APONVIE as the Foundation of a Multimodal Regimen for Patients at Medium-to-High Risk of Postoperative Nausea and Vomiting (PONV)

Vallejo et al: Prospective Study Shows Aprepitant as Part of a Multimodal Approach Is Highly Effective for Moderate-to-High-Risk Plastic Surgery Patients²

This prospective, double-blinded, randomized 2-arm study evaluated the occurrence of vomiting and the severity of nausea in the 48 hours following surgery in 150 ambulatory plastic surgery patients undergoing general anesthesia with 2 or more risk factors for PONV. Patients received either aprepitant plus intravenous (IV) ondansetron or IV ondansetron and placebo.

Primary Endpoint

% patients with no vomiting, 0-48 hours

When aprepitant was added to IV ondansetron, 20% more patients experienced no vomiting in the first 48 hours following surgery (P = .003). In both treatment groups, all episodes of vomiting occurred in the first 12 hours.

Secondary Endpoint

Mean nausea verbal rating score, 0-48 hours

In a summary analysis of the first 48 hours following surgery,^a patients receiving aprepitant in addition to IV ondansetron had significantly lower-severity nausea (P = .024^b).

Note: Nausea was rated on a verbal rating scale of 0 to 10, with a score of 0 meaning no nausea and a score of 10 meaning the worst nausea ever.

^aMean differences in verbal rating scores over 48 hours tested simultaneously with a multivariate analysis of variance.

^bUnadjusted P value.

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Dilorio et al: Retrospective Chart Review Showed That Total Knee Arthroplasty and Total Hip Arthroplasty Patients Receiving Aprepitant Experienced Reduced Severity of PONV³

Fifty patients undergoing total hip arthroplasty or total knee arthroplasty who received a preoperative dose of oral aprepitant were matched to 50 patients who received no PONV prophylactic. Patients in both groups were treated postoperatively with IV ondansetron 4 mg only as rescue medication if PONV occurred. Patients' charts were retrospectively reviewed. Instances of PONV were noted for the entire length of hospital stay.

Severity of PONV

Number of patients

Key Metrics of PONV Reduced

On average, patients receiving oral aprepitant had approximately 40% fewer episodes of PONV, required less than half the amount of rescue medication, and were ready for discharge a day sooner.

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Habib et al: Prospective Study Showed That Aprepitant Reduced the Incidence of Vomiting in Craniotomy Patients⁴

In this prospective, double-blind, randomized study of 104 patients undergoing craniotomy under general anesthesia, patients received dexamethasone as well as either oral aprepitant or IV ondansetron. Though the complete response was similar between treatment groups, using aprepitant in addition to dexamethasone significantly reduced the incidence of vomiting compared to IV ondansetron at multiple timepoints.

Incidence of Vomiting

Aprepitant significantly reduced the incidence of vomiting compared to IV ondansetron at multiple timepoints.

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Kaur et al: Prospective Study Showed Aprepitant Demonstrated a Longer-Acting Effect Than IV Ondansetron in Laparoscopic Cholecystectomy⁵

In a randomized, double-blind, prospective trial, 90 patients undergoing laparoscopic cholecystectomy were treated with either oral aprepitant 40 mg, IV ondansetron 4 mg, or placebo. Though nausea scores across both treatment groups were similar, and the difference in the number of episodes of vomiting was not statistically significant in the first 24 hours, fewer episodes of vomiting were reported in the 24- to 48-hour time period in patients treated with aprepitant than in those treated with IV ondansetron.

Episodes of Vomiting

There was no statistically significant difference in early episodes of vomiting between the aprepitant and IV ondansetron groups; however, aprepitant demonstrated a longer-acting effect than IV ondansetron and better prevented delayed vomiting.

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Trimas et al: Retrospective Analysis Shows Aprepitant Reduced Postoperative Nausea in Facial Plastic Surgery⁶

In a retrospective analysis of 172 consecutive patients undergoing facial plastic surgery with general anesthesia, patients were treated with IV ondansetron and dexamethasone. In addition, 56 patients also received aprepitant. The addition of aprepitant reduced the likelihood of postoperative nausea compared to IV ondansetron and dexamethasone.

98% of patients receiving aprepitant in addition to IV ondansetron and dexamethasone experienced no PONV

84% of patients receiving only IV ondansetron and dexamethasone experienced no PONV

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Hartrick et al: Open-Label Study Showed Aprepitant Outperformed Multimodal PONV Therapies in TKA⁷

In a sequential, open-label, matched case control study, 24 patients underwent total knee arthroplasty with extended-release epidural morphine. One group of patients received ondansetron and dexamethasone, combined with either metoclopramide, diphenhydramine, or prochlorperazine, while the other received only oral aprepitant preoperatively. Incidence of PONV was then compared between the 2 groups. In this study, patients were considered positive for PONV if they reported any incidence of nausea or vomiting. Aprepitant used as a single agent significantly reduced the incidence of PONV compared to a multimodal antiemetic regimen (P = .039).

75% of patients who received aprepitant experienced no PONV

25% of patients who received the multimodal therapy experienced no PONV

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References: 1. Gan TJ, Jin Z, Ayad S, et al. Fifth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting: Executive Summary. Anesth Analg. 2025 Nov 14. Online ahead of print. doi:10.1213/ANE.0000000000007816. 2. Vallejo MC, Phelps AL, Ibinson JW, et al. Aprepitant plus ondansetron compared with ondansetron alone in reducing postoperative nausea and vomiting in ambulatory patients undergoing plastic surgery. Plast Reconstr Surg. 2012;129(2):519-526. doi:10.1097/PRS.0b013e31822b6932. 3. Dilorio TM, Sharkey PF, Hewitt AM, Parvizi J. Antiemesis after total joint arthroplasty: does a single preoperative dose of aprepitant reduce nausea and vomiting? Clin Orthop Relat Res. 2010;468(9):2405-2409. doi:10.1007/s11999-010-1357-x. 4. Habib AS, Keifer JC, Borel CO, White WD, Gan TJ. A comparison of the combination of aprepitant and dexamethasone versus the combination of ondansetron and dexamethasone for the prevention of postoperative nausea and vomiting in patients undergoing craniotomy. Anesth Analg. 2011;112(4):813-818. doi:10.1213/ANE.0b013e3181ff47e2. 5. Kaur U, Sharma VK, Sidhu JS. A comparison of aprepitant and ondansetron in prophylaxis of postoperative nausea and vomiting in laparoscopic cholecystectomy. Sch J App Med Sci. 2014;2(3B):1020-1027. 6. Trimas SJ, Trimas MD. Use of aprepitant and factors associated with incidence of postoperative nausea and vomiting in patients undergoing facial plastic surgery. JAMA Facial Plast Surg. 2015;17(4):251-255. doi:10.1001/jamafacial.2015.0307. 7. Hartrick CT, Tang YS, Hunstad D, et al. Aprepitant vs. multimodal prophylaxis in the prevention of nausea and vomiting following extended-release epidural morphine. Pain Pract. 2010;10(3):245-248. doi:10.1111/j.1533-2500.2010.00364.x.