"Ondansetron augmentation for obsessive-compulsive disorder: A systematic review and meta-analysis of randomized...

A substantial proportion of adults with obsessive-compulsive disorder (OCD) experience persistent symptoms despite optimized first-line treatment with exposure and response prevention and/or serotonin reuptake inhibitors (SRIs). Ondansetron, a selective 5-hydroxytryptamine-3 (5-HT3) receptor antagonist with plausible circuit-level relevance to cortico-striato-thalamo-cortical dysfunction, has been evaluated as an augmentation strategy. Still, evidence is dispersed across small randomized trials.

We conducted a PRISMA 2020-adherent systematic review and random-effects meta-analysis (PROSPERO: CRD420261302132). Embase (Ovid and Embase.com), MEDLINE, PubMed, and Scopus were searched from inception to 12 February 2026. Eligible studies were randomized, double-blind, placebo-controlled trials of oral ondansetron augmentation in adults (≥ 18 years) with OCD on stable background treatment. The primary outcome was change in Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) total score, pooled at prespecified acute windows (week 4, ~week 8 primary, week 12). Secondary outcomes included Y-BOCS obsession and compulsion subscales. Risk of bias was assessed using RoB 2. Random-effects models (DerSimonian-Laird) were used; Wan's method was applied when required.

Five trials (total N = 289) were included. Ondansetron augmentation was associated with greater improvement in Y-BOCS total score versus placebo at week 4 (MD 2.63; 95% CI 0.87-4.39; I²=62%); heterogeneity resolved after excluding one influential study (MD 1.94; 0.37-3.51; I²=0%). At week 8 (four trials; N = 244), benefit was larger (MD 5.53; 3.45-7.60; I²=48%) and remained robust in sensitivity analysis (MD 6.76; 5.81-7.71; I²=0%). At week 12 (three trials; N = 200), effects persisted (MD 6.41; 4.28-8.53; I²=55%) with reduced heterogeneity after excluding one study (MD 5.06; 2.82-7.30; I²=0%). In two trials reporting subscales (N = 214), obsessions improved at weeks 4 and 8 (overall MD 2.67; 1.66-3.67; I²=0%), while compulsions showed a smaller, later signal (overall MD 1.02; 0.19-1.86; I²=0%). Safety reporting was variably detailed across trials; known QT-prolongation considerations remain relevant for off-label use.

In randomized, placebo-controlled trials, ondansetron augmentation was associated with greater improvement in clinician-rated OCD severity than placebo over short-term follow-up, with signals emerging by week 4 and persisting through 8-12 weeks. However, these findings should be interpreted cautiously because the evidence base is small, geographically concentrated, and partly influenced by individual studies. The current evidence should therefore be considered preliminary and hypothesis-generating rather than definitive. Larger multicenter trials with standardized background SRI optimization, preregistered outcomes, and rigorous safety monitoring are required before routine clinical adoption can be considered.