparoscopic gastrointestinal surgery: a randomised trial. Br. J. Anaesth. 131, 673–681 (2023). doi: 10.1016/j.bja.2023.06.029