Combination Antiemetic Regimen for Prevention of PONV in Breast Surgery Patients

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details. Identifier: NCT00738621
Recruitment Status : Completed
First Posted : August 20, 2008
Last Update Posted : December 19, 2013
Merck Sharp & Dohme Corp.
Information provided by:
Scott and White Hospital & Clinic

Brief Summary:
The purpose of this study is to compare the efficacy of the use of oral aprepitant in combination with intravenous ondansetron and dexamethasone with the efficacy provided by the use of oral aprepitant and dexamethasone for preventing vomiting during the first 24-48 hours after breast surgery.

Condition or disease Intervention/treatment Phase
Postoperative Nausea and Vomiting Drug: Aprepitant, Dexamethasone, Ondansetron Drug: Aprepitant, Dexamethasone, Placebo Phase 4

Detailed Description:

Postoperative nausea and vomiting (PONV) is one of the most common complications associated with surgery. The overall incidence of PONV is reported to be about 25-30% with specific surgeries having an incidence up to 70-80%.1-5 Although PONV is typically not life threatening, patients dread the sensation of nausea and the serious effects of retching and vomiting. PONV in the surgical patient can cause wound dehiscence, electrolyte imbalance, increased intraocular pressure, increased intracranial pressure, aspiration, esophageal rupture, and loss of vision due to retinal detachment. 6-11 In several studies, investigators found that patients rank vomiting as the most undesirable common side effect after surgery. PONV is costly in economic terms and is a reason day surgery patients must be admitted in the hospital for an overnight stay.12, 13 It is estimated that a patient who experiences an episode of vomiting costs an additional $300 based on emesis basins, supplies, gowns, bedding, additional medications, and nursing/physician time.14-20

In general, PONV is highest in women (with a 2-3 times increased risk) and particularly after procedures such as gynecological surgery, laparoscopy, thyroidectomy and breast surgery.5, 21-35 A study by Sinclair and group found that patients undergoing breast augmentation experienced an 8-10 fold higher incidence of PONV than patients undergoing other types of plastic surgery.26 Similar incidences were found in other studies of 48% to 68% of PONV in patients undergoing mastectomies, breast reconstruction, and implantation.36-40

The hospitalization of patients undergoing breast cancer surgery has significantly decreased by 40% between 1993 and 2003. Many surgeries are now being performed on an outpatient basis according to the Agency for Healthcare Research and Quality (AHRQ), with 96% of lumpectomies, 86% of partial mastectomies and 22% of complete mastectomies scheduled as ambulatory surgeries.41 Carroll and group found that 35% of outpatients suffered from nausea and vomiting after they left the surgical center.42 Therefore, the resulting problem is not only the high incidence of nausea and vomiting in this specific group of patients but the post discharge nausea and vomiting (PDNV) that will occur when these patients are at home and without direct medical oversight.

Although still unclear, it is postulated that the etiology of postoperative nausea and vomiting is the central mechanism involving stimulation of the chemoreceptor trigger zone (CTZ) located bilaterally at the floor of the fourth ventricle in the area postrema. The CTZ is sensitive to toxins and other substances in the blood and cerebrospinal fluid. The CTZ also receives sensory signals from the gastro-intestinal tract. The are three major central nervous system (CNS) areas involved with PONV which all have specific emetogenic receptors. Blockade of these receptors is postulated to be the mechanism of action of the commonly used antiemetics. The agents' antagonist activity may be at one or more receptors with different binding affinities and acting at different emetic neuroreceptors. The multifactorial etiology of PONV involving multiple receptors is believed to be the reason one single agent is not 100% effective. The administration of an agent working on one receptor type will typically reduce the PONV incidence by 30%. Use of a combination of antiemetic agents acting on different receptor sites will further reduce the incidence. This combination has shown greater efficacy than a single agent alone. Although this regimen has improved outcomes it has not eliminated the problem of PONV and patients needing rescue therapy post surgery occurs frequently. It would appear reasonable to assume that the use of more than 2 antiemetics would further reduce the incidence of PONV.43 However; published evidence of greater than 2 agents is scarce. Therefore, the main objective of our proposal is to study a combination antiemetic regimen (3 agents vs. 2 agents) in females scheduled for breast surgery, a patient population considered at high risk for postoperative vomiting. The selected agents will cover different receptors based on the hypothesized PONV multifactorial etiology with stimulation of several factors. It is unknown which of these receptors may be stimulated and by which stimuli (anesthetic, surgery, or patient factors).

Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 100 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Triple (Participant, Care Provider, Investigator)
Primary Purpose: Prevention
Official Title: A Comparison of Combination Antiemetic Regimen for Prevention of PONV in Breast Surgery Patients
Study Start Date : July 2008
Actual Primary Completion Date : August 2010
Actual Study Completion Date : August 2010

Arm Intervention/treatment
Active Comparator: 1
Oral aprepitant 40 mg - given within 3 hours prior to induction dexamethasone (4mg intravenous) administered immediately after induction ondansetron (4mg (2ml) intravenous) administered at cessation of anesthesia
Drug: Aprepitant, Dexamethasone, Ondansetron
Aprepitant oral 40mg one dose, dexamethasone IV 4mg one dose, ondansetron 4 mg one dose
Other Name: Emend=aprepitant

Placebo Comparator: A,2
Oral aprepitant 40 mg- given within 3 hours prior to induction dexamethasone (4mg intravenous) administered immediately after induction Placebo ( intravenous saline 2ml) administered at cessation of anesthesia
Drug: Aprepitant, Dexamethasone, Placebo
Aprepitant 40mg oral one time, dexamethasone IV 4mg one time placebo one time
Other Name: Emend=aprepitant

Primary Outcome Measures :
  1. Compare the efficacy of the use of oral aprepitant in combination with intravenous ondansetron and dexamethasone with the efficacy provided by the use of oral aprepitant in combination with dexamethasone alone for preventing vomiting for 1st 24hrs [ Time Frame: 2 yrs ]

Secondary Outcome Measures :
  1. Compare efficacy of oral aprepitant in combination with IV ondansetron and dexamethasone with efficacy of dexamethasone and oral aprepitant alone for preventing vomiting during the 24-48 hours after breast surgery [ Time Frame: 2 yrs ]

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Ages Eligible for Study:   18 Years to 65 Years   (Adult, Older Adult)
Sexes Eligible for Study:   Female
Accepts Healthy Volunteers:   Yes

Inclusion Criteria:

All of the following criteria must be met for the potential subject to be eligible for participation:

  1. The subject is a female scheduled to undergo ambulatory breast surgery performed under general anesthesia
  2. The subject is expected to undergo general inhalation anesthesia.
  3. The subject presents with two of the three following high-risk factors associated with PONV (must be in their medical history in order to be eligible)

    • She is a non-smoker.
    • She has documented history of PONV and/or motion sickness.
    • She is expected to receive intra-operative and postoperative opioid.
  4. The subject's American Society of Anesthesiologist physical status is ASA I-III
  5. The subject is between18 to 65 years of age.
  6. The subject is expected to be discharged from the hospital/surgical center on the same day as the surgery.
  7. The subject has provided written informed consent to participate in the study.

If any of the following exclusion criteria are met, the potential subject is NOT eligible for participation:

  1. The subject has a history of allergic reaction to, intolerances of or contraindications for any of the study medications or required anesthetic agents.
  2. The subject has received or is expected to receive any excluded preoperative drug within 48 hours prior to induction; or is expected to receive any excluded intra-operative or postoperative medications.
  3. The subject is pregnant or lactating. (If the potential subject is pre-menopausal, a urine pregnancy test must be performed within 24 hours/1 day of study prior to the planned surgery time and confirmed negative in order for the potential subject to be enrolled).
  4. The subject is taking warfarin.
  5. The subject has a history of alcohol and/or drug abuse within 1 year of study medication, or has a positive screening or pre-study test for alcohol or drugs of abuse.
  6. The subject is expected to require the use of a nasogastric tube postoperatively.
  7. The subject has a diagnosed latex allergy.
  8. The subject has used oral aprepitant (Emend®) within the last 30 days.
  9. The subject has participated in a randomized study or has been exposed to any experimental drug within 30 days prior to enrollment of this study.

Exclusion Criteria:

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its identifier (NCT number): NCT00738621

United States, Texas
Scott and White Healthcare
Temple, Texas, United States, 76508
Sponsors and Collaborators
Scott and White Hospital & Clinic
Merck Sharp & Dohme Corp.
Principal Investigator: Tricia A Meyer, PharmD Scott and White Healthcare

Responsible Party: Richard Beswick, Scott and White Healthcare Identifier: NCT00738621     History of Changes
Other Study ID Numbers: Scott and White
First Posted: August 20, 2008    Key Record Dates
Last Update Posted: December 19, 2013
Last Verified: August 2008

Keywords provided by Scott and White Hospital & Clinic:
breast surgery

Additional relevant MeSH terms:
Postoperative Nausea and Vomiting
Signs and Symptoms, Digestive
Signs and Symptoms
Postoperative Complications
Pathologic Processes
Dexamethasone acetate
BB 1101
Anti-Inflammatory Agents
Autonomic Agents
Peripheral Nervous System Agents
Physiological Effects of Drugs
Gastrointestinal Agents
Hormones, Hormone Substitutes, and Hormone Antagonists
Antineoplastic Agents, Hormonal
Antineoplastic Agents
Protease Inhibitors
Enzyme Inhibitors
Molecular Mechanisms of Pharmacological Action
Dermatologic Agents
Serotonin Antagonists