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Three Part Question

In [patients treated with opiods] is [metoclopramide better than nothing] in [reducing nausea and vomiting]?

Clinical Scenario

A 52 year old man attends the emergency department having been kicked on his right leg by a horse. He is complaining of severe pain in the leg and examination shows deformity. You make the clinical diagnosis of a fracture. You ask for an opiod to relieve his pain; the nurses insist you give metoclopramide as well. You wonder whether there is any evidence to support their assertion that metoclopramide should be given routinely with opiods.

Search Strategy

Medline 1966-01/04 using the Ovid interface.
[(exp vomiting OR exp Nausea OR vomit$.mp OR exp Vomiting, anticipatory OR emesis$.mp OR nausea$.mp) AND (exp metoclopramide OR metoclopramide$.mp) AND (randomised controlled trial.mp OR exp clinical trials OR exp random allocation OR exp randomized controlled trials OR double-blind trial.mp OR exp double-blind method OR exp clinical trials] LIMIT to human AND English.

Search Outcome

Altogether 405 papers were found of which one is relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Talbot-Stern J & Paoloni R, 2000, Australia	122 patients of which 63 were given metoclopramide	PRCT, double blind	At 30 min. At 60 min.	No significant difference	Small study Numbers did not add up
			Nausea at 30 mins and 60 mins	Metoclopramide 3.2% v placebo 6.8% at 30 mins. Metoclopramide 4.8% v placebo 3.4% at 60 mins.
			Vomiting at 30 mins and 60 mins	Metoclopramide 0% v placebo 0% at 30 mins. Metoclopramide 0% v placebo 1.7% at 60 mins
			Side effect	Metoclopramide 7.9 % vs placebo 3.4%

Comment(s)

While many studies evaluated the effects of metoclopramide postoperatively, only this study evaluated the effects in the emergency department. Because of the low incidence of nausea and vomiting in both groups of this study, it is not possible to make a specific conclusion regarding the prophylactic effect of metoclopramide in reducing opiods associated nausea and vomiting.

Editor Comment

A more up to date version of this BET topic is at http://www.bestbets.org/cgi-bin/bets.pl?record=00266 BET 266 includes other papers not found on this original submission and should be reviewed as well as the above.

Clinical Bottom Line

The incidence of nausea and vomiting with opiods is very low in these groups of patients. This study did not provide evidence that prophylactic metoclopramide is effective.

References

1. Talbot-Stern J, Paoloni R Prophylactic metoclopramide is unnecessary with intravenous analgesia in the ED. Am J Emerg Med 2000;18(6):653-7.