Next up from the top ten articles presented at the recent AAP NCE in San Diego is a retrospective observational analysis from Freedman et al. on the increasing use of ondansetron and its effects on clinic outcomes in children. Certainly many of you have written for ondansetron. I have written about ondansetron; including a Why We Do What We Do focusing on the evidence behind its use, a companion podcast, and a Briefs on the curious tendency of its association with increased risk of return to the ED.

Impact of increasing ondansetron use on clinical outcomes in children with gastroenteritis

Freedman SB, Hall M, Shah SS, Kharbanda AB, Aronson PL, Florin TA, Mistry RD, Macias CG, Neuman MI. JAMA Pediatrics, 2014
Links PubMed JAMA Pediatrics

The bottom line

We are giving too much ondansetron, especially to kids who aren’t really in need of or at risk for needing IV rehydration.

What they did

The authors performed a retrospective observational analysis of children under the age of 18 diagnosed with gastroenteritis via a large database that included 18 Pediatric Emergency Departments. Oral ondansetron use was studied at a hospital level and categorized based on percentage of use in eligible patients: low (<5% administered ondansetron), medium (5%-25%), or high (>25%). This study was concerned with transitions between usage rates as ondansetron became more en vogue. The primary outcome was IV rehydration, and the secondary outcomes were hospitalization and emergency department revisits within 3 days. They noted the following:

  • Oral ondansetron use (median institutional rate per this study) increased substantially between 2002 and 2011 –  from 0.11% (interquartile range, 0.04%-0.44%) of patient visits in 2002 to 42.2% (interquartile range, 37.5%-49.1%) in 2011 (P < .001)
  • Oral ondansetron was provided to 13.5% (95% CI, 13.3% to 13.7%) of children administered intravenous rehydration
  • IV rehydration rates only decreased slightly as ondansetron use grew; 43,41/232,706 (18.7%) during period of low use to 59,450/334,264 (17.8%) during the high use period (adjusted percentage change = −0.33%; 95% CI, −1.86% to 1.20%)
  • No change in the hospitalization rate (adjusted percentage change = −0.33%; 95% CI, −0.95% to 0.29%)
  • Emergency department revisits decreased (adjusted percentage change = −0.31%; 95% CI, −0.49% to −0.13%)
  • Median adjusted total hospital costs/patient increased from $252 to $307

The above results take into account the aggregate data across 18 hospitals. Though overall rates of IV fluids, admission and ED revisits did not change substantially, these changes were more pronounced in hospitals with varying levels of usage. One-third of the hospitals did see a reduction in IV fluid administration rates, and 3/18 saw a reduction in admission rates when ondansetron use increased. So it appears as though some facilities used it in the right clinical scenarios, at least according to the RCTs.

What you can do

  • Recognize that for children with mild to moderate dehydration oral rehydration therapy (ORT) is the first line treatment option
  • In the right situation ondansetron may reduce the need for IV fluids or admission
  • In that this study showed no rise in rates of IV fluid administration concomitant with increased use of ondansetron suggests that we may be giving it too frequently in the Emergency Department
  • Find out if ondansetron is protocoled/bundled in your ED and thus being given less discriminately than it should
  • As yourself the following:
    • How frequently are you using ondansetron?
    • Are you using it for the right patients?
    • Are you providing adequate patient education and guidance?
  • Know that just giving it to stop a patient from vomiting is not something that we should do just for the sake of “customer service” alone. Spending adequate time addressing parental concerns about why the vomiting is occurring and providing reassurance is likely to be highly effective as well.