Nbghemergencydepartment.homestead.com

Ondansetron Decreases Vomiting Associated With Acute Gastroenteritis:
A Randomized, Controlled Trial
John J. Reeves, MD*; Michael W. Shannon, MD, MPH‡; and Gary R. Fleisher, MD‡ ABSTRACT.
Objective.
Relatively little research has
examined the role of antiemetic agents in the treatment
United States develop acute gastroenteritis of acute gastroenteritis. The use of the selective 5-HT3
every year. Of these, 3 million seek evalua- receptor antagonists (eg, ondansetron) offers a poten-
tion by physicians, and a large number of these pa- tially valuable treatment option. The objective of this
tients are treated in emergency departments (EDs).
study was to evaluate the efficacy of ondansetron for the
An estimated 220 000 children younger than 5 years treatment of vomiting associated with acute gastroenter-
are hospitalized every year for treatment of dehydra- itis in children.
tion secondary to acute gastroenteritis.1–6 Methods.
A randomized, double blind, placebo-con-
Current recommendations for the treatment of trolled trial was conducted in the emergency department
acute gastroenteritis focus primarily on the correc- of a tertiary-care children’s hospital. Eligible patients
tion of dehydration and electrolyte abnormalities.
were 1 month to 22 years old and required intravenous
Oral rehydration is the preferred therapy in mild to fluids for gastroenteritis. Of 172 patients approached, 107
moderate dehydration, whereas intravenous fluids were enrolled (54 to intravenous ondansetron, 53 to pla-
cebo). The mean age was 5.3 years, and 53% of the pa-
are recommended in more severe cases. Administra- tients were male. The frequency of vomiting, admission
tion of an antiemetic drug, which could safely sup- rate, and occurrence of complications were measured.
press vomiting, would be useful in promoting suc- Results.
After drug administration, 38 (70%) of the 54
cessful oral rehydration. Although several studies patients in the ondansetron group had complete cessa-
have shown some benefit with the use of antiemetic tion of vomiting compared with 27 (51%) of the 53 pa-
medications, including prochlorperazine, prometha- tients in the placebo group. Sixteen (30%) of the 53 pa-
zine hydrochloride, and metoclopramide, clinical ex- tients in the placebo group required admission compared
perience with these drugs has revealed an unaccept- with 14 (26%) of the 54 in the ondansetron group. An
ably high incidence of adverse effects, such as analysis of previously untreated patients with a mea-
sedation and extrapyramidal reactions.7–12 Reflecting sured serum carbon dioxide >15 mEq/L showed that 11
this unfavorable clinical experience, we could find no (23%) of the 47 who received placebo were admitted
recent review articles or guidelines in which the use compared with 3 (7%) of the 43 who received ondanse-
of antiemetic agents for the treatment of childhood tron. No significant complications were detected.
gastroenteritis was encouraged. Recent guidelines Conclusions.
Intravenous
ondansetron
decreases
published by the American Academy of Pediatrics vomiting in children with gastroenteritis. In addition,
for the treatment of gastroenteritis expressed con- ondansetron reduces the need for admission in those
cerns about the frequency of adverse effects such as who are treated at an initial visit to the emergency de-
sedation and extrapyramidal reactions, seen with partment and have a measured serum carbon dioxide >15
older antiemetics.1 Although a number of investiga- mEq/L. The safety and low cost of this therapy suggests
tors have examined newer antiemetic agents such as that ondansetron can be valuable in treating gastroenter-
ondansetron in other areas of clinical practice where itis in children. Pediatrics 2002;109(4). URL: http://www.
pediatrics.org/cgi/content/full/109/4/e62; pediatric, gas-
mitigation of nausea and vomiting is the goal, few troenteritis, vomiting, ondansetron, antiemetic.
studies have been done to identify agents that cancontrol the vomiting associated with acute gastroen-teritis in the ambulatory setting.13–19 The main objec- ABBREVIATIONS. ED, emergency department; CO2, carbon di- tive of this trial was to study the safety and efficacy of ondansetron, a recently developed 5-HT3 receptor antagonist, in the treatment of the vomiting associ-ated with gastroenteritis in children seen in a pedi-atric ED.
From the *Department of Pediatric Emergency Medicine, University Med- ical Center, Las Vegas, Nevada; and ‡Division of Emergency Medicine,Children’s Hospital Boston, Harvard Medical School, Boston, Massachu- The study design was a double-blind, randomized, placebo- controlled clinical trial. This investigation was performed in the Received for publication Jul 24, 2001; accepted Dec 19, 2001.
Children’s Hospital Boston ED between May 15, 1999, and May 1, Reprint requests to (J.J.R.) University Medical Center, Department of Pedi- 2000. This ED has a census of approximately 50 000 visits annu- atric Emergency Medicine, 1800 W Charleston Blvd, Las Vegas, NV 89102.
Patients who were between the ages of 1 month and 22 years, PEDIATRICS (ISSN 0031 4005). Copyright 2002 by the American Acad- had vomiting from acute infectious gastroenteritis, and were iden- tified as requiring intravenous fluids for rehydration were eligible http://www.pediatrics.org/cgi/content/full/109/4/e62 for enrollment. This age range was selected to capture the popu- of Յ14 mEq/L or a history of intravenous hydration for the same lation of patients seen at our institution. An attending physician in illness were generally admitted. Both of these factors are believed pediatric emergency medicine made the diagnosis of apparent to indicate a more serious level of dehydration and need for infectious gastroenteritis and then determined the need for intra- hospitalization. Information collected by the study investigators venous fluids on a clinical basis. Because the primary goal was the was not used in determining the need for hospital admission.
control of emesis, patients were enrolled only when they had had The primary outcomes recorded were the frequency of vomit- 3 or more episodes of vomiting in the previous 24 hours. Typi- ing episodes after drug administration and the need for hospital- cally, the vomiting associated with gastroenteritis precedes the ization. A vomiting episode was defined as any episode of forceful diarrheal symptoms of this disease.3 To help ensure that our study expulsion of stomach contents. Nonproductive retching, spilling population reflected clinical practice, we did not require the pres- of oral contents during feeding, and drooling were not considered ence of diarrhea and/or fever for enrollment as long as the overall vomiting episodes. Vomiting episodes were recorded by the re- clinical picture, as determined by an experienced practitioner, was search assistant or investigator while the patient was in the ED.
gastroenteritis. Because the study protocol included telephone After patients left the ED, the frequency and timing of vomiting follow-up, access to a home telephone or pager was required.
episodes and other symptoms were determined from inpatient Patients were excluded when they had received any antiemetic nursing flow sheets and home symptom journals, completed by therapy within 72 hours of enrollment or had a history of hepatic parents and/or adult patients. Standardized telephone follow-up disease or a past adverse drug reaction to ondansetron. Patients was performed 5 to 7 days after patient enrollment. Vomiting were also excluded when they had diarrhea that had been present episodes were tabulated in 24-hour blocks starting from the time for Ͼ7 days; a history of chronic gastrointestinal disease; or any of drug administration until reported cessation of vomiting. After preexisting active medical condition, such as congenial heart dis- the initial analysis of hospitalization rate was performed, a sub- ease, malignancy, immunodeficiency, cystic fibrosis, sickle cell group analysis was performed, limited to those patients who did anemia, or diabetes mellitus. The presence of headache or a focal not fulfill the requirements for admission in the established clin- neurologic examination was also an exclusion criteria.
One of 3 trained research assistants conducted patient enroll- therapy). Secondary outcomes included duration of vomiting ment Monday through Friday from 4 to 11 pm and on Saturday symptoms after drug administration, number and duration of and Sunday from noon to 5 pm. At other times, patient enrollment diarrhea symptoms, frequency of return visits to an urgent or was performed by 1 of the study investigators. Patients who were emergency care center, need for readministration of intravenous believed to have infectious gastroenteritis by clinical assessment fluids, and need for later hospital admission. Length of stay in the and to be in need of intravenous fluids, as judged by the emer- ED, duration and amount of intravenous fluids given, and dura- gency physician, were approached for study enrollment. A ques- tion of hospitalization were also recorded, as were any observedcomplications. Although specific safety parameters were not mea- tionnaire detailing demographics, history of present illness, med- sured, data collection was constructed to help identify potential ical history, allergies, and medications was completed, and complications. All potential complications noted from chart re- written informed consent was obtained. A log of all patients who view, symptom journal, and telephone follow-up were recorded.
were approached for enrollment was kept, and reasons for refusal To help ensure complete data collection and to help confirm that were recorded. After enrollment, intravenous fluids were insti- the initial clinical diagnosis of gastroenteritis was correct, we tuted as an initial 20-mL/kg bolus of 0.9% saline followed by 5% followed all patients by telephone until resolution of their vomit- dextrose in 0.45% saline solution at twice the patient’s mainte- nance rate. Serum electrolytes, blood urea nitrogen, and creatinine The study sample size was calculated as follows. On the basis were obtained on all patients in accordance with previously de- of a retrospective review of ED records, we anticipated that 40% of signed practice guidelines. Children with symptoms suggestive of the patients in the control group would be admitted to the hospital bacterial enteritis (eg, grossly bloody stools, fever above 39.0°C) for treatment of gastroenteritis. We sought to detect a 50% reduc- underwent stool swab for white blood cells, stool guaiac, and stool tion in admission rate after use of ondansetron, ie, reduction in cultures. Other laboratory studies were obtained at the discretion admission rate to 20% or less. At the end of the gastroenteritis season in 2000, an independent statistical advisor and study mon- A computer randomization code was produced by a member of itor reevaluated the sample size calculation. The advisor noted the medical school’s center for clinical investigation. Blocking was that admission rates were lower than anticipated in the control used in groups of 4, 6, or 10 as generated randomly by computer group, thus invalidating our a priori sample size estimate. A more to ensure that equal numbers of patients were enrolled in both the accurate sample size of 106 total patients was calculated. On the control group and the treatment group throughout the study. This basis of this more realistic sample size calculation and the desire randomization code was controlled by the center for clinical in- not to delay significantly the availability of study results by wait- vestigation and provided to the pharmacy for drug distribution.
ing to enroll additional patients during the next gastroenteritis All providers except the pharmacist were blinded to group assign- season, we decided to stop enrollment at the end of the 2000 ment until after data analysis. The study investigators remained gastroenteritis season. This decision was made before release of blinded until after complete statistical analysis was performed to the randomization codes and unblinding of the investigators. The test the primary and secondary outcome measures. The pharmacy Children’s Hospital Committee on Clinical Investigation ap- provided a single syringe, labeled “gastroenteritis study drug,” proved this study and the modification described above. Statistical that contained either ondansetron (Zofran Injection; Glaxo Well- analyses were performed using the Statistical Package for the come Inc, Research Triangle Park, NC) calculated to provide a Social Sciences (Windows Version 9.0.0; SPSS, Inc, Chicago, IL) dose of 0.15 mg/kg (maximum of 8 mg) or an equal volume of and consisted of the ␹2 or Fisher exact test for categorical variables; 0.9% saline solution. The appearance of ondansetron is indistin- an unpaired, 2-tailed Student t test for continuous variables; and guishable from that of 0.9% saline. The contents of the syringe the Mann-Whitney U test for ordinal variables. Significance was were administered intravenously over 2 minutes, followed by 3 to 5 mL of a 0.9% saline flush. Drug administration was performedduring the initial fluid bolus. Repeat doses of the study drug werenot given, and no other antiemetic medications were allowed during patient enrollment. Antipyretics were given when indi- During the study period from May 1999 to May cated for fever. Other medications given to the patient either 2000, 172 children between the ages of 1 month and during the visit or after discharge were recorded. All patients were 22 years were approached for study enrollment. Of kept in the ED for at least 1 hour after drug administration beforefinal disposition was made. This length of time was determined by these, 107 (62%) provided informed consent. Of these the pharmacologic profile of ondansetron. The antiemetic proper- 107 patients, 105 (98%) received the study drug; 2 ties of intravenous ondansetron has been shown in previous stud- (2%) did not complete the study because of loss of or ies to be Ͻ20 minutes.20,21 Decisions on repeat fluid boluses, failure to obtain intravenous access before drug or duration of fluid administration, and need for hospital admission fluid administration. All 107 patients were included all were left to the discretion of the attending physician. In accor-dance with preexisting institutional practice guidelines at our for data analysis as an intent-to-treat population (Fig institution, patients with a measured serum carbon dioxide (CO ONDANSETRON DECREASES VOMITING IN ACUTE GASTROENTERITIS Fig 1. Profile of randomization and allocation of patients.
Of the 107 patients, 53% were male with a mean graphics, duration and frequency of symptoms, pres- age of 5.3 years (standard deviation: Ϯ4.9). The on- ence of fever, presence of other medical problems, or dansetron group had 54 patients, and the placebo a previous visit to a physician (Table 1). A signifi- group had 53. No significant differences were noted cantly higher proportion of patients randomized to between the 2 groups with respect to patient demo- ondansetron had a measured serum CO2 of Յ14 Demographic Characteristics of the Study Population Vomiting in previous 24 h (median [range]) Diarrhea in previous 24 h (median [range]) SD indicates standard deviation; BUN, blood urea nitrogen.
* The most commonly reported underlying medical condition was asthma.
† There were no statistically significant differences between the 2 study groups with the exception ofmeasured serum CO2 (P Ͻ .01).
http://www.pediatrics.org/cgi/content/full/109/4/e62 mEq/L (11 [20%] of 54 vs 2 [4%] of 53; P Ͻ .01), as treatment failures did not alter the results.
No significant differences were noted with regard Before patient enrollment, the median number of to reported or observed complications between the 2 vomiting episodes in the previous 24 hours for all groups. Reported and observed complications after patients was 7 episodes (range: 3– 40). After drug drug or placebo administration included abdominal administration, 38 (70%) of the patients in the ondan- pain (1 in the placebo group), “sinusitis” (1 in the setron group had complete cessation of vomiting, placebo group), and rash (1 in the ondansetron compared with 27 (51%) in the placebo group (P ϭ group). One patient in the ondansetron group devel- .04). For patients who continued to have vomiting, oped a diffuse nonurticarial rash 24 hours after drug the median number of episodes after drug adminis- administration while in the hospital. The rash re- tration was 2 (range: 1– 4) for the ondansetron group solved spontaneously and was attributed to his viral as compared with 4 (range: 1– 46) for the placebo illness by his inpatient treating physicians, who were of course unaware of the patient’s enrollment group.
At the time of enrollment, 62 children (58%) had a All patients with grossly bloody stools or a fever history of accompanying diarrhea. No significant dif- above 39.0°C underwent stool testing for leukocytes ference was seen between the treatment and control and bacterial culture (6 patients in the ondansetron group with regard to pre- and postdiarrheal com- group and 8 patients in the control group). Three plaints. Both groups had a decrease in the number of cultures were positive for presumed bacterial patho- diarrheal episodes and the total duration of diarrheal gens, all for Escherichia coli 0157:H7. Two patients, 1 in each group, had a positive stool culture for E coli Fourteen patients (26%) who received ondansetron 0157:H7, which did not require additional treatment.
were hospitalized at the time of enrollment versus 16 Another patient in the ondansetron group was be- patients (30%) in the placebo group (P ϭ NS). Of the lieved to require additional treatment and was read- 16 admitted patients in the placebo group, 2 had mitted after enrollment for hemolytic uremic syn- been seen in the ED and received intravenous fluids drome. As this patient had a positive stool culture for within the 48 hours preceding enrollment. An addi- E coli 0157:H7 at the time of initial enrollment, he was tional 3 of the patients in this group were noted to likely in the prodromal period for this disease. At last have a measured serum CO2 of Յ14 mEq/L. In the follow-up (8 months after hospital discharge), this ondansetron group, 2 of the patients who were ad- mitted had been seen previously and had failed in-travenous hydration and an additional 8 of the pa- DISCUSSION
tients who were admitted had a measured serum We found that adding ondansetron to standard intravenous rehydration therapy significantly de- A subgroup analysis excluding those patients who creased the amount of vomiting in children with gastroenteritis. Furthermore, we were able to show been seen previously for intravenous hydration, or 3) that in first-time treated children, with a measured failed to complete enrollment because of lack of in- travenous access left a total of 90 patients. Fourteen decreased the hospital admission rate.
(16%) of these patients required admission; 3 (7.5%) Children who were given ondansetron and intra- of 43 patients who received ondansetron versus 11 venous fluids were more likely to have complete (23%) of 47 patients in the placebo group (P ϭ .04).
cessation of vomiting symptoms compared with The average length of hospitalization was 2 days for those who were given intravenous fluids and pla- cebo (70% vs 51%; P ϭ .04). A single, limited trial No significant intergroup difference was seen with evaluating the antiemetic activity of ondansetron in regard to ED reevaluation or readmission rates (Ta- the treatment of acute gastroenteritis showed similar ble 2). Reanalysis of the data including these patients results. Cubeddu et al22 studied a total of 36 children * First-time patients with measured serum CO Ն ONDANSETRON DECREASES VOMITING IN ACUTE GASTROENTERITIS with acute gastroenteritis. The children who were tis.27 Any study that uses an outcome that depends evaluated in their study received a standard dose of on a multitude of interrelated factors (eg, admission ondansetron, metoclopramide, or placebo in addi- rate) may be difficult to generalize to other popula- tion to oral rehydration therapy. The patients who tions. Despite this, our study design allowed for a received either of the antiemetic medications showed double-blind comparison of admission rates between a statistically significant (P Ͻ .05) improvement in virtually identical treatment and placebo groups.
the number of emetic episodes, in the percentage of Thus, we would expect similar improvements in out- patients with no emetic episodes, and in the percent- come to be realized at other institutions.
age of patients with treatment failures, when com- On the basis of our data, approximately 8.5 chil- pared with saline placebo during the 24-hour study dren would need to be treated with ondansetron to period. This study differed from our study in many prevent 1 hospitalization. This estimate, which is important respects. The dose of ondansetron used conservative, includes all children who received on- was 0.3 mg/kg (compared with 0.15 mg/kg). Fur- dansetron in the study. The cost of ondansetron is thermore, patients in the Cubeddu study all were approximately $26 per 4-mg vial. The total cost of admitted for inpatient oral rehydration. The use of ondansetron during this study was $1378 for 53 total oral rehydration may account only for the higher vials. A random sampling (20%) of patients who proportion of patients with continued vomiting after required hospitalization during our study showed an drug treatment. Oral fluids when used to treat gas- average cost of $1900 per hospital admission, exclud- troenteritis, although effective for rehydration, have ing ED charges. According to our analysis, we pre- been shown to be associated with a higher number of vented 6 admissions during the course of the study.
vomiting episodes compared with intravenous hy- The cost reduction as a result of prevented admis- dration.23 The brief (24-hour) period of data collec- sions was approximately $11 400, yielding a savings tion in the Cubeddu study makes it impossible to of approximately $10 022 after deducting the cost for evaluate the potential for later return of symptoms or purchase of the drug. The use of ondansetron to complications. Despite these differences, this earlier control vomiting and promote successful outpatient work is consistent with our findings.
management of gastroenteritis therefore represents a Clear, objective criteria for identifying children potential for significant cost savings in terms of ac- who require hospitalization are not available. As tual dollars spent as well as the potential cost savings noted previously, at our institution, patients with from time lost from work and/or school. Because vomiting and diarrhea symptoms are admitted to the ondansetron was administered to children who re- hospital when they return to the ED for a second visit quired placement of an intravenous line for rehydra- after a trial of intravenous fluids and home manage- tion, the additional expense is attributable only to the ment or when they have a measured serum CO Յ mEq/L. A subgroup analysis taking these factors The safety profile of ondansetron, after numerous into account found that ondansetron significantly studies of its use in a wide variety of disorders, is reduced the rate of admission from 23% to 7% (P ϭ favorable. Common side effects associated with the use of ondansetron include headache, diarrhea, con- Results of studies that evaluated hospital admis- stipation, fever, and malaise/fatigue.20,21 In a study sion rate for gastroenteritis after rehydration vary that evaluated the use of ondansetron in the treat- widely. In a study of 42 patients with estimated mild ment of postoperative emesis in 1900 patients, the to moderate dehydration, oral and intravenous rehy- incidence of the above side effects was similar to dration were equally effective in preventing hospi- placebo.28 Only rarely has ondansetron been associ- talization (successful rehydration 82% vs 78%).23 In ated with extrapyramidal reactions. Of the 3 re- another report, of 17 children who had mild to mod- ported instances of extrapyramidal reactions, all oc- erate dehydration and were rehydrated with intra- curred in adults who were being treated for venous fluids, none required admission.24 Among 58 chemotherapy-induced nausea and vomiting.29–31 children who were aged 6 months to 13 years and All 3 were taking multiple medications; therefore, it had acute gastroenteritis and dehydration described is unclear whether ondansetron was the direct cause by Reid and Bonadio,25 28% required admission be- of these reactions. To our knowledge, no cases of cause of inability to tolerate oral fluids despite intra- extrapyramidal reactions have been reported in chil- venous hydration. In this same study, of the 42 pa- dren. Allergic reactions have been reported in ap- tients (72%) who were discharged after intravenous proximately 20 cases to date.30–32 To our knowledge, hydration, 15% were subsequently readmitted after no cases of serious morbidity have been described failure of outpatient management. As an additional with the appropriate use of ondansetron.
factor, several studies have shown that admission There are several potential limitations of this rates can vary widely between institutions. One study. Our data collection method, which used jour- study noted up to an 18-fold difference in admission nal collection and telephone follow-up, has potential rates for children with gastroenteritis when compar- limitations. Although 60% of patients did not return ing the admission practices of multiple, local EDs.
a symptom journal, we were able to conduct a struc- The authors were unable to explain these differences tured telephone interview for data collection on on the basis of objective analysis of the various pop- 100% of patients. Inaccuracies in symptom recall by ulations.26 A study that compared children in Boston family members may have influenced our results.
with those in New York noted an unexplainable 2- to Although we were able to show a significant de- 3-fold difference in admission rate for gastroenteri- crease in vomiting in patients who received ondan- http://www.pediatrics.org/cgi/content/full/109/4/e62 setron when compared with those who received pla- associated mortality in US children, 1968 through 1991. JAMA. 1995; cebo, we were unable to make firm conclusions 5. Lieu TA, Black SB, Rieser N, et al. The cost of childhood chickenpox: a regarding the effect of ondansetron on hospitaliza- parents’ perspective. Pediatr Infect Dis J. 1994;13:173–177 tion because of the size of the study population.
6. Halloran ME, Cochi SL, Lieu TA, et al. Theoretical epidemiologic and Because all patients were given intravenous fluids in morbidity effects of routine varicella immunization of preschool chil- addition to ondansetron or placebo, we are unable to dren in the United States. Am J Epidemiol. 1994;140:81–104 determine the effect of ondansetron alone in lieu of 7. DeGrandi T, Simon JE. Promethazine-induced dystonic reaction. Pediatr other therapy. A large proportion of patients with 8. Krstenansky PM, Petree J, Long G. Extrapyramidal reaction caused by gastroenteritis improve after intravenous fluids ondansetron [letter]. Ann Pharm. 1994;28:280 alone. In fact, some patients may have recovered 9. Mathews HG III, Tancil CG. Extrapyramidal reaction caused by ondan- with aggressive oral rehydration therapy without the setron [letter]. Ann Pharm. 1996;30:196 10. Leary PM. Adverse reactions in children. Special considerations in use of other therapy. Although the double-blinded, prevention and management. Drug Saf. 1991;6:171–182 randomized design of the study should reduce the 11. Bateman DN, Darling WM, Boys R, et al. Extrapyramidal reactions to effect of confounding variables, the potential for un- metoclopramide and prochlorperazine. Q J Med. 1989;71:307–311 foreseen factors that may have influenced our results 12. Boulloche J, Mallet E, Mouterde O, et al. Dystonic reactions with does exist. Despite the randomized nature of the metoclopramide: is there a risk population? Helv Paediatr Acta. 1987;42:425– 432 study, we did note that by chance a higher propor- 13. Morris RW, Aune H, Feiss P, et al. International, multi-center, placebo- tion of patents in the ondansetron group had a mea- controlled study to evaluate the effectiveness of ondansetron vs. meto- clopramide in the prevention of post-operative nausea and vomiting.
with this degree acidosis are routinely admitted to Eur J Anaesthesiol. 1998;15:69 –79 14. Splinter WM, Rhine EJ. Prophylaxis for vomiting by children after our hospital for ongoing intravenous fluids likely tonsillectomy: ondansetron compared with perphenazine. Br J Anaesth.
influenced our results. Because the ondansetron group contained a higher proportion of these pat- 15. Axelrod RS. Antiemetic therapy. Compr Ther. 1997;23:539 –545 ents, we would expect any bias for admission to be 16. Roila F, Del Favero A. Antiemetics revisited. Curr Opin Oncol. 1997;9: placed against the ondansetron group.
17. Ettinger DS. Preventing chemotherapy-induced nausea and vomiting: In conclusion, our data demonstrate that single- an update and review of emesis. Semin Oncol. 1995;22:6 –18 dose ondansetron decreases vomiting in children 18. Dicato M. Mechanisms and management of nausea and emesis [edito- with acute infectious gastroenteritis. Moreover, on- rial]. Oncology. 1996;53(suppl 1):1–3 dansetron reduced the need for admission in those 19. Morrow GR, Hickok JT, Rosenthal SN. Progress in reducing nausea and who were treated at an initial visit to the ED and had 20. Roila F, Del Favero A. Ondansetron clinical pharmacokinetics. Clin tional research is needed to determine drug safety 21. Wilde MI, Markham A. Ondansetron: a review of its pharmacology and and cost-effectiveness better, these encouraging find- preliminary clinical findings in novel applications. Drug Eval. 1996;52: ings suggest that ondansetron may have a role in the 22. Cubeddu LX, Trujillo LM, Talmaciu I, et al. Antiemetic activity of treatment of gastroenteritis in young children.
ondansetron in acute gastroenteritis. Aliment Pharmacol Ther. 1997;11:185–191 23. Issenman RM, Leung AK. Oral and intravenous rehydration of children.
ACKNOWLEDGMENTS
Can Fam Physician. 1993;39:2129 –2136 Grant support was provided by Glaxo Wellcome Inc, which 24. Moineau G, Newman J. Rapid intravenous rehydration in the pediatric played no role in the conception, design, conduct, interpretation, emergency department. Pediatr Emerg Care. 1990;6:186 –188 or analysis of this study but reviewed the final manuscript before 25. Reid SR, Bonadio WA. Outpatient rapid intravenous rehydration to correct dehydration and resolve vomiting in children with acute gas- We thank Bridget Fey, Allison Douglas, and Alaina Kipps for troenteritis. Ann Emerg Med. 1996;28:318 –323 their instrumental role in patient enrollment; Patricia Hibberd, 26. Connell FA, Day RW, LoGerfo JP, et al. Hospitalization of Medicaid MD, PhD, for assistance in monitoring the study; and Rocco children: analysis of small area variations in admission rates. Am J Anzaldi, RPh, and the pharmacy staff of Children’s Hospital, Public Health. 1981;71:606 – 613 27. Perrin JM, Homer CJ, Berwick DM, et al. Variations in rates of hospi- talization of children in three urban communities. N Engl J Med. 19894;320:1183–1187 REFERENCES
28. Bryson JC. Clinical safety of ondansetron. Semin Oncol. 1992;19(suppl 1. American Academy of Pediatrics, Provisional Committee on Quality Improvement and Subcommittee on Acute Gastroenteritis. Practice 29. Camp-Sorrel D. Managing an extrapyramidal reaction caused by on- parameter: the management of acute gastroenteritis in young children.
dansetron. Oncol Nurs Forum. 1995;22:718 –719 30. Chen M, Tanner A, Gallo-Torres H. Anaphylactoid-anaphylactic reac- 2. Burkhart D. Management of acute gastroenteritis in children. Am Fam tions associated with ondansetron [letter]. Am J Psychiatry. 1995;152: Physician. 1999;60:2555–2563, 2565–2566 3. Fleisher GR. Infectious disease emergencies. In: Fleisher GR, Ludwig S, 31. Madera J, Sanz S, Perez CI, et al. Urticaria and angioedema caused by eds. Textbook of Pediatric Emergency Medicine. 4th ed. Philadelphia, PA: ondansetron. Allergy. 1995;50(suppl):26:214 Lippincott Williams & Wilkins; 2000:757–762 32. Kossey JL, Kwok KK. Anaphylactoid reactions associated with ondan- 4. Kilgore PE, Holman RC, Clarke MJ, et al. Trends of diarrheal disease setron. Ann Pharmacother. 1994;28:1029 –1030 ONDANSETRON DECREASES VOMITING IN ACUTE GASTROENTERITIS

Source: http://nbghemergencydepartment.homestead.com/Zofranvomitingchildren.pdf