Prevention versus treatment of intrathecal morphine-induced pruritus with ondansetron

Kung, Adrienne; Yang, Xin; Li, Y.; Vasudevan, Anasuya; Pratt, Stephen D.; Hess, Philip E.

doi:10.1016/j.ijoa.2014.04.007

Cited by 16 publications

(14 citation statements)

References 18 publications

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“…In another study investigating intrathecal morphine-induced itching, Kung et al prophylactically used 8 mg IV ondansetron during umbilical cord clamping or postoperatively in the postanesthesia recovery room as a therapeutic dose in 82 patients who had undergone cesarean section, while the placebo group received only physiologic saline. When compared to the placebo group, prophylactic or therapeutic use of ondansetron did not decrease severity of itching at all [12]. In the present study, decrease in the severity of itching at third and sixth hours after administration of ondansetron was observed, but without any significant difference when compared to placebo group.…”

Section: Discussioncontrasting

confidence: 60%

Comparison of Mirtazapine,Gabapentin and Ondansetron to prevent intrathecal morphine induced pruritus

Akhan

Subaşı

Bosna

et al. 2016

North Clin Istanbul

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OBJECTIVE:Antagonism of the central nervous system inhibitor neurotransmitter gamma-Aminobutyric acid (GABA) or serotonergic system activation is an important factor in the pathogenesis of intrathecal morphine-induced pruritus. This study tested the hypothesis that preoperative use of ondansetron, gabapentin or mirtazapine can prevent morphine-induced pruritus.METHODS:We randomly allocated 80 patients of American Society of Anesthesiology (ASA) classification I and II physical status who were to undergo unilateral inguinal hernia or pilonidal sinus operations under spinal anesthesia into 4 equal groups. The first 3 groups received oral doses of 30 mg mirtazapine, 8 mg ondansetron, and 1200 mg gabapentin at 2 hours, 10 minutes, and 1 hour before surgery, respectively, and the fourth group was given a placebo. All patients received intrathecal injection of 15 mg of 0.5% hyperbaric bupivacaine and 0.2 mg morphine. Pruritus was evaluated at 0, 3, 6, 9, 12, and 24 hours after intrathecal morphine administration, and details of presence, onset time, duration, localization, and severity of pruritus were recorded.RESULTS:Incidence of pruritus was significantly more frequent in the placebo group compared to ondansetron, gabapentin, and mirtazapine groups (70%, 55%, 35%, and 35%, respectively). In general, onset of pruritus was between 2 and 6 hours after intrathecal morphine injection; however, onset in the gabapentin group (mean±SD: 4.75±2.7 hours; p=0.019) was delayed compared to other groups. It was observed that pruritus persisted relatively longer in the ondansetron and placebo groups (mean±SD: 6±3.08; 5.82±2.96 hours, respectively; p=0.047). No statistical determination was made regarding location of pruritus. Severity of pruritus was greater in the placebo group (p=0.0001). Necessity for antipruritic treatment was not statistically significantly different between groups.CONCLUSION:Incidence and severity of intrathecal morphine-induced pruritus decreased with use of each of all 3 drugs compared to placebo.

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Section: Discussioncontrasting

confidence: 60%

Comparison of Mirtazapine,Gabapentin and Ondansetron to prevent intrathecal morphine induced pruritus

Akhan

Subaşı

Bosna

et al. 2016

North Clin Istanbul

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“…After screening the titles and abstracts, 55 articles were excluded as they were obviously irrelevant trials or duplicates. Subsequently, 15 potentially eligible articles were carefully reviewed and five studies were excluded for they did not meet the eligibility criteria: three were studies without control groups, one was lack of full text after contacting the author and one did not give the incidence of pruritus after we contacted the authors for original data . Finally, ten RCTs comparing the preventive efficacy of intravenous ondansetron with control on neuraxial morphine‐induced pruritus were included in this meta‐analysis …”

Section: Resultsmentioning

confidence: 99%

Ondansetron for neuraxial morphine-induced pruritus: A meta-analysis of randomized controlled trials

Wang

Zhou

2017

J Clin Pharm Ther

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SummaryWhat is known and objective: Pruritus is one of the most common adverse effects associated with neuraxial morphine. Ondansetron has been used to deal with the problem of neuraxial morphine-induced pruritus (NMIP). The aim of this meta-analysis was to evaluate the preventive efficacy of ondansetron on NMIP. Methods: Online databases such as PubMed, EMBASE and the Cochrane CentralRegister of Controlled Trials were searched for eligible randomized controlled trials (RCTs). The primary outcome was the incidence of NMIP. We calculated risk ratios (RR) with 95% confidence intervals (CI) for dichotomous data. Trial sequential analysis (TSA) was performed to avoid the risk of making a spurious claim of significant effect and to calculate the sample size necessary to make a robust claim of effect. Results and discussion:Our traditional meta-analysis showed that prophylactic ondansetron could significantly reduce the incidence of NMIP in non-obstetric patients (three trials, RR=0.63, 95% CI 0.45-0.89, P=.008) with modest heterogeneity (I 2 =47%)while it did not show the preventive efficacy of NMIP in obstetric patients (seven trials, RR=0.84, 95% CI 0.69-1.03, P=.10) with obvious heterogeneity (I 2 =82% ). However, TSA demonstrates that more high-quality RCTs are still needed to confirm the preventive efficacy of ondansetron on NMIP in non-obstetric populations and to study whether ondansetron prevents NMIP in obstetric patients.What is new and conclusion: Prophylactic ondansetron can significantly reduce the incidence of NMIP in non-obstetric patients but not in obstetric patients. However, more well-designed trials are still required to test the reliability of the results in our traditional meta-analysis. K E Y W O R D Sclinical pharmacy, meta-analysis, morphine, ondansetron, pruritus to be applied in meta-analyses to assess the reliability of the evidence in traditional meta-analysis and provide the sample size necessary to make a robust claim of effect (termed as the required information size, RIS). 10,11 Therefore, we performed this study to evaluate the preventive efficacy of ondansetron on neuraxial morphine-induced pruritus. | WHAT IS KNOWN AND OBJECTIVE | METHODS This meta-analysis was conducted according to the PreferredReporting Items for Systematic Reviews and Meta-analyses (PRISMA)guidelines. 12 | Search strategyThree databases such as PubMed, EMBASE and the Cochrane CentralRegister of Controlled Trials were searched with language restriction to English for randomized controlled trials (RCTs) assessing the preventive effectiveness of ondansetron on NMIP. Besides, we also manually screened the reference lists of relevant reviews and studies for eligible articles. The search strategies for the three online databases were given in Appendix S1. The last search was conducted on 10 March 2017. | Eligibility criteria and study selectionFull-text RCTs published in English that compared the preventive efficacy of intravenous ondansetron versus control (namely, 0.9% normal saline) on pruritus induced by neuraxia...

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“…Pruritus - an unpleasant and irritating sensation leading to scratching - is a common adverse effect of neuraxial morphine with the highest prevalence (up to 100%) associated with intrathecal morphine administration [ 11 ]. It is generally mild and localized to the face and trunk, but it can be severe and cause significant maternal discomfort [ 15 ]. Despite its frequent occurrence and practice of utilizing various pharmacological therapies including antihistamines, 5-HT3 receptor antagonists, opiate antagonists, propofol (hypnotic agent), non-steroidal anti-inflammatory drugs (NSAIDS) and anti-dopaminergic drugs, there are no consistently effective therapies established for opioid-induced pruritus [ 3 , 11 , 16 ].…”

Section: Discussionmentioning

confidence: 99%

Prophylactic administration of ondansetron in prevention of intrathecal morphine-induced pruritus and post-operative nausea and vomiting in patients undergoing caesarean section

2015

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BackgroundIntrathecal morphine is commonly used for post caesarean analgesia. However, their use is frequently associated with the incidence of troublesome side effects such as nausea, vomiting and pruritus. Various mechanisms have been postulated for the opioid-induced pruritus, with a variety of medications with different mechanisms of actions formulated for the prevention and treatment. But, the results are inconsistent and hence the prevention and treatment of opioid-induced pruritus still remains a challenge. Ondansetron which is antiemetic, non-sedative and has no antianalgesic effect is an antagonist to 5-HT3 receptor, the receptor with which opioids interacts and imparts its effects. Ondansetron, thus, would be an attractive treatment strategy for both opioid-induced pruritus and post-operative nausea and vomiting.MethodsAfter the approval from institutional review committee and written consent received from the patient, 50 healthy parturients of ASA I and II physical status undergoing caesarean section under spinal anaesthesia were enrolled for the study. They were randomly categorized into placebo group (2 ml normal saline) and treatment group (2 ml of 4 mg ondansetron), each group containing 25 patients. Pruritus and post-operative nausea and vomiting scores were recorded up to 24 hours after the administration of intrathecal morphine. Statistical analysis was performed using chi-square test.ResultsThe incidence, severity and necessity of treatment for pruritus in the treatment group was significantly reduced compared to the placebo group (16% vs 88%). Similarly, the risk of post-operative nausea and vomiting in the treatment group was less compared to the placebo group (8% vs 56%).ConclusionProphylactic administration of ondansetron to parturients receiving intrathecal morphine for post-operative analgesia provides a significant reduction of intrathecal morphine-induced pruritus and nausea and vomiting.Trial registrationCTRI/2015/01/005362 registered on 07/01/2015 in Clinical Trials Registry – India (ctri.nic.in).

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Prevention versus treatment of intrathecal morphine-induced pruritus with ondansetron

Cited by 16 publications

References 18 publications

Comparison of Mirtazapine,Gabapentin and Ondansetron to prevent intrathecal morphine induced pruritus

Comparison of Mirtazapine,Gabapentin and Ondansetron to prevent intrathecal morphine induced pruritus

Ondansetron for neuraxial morphine-induced pruritus: A meta-analysis of randomized controlled trials

Prophylactic administration of ondansetron in prevention of intrathecal morphine-induced pruritus and post-operative nausea and vomiting in patients undergoing caesarean section

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