Aprepitant as a fourth antiemetic prophylactic strategy in high-risk patients: a double-blind, randomized trial

Post-operative nausea and vomiting (PONV) is one of the most important causes of patient discomfort after laparoscopic surgeries despite the use of a multimodal pharmacological approach. This study assessed whether the addition of aprepitant to a multimodal regimen would further decrease the incidence of PONV in high-risk patients.

Apfel-score three or four patients, scheduled for laparoscopic procedures to treat abdominal or pelvic cancer, were randomized to receive oral starch (control group) or 80 mg of oral aprepitant (treatment group) before induction of anaesthesia in a double-blind study. All patients received 4-8 mg of intravenous dexamethasone (at induction) and 4-8 mg of ondansetron (at the end) and a standardized total intravenous anaesthesia (TIVA) technique combined with neuraxial blockade. PONV was defined as any episode of nausea, vomiting or retching in the first 24 h after anaesthesia.

Sixty-six patients completed the study. Vomiting occurred in 13/32 (40.6%) patients in the control group and in 1/34 (2.9%) patients in the treatment group (P = 0.0002, 95%CI: 18-54%) in the first 24 h after anaesthesia. Severe nausea occurred in two (6.3%) patients, and severe vomiting occurred in four (12.5%) patients in the control group. One patient presented with severe vomiting in the treatment group in the first 24 post-operative hours.

Eighty milligrams of aprepitant added to a three-drug multimodal prophylaxis strategy can bring benefits to a high-risk population by reducing PONV episodes and rescue antiemetic requirements. This study was registered in the ClinicalTrials.gov (NCT 02357693) database.