Review/excerpt of this study from NEJM Journal Watch: by Daniel J. Pallin, MD, MPH.
In the current trial, 120 adult ED patients with nausea or vomiting who did not require intravenous access were randomized to inhaled isopropyl alcohol plus 4 mg oral ondansetron; inhaled isopropyl alcohol plus oral placebo; or inhaled saline plus 4 mg oral ondansetron. Isopropyl alcohol was provided in the form of a standard alcohol swab. Patients received a single dose of the oral intervention but could sniff alcohol or saline swabs repeatedly. Nausea was measured on a 100-mm visual analog scale at baseline and 30 minutes.
Mean nausea scores decreased by 30 mm in the alcohol/ondansetron group, 32 mm in the alcohol/placebo group, and 9 mm in the saline/ondansetron group. Rescue antiemetic therapy was given to 28%, 25%, and 45% of each group, respectively. Differences between alcohol and saline groups were statistically significant. Patients in the inhaled alcohol groups also had better nausea control at the time of discharge and reported higher satisfaction with nausea treatment. No adverse events occurred. The mechanism of action is currently unknown.
Dr. Pallin’s comments on study:
It is uncommon for us to assign a rating of “Practice Changing” to a small, single-center study, but these results are truly remarkable and are consistent with prior research. For patients not obviously requiring IV therapy, we should treat nausea with repeated inhalations from an isopropyl alcohol swab instead of administering any other drug. And, although this study provides no direct evidence of benefit to patients who do require IV therapy, there would seem to be little downside to trying this simple and safe intervention in that group, too.
My take: Who is doing the pediatric study to try to replicate these results in the pediatric population?
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Another study (AS Danewa et al J Pediatr 2016; 169: 105-9) has shown that ondansetron (zofran) is effective for gastroenteritis. In children (n=170) between 3 months and 5 years with acute diarrhea and vomiting in India, a single dose of ondansetron (0.2 mg/kg) syrup prior to the use of oral rehydration therapy (ORT) improved outcomes.
Failure of ORT was 31% in those treated with ondansetron compared with 62% given placebo (P<.001). there was fewer vomiting episodes and lower rates of IVF usage in those who received ondansetron.
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Ondansetron (Zofran ®) use has become more common and is making a difference (JPGN 2012; 54: 381-86). This drug has been a terrific advance for so many individuals with disorders that provoke vomiting and nausea. Not only does it have a high degree of effectiveness, but side effects are also quite uncommon.
The cited study documents ondansetron’s increasing use in Toronto. This retrospective cohort study of children younger than 18 years with gastroenteritis examined emergency room visits between 2003 and 2008. 20% of 22,125 charts were selected randomly for review (n=3508 patients in final analysis). During the study period, intravenous rehydration decreased from 27% to 13% and ondansetron use increased from 1% to 18%. Associated with ondansetron use, mean length of stay decreased from 8.6 to 5.9 hours. Also, the week following the index visit, there was a reduction in return visits from 18% to 13% as well as decreased need for intravenous rehydration (7% to 4%).
The authors state that analysis elsewhere has indicated that appropriate usage of ondansetron for this indication could result in savings of more than $65 million each year in the U.S. The main limitation of this study is that other factors could have changed during the study period and resulted in some of these improvements; though, this institution did not have any major changes which could be identified.
Of course, ondansetron is used in many other clinical settings besides the emergency room. Though the drug is expensive, it is worth the cost.
- -Arch Pediatr Adolesc Med 2008; 162: 858-65. Use of antiemetic agents in AGE.
- -Ann Emerg Med 2008; 52: 22e6-9e6. Use of oral ondansetron in children with AGE who failed oral rehydration.
- -NEJM 2006; 354: 1698. Use of zofran did not decrease hospitalization but did decrease need for IV fluids and decreased vomiting.