A comparison of the combination of aprepitant and dexamethasone versus the
combination of ondansetron and dexamethasone for the prevention of postoperative
nausea and vomiting in patients undergoing craniotomy.
Author(s): Habib AS, Keifer JC, Borel CO, White WD, Gan TJ.
Affiliation(s): Duke University Medical Center, Box 3094, Durham, NC 27710, USA.
Publication date & source: 2011, Anesth Analg. , 112(4):813-8
BACKGROUND: Postoperative nausea and vomiting (PONV) occur commonly after
craniotomy. In patients receiving prophylaxis with ondansetron and dexamethasone,
vomiting occurred in 45% of patients at 48 hours. In addition to causing patient
discomfort, the physical act of vomiting may increase intracranial pressure or
cerebral intravascular pressure, jeopardizing hemostasis and cerebral perfusion.
Aprepitant is a neurokin-1 receptor antagonist with a long duration of action and
no sedative side effect. In a large multicenter study in patients undergoing
abdominal surgery, aprepitant was significantly more effective than was
ondansetron in preventing vomiting at 24 and 48 hours postoperatively. We
hypothesized that the combination of aprepitant with dexamethasone will decrease
the incidence of postoperative vomiting when compared with the combination of
ondansetron and dexamethasone in patients undergoing craniotomy under general
METHODS: Patients scheduled to undergo craniotomy under general anesthesia were
enrolled in this prospective, double-blind, randomized study. Patients were
randomized to receive oral aprepitant 40 mg (or matching placebo) 1 to 3 hours
before induction of anesthesia or ondansetron 4 mg IV (or placebo) within 30
minutes of the end of surgery. All patients received dexamethasone 10 mg after
induction of anesthesia. The anesthetic technique was standardized. Data were
collected at regular intervals by blinded personnel for 48 hours after surgery.
Statistical analysis was performed using Wilcoxon's ranked sum test and χ(2)
test. P < 0.05 was considered statistically significant.
RESULTS: One hundred four patients completed the study. The cumulative incidence
of vomiting at 48 hours was 16% in the aprepitant group and 38% in the
ondansetron group (P = 0.0149). The incidence of vomiting was also decreased in
the aprepitant group at 2 hours (6% vs. 21%, P = 0.0419) and 24 hours (14% vs.
36%, P = 0.0124). From 0 to 48 hours, there was no difference between the
aprepitant and ondansetron groups in the incidence of nausea (69% vs. 60%),
nausea scores, need for rescue antiemetics (65% vs. 60%), complete response (no
PONV and no rescue, 22% vs. 36%), or patient satisfaction with the management of
CONCLUSION: The combination of aprepitant and dexamethasone was more effective
than was the combination of ondansetron and dexamethasone for prophylaxis against
postoperative vomiting in adult patients undergoing craniotomy under general
anesthesia. However, there was no difference between the groups in the incidence
or severity of nausea, need for rescue antiemetics, or in complete response
between the groups.