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Three Part Question

In [pregnant women who present to the emergency department with nausea and vomiting] is [ondansetron] compared to [metoclopramide] associated with [improved symptoms]?

Clinical Scenario

A pregnant female presents to the emergency department with repeated episodes of vomiting. She has not used any medications at home for relief. She has been unable to tolerate fluids. While a nurse prepares to place a peripheral IV, you begin to wonder if ondansetron or metoclopramide would be more beneficial for a pregnant woman with vomiting.

Search Strategy

Medline 1966-08/17 using OVID interface, Cochrane Library (2017), and Embase


[(exp metoclopramide AND exp ondansetron)] AND [(exp pregnancy OR hyperemesis)]

Search Outcome

33 studies were identified; two randomized trials addressed the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kashifard et al 2013 Iran	83 pregnant women with hyperemesis gravidarum in 2011-2012 83 pregnant women with HG were enrolled in 2011-2012	Double blinded RCT	Severity of nausea and vomiting	No significant difference in nausea score, but significant decrease in vomiting with ondansetron compared to metoclopramide	Small sample size, relied on subjective nausea scores.
Abas et al 2014 Malaysia	160 women with hyperemesis gravidarum in 2011-2012	Double blind RCT	Well-being score and vomiting episodes	No significant difference between nausea or vomiting, but better side effect profile with ondansetron	Likely underpowered for less common side effects; the primary outcomes were over the course of a 24-hour time scale only.

Comment(s)

Two randomized controlled trials showed that ondansetron and metoclopramide are both effective in controlling nausea and vomiting in pregnant patients. The studies also showed that there were more side effects with metoclopramide. Both drugs are economical, have a long history of widespread use, have an excellent fetal safety record, and are reasonable first-line short-term antiemetics of choice in hyperemesis gravidarum.

Clinical Bottom Line

Pregnant patients with hyperemesis gravidarum can be effectively treated by ondansetron or metoclopramide, but there are more side effects with metoclopramide.

References

1. Kashifard M, Basirat Z, Kashifard M, Golsorkhtabar-Amiri M, Moghaddamnia A. Ondansetrone or metoclopromide? Which is more effective in severe nausea and vomiting of pregnancy? A randomized trial double-blind study. Clin Exp Obstet Gynecol. 2013;40(1):127-30.
2. Abas MN, Tan PC, Azmi N, Omar SZ. Ondansetron compared with metoclopramide for hyperemesis gravidarum: a randomized controlled trial. Obstet Gynecol. 2014 Jun;123(6):1272-9. 2014 Jun;123(6):1272-9.