Which medicines work best to prevent people from being sick | Figure 1
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Which medicines work best to prevent people from being sick (vomiting) after an operation?
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Why are people sick after an operation?
Feeling sick (nausea) or being sick (vomiting) is a common unwanted effect of general anaesthesia—medicine that makes people unconscious and unresponsive so they don't move or feel pain during an operation.
Most unwanted effects of general anaesthesia, including feeling or being sick, happen immediately and stop after a few hours, although some people may continue to feel sick for up to a day. If people carry on feeling or being sick, they might have to stay in hospital longer than expected and may experience other unwanted effects or complications.
Women are more likely to be sick after an operation, as are people taking opioid painkillers, those who have had motion sickness, and those who have been sick after previous operations.
Medicines to prevent people from being sick
Medicines called antiemetics are given to prevent people from feeling or being sick. These medicines may be given before or during anaesthesia.
Antiemetic medicines are grouped into six main classes based on how they act. Combining medicines from different classes sometimes makes them work better.
Why we did this Cochrane Review
We wanted to find out which medicines work best to prevent people from being sick after an operation and cause the fewest unwanted effects. Some unwanted effects of antiemetic medicines include headache, constipation, movement disorders such as tremors, sleepiness, irregular heartbeat, and wound infection.
What did we do?
We searched for studies that looked at the use of antiemetic medicines in adults having general anaesthesia to prevent people from being sick afterwards.
We looked for randomized controlled studies, in which the treatments people received were decided at random. This type of study usually gives the most reliable evidence about the effects of a treatment.
Search date
We included evidence published up to November 2017; in April 2020, we found another 39 studies, which are not yet included in the analysis.
What we found
We found 585 studies in 97,516 people who were given antiemetic medicines before or during general anaesthesia. People included in the studies were more likely to be sick after anaesthesia, as 83% were women and 88% were taking opioid painkillers. Most studies were conducted in Asia, Europe, or North America.
These studies either measured how many people were sick in the first 24 hours after their operation or how many unwanted effects were reported, or both of these outcomes. Most studies compared medicines (given alone or in combination) with a dummy (placebo) treatment.
We compared all antiemetic medicines with each other using a mathematical method called network meta‐analysis.
What were our main results and how reliable are these results?
Compared with placebo treatment, 10 out of 28 single medicines and 29 out of 36 combinations of medicines prevented people from being sick in the first 24 hours after their operation (282 studies). Combinations of antiemetic medicines generally worked better than single medicines given alone. However, aprepitant, casopitant, and fosaprepitant worked as well alone as most combinations of antiemetics. The single medicine that worked best in the ranking of all medicines was fosaprepitant, followed by casopitant, aprepitant, ramosetron, granisetron, dexamethasone, tropisetron, ondansetron, dolasetron, and droperidol.
We are confident that aprepitant, ramosetron, granisetron, dexamethasone, and ondansetron prevent people from being sick. We are moderately confident about how well fosaprepitant and droperidol work, but this finding may change when further evidence becomes available. We are uncertain about how well casopitant, tropisetron, and dolasetron work.
Not all studies looked at serious, life‐threatening unwanted effects. We are uncertain how many of these effects were reported when taking an antiemetic medicine and whether serious, life‐threatening unwanted effects occur at a similar rate or are reduced compared to placebo (28 studies).
Of the best medicines with most reliable evidence for preventing being sick, granisetron and ondansetron probably made little to no difference in the occurrence of unwanted effects compared to placebo, whereas dexamethasone and droperidol may cause fewer unwanted effects than placebo. We are uncertain about unwanted effects with aprepitant and ramosetron (61 studies). We found no studies looking at unwanted effects for fosaprepitant.
We are less confident about unwanted effects of other antiemetic medicines because we found little reliable evidence about this. Our results for unwanted effects are likely to change when further evidence is available.
Conclusions
For people at higher risk, we found that some antiemetic medicines work well to prevent them from being sick after general anaesthesia. The best antiemetic medicines with reliable evidence were aprepitant, ramosetron, granisetron, dexamethasone, and ondansetron, followed by fosaprepitant and droperidol.
However, we did not find enough reliable evidence about potential unwanted effects to rank these medicines reliably according to how well they are tolerated.
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\ \ Is chloroquine or hydroxychloroquine useful in treating people with COVID‐19, or in preventing infection in people who have been exposed to the virus?\ What is the aim of this review?\ COVID‐19 is an infectious respiratory disease caused by a coronavirus called SARS‐CoV‐2. If the infection becomes severe, people may need intensive care and support in hospital, including mechanical ventilation.\ Drugs used for other diseases were tried out in COVID‐19, and this included chloroquine, used for malaria; and hydroxychloroquine used for rheumatic diseases, such as rheumatoid arthritis or systemic lupus erythematosus. We sought evidence of the effects of these drugs in treating people ill with the disease; in preventing the disease in people at risk of getting the disease, such as health workers; and people exposed to the virus developing the disease.\ Key messages\ Hydroxychloroquine does not reduce deaths from COVID‐19, and probably does not reduce the number of people needing mechanical ventilation.\ Hydroxychloroquine caused more unwanted effects than a placebo treatment, though it did not appear to increase the number of serious unwanted effects.\ We do not think new studies of hydroxychloroquine should be started for treatment of COVID‐19.\ What was studied in the review?\ We searched for studies that looked at giving chloroquine and hydroxychloroquine to people with COVID‐19; people at risk of being exposed to the virus; and people who have been exposed to the virus.\ We found 14 relevant studies: 12 studies of chloroquine or hydroxychloroquine used to treat COVID‐19 in 8569 adults; two studies of hydroxychloroquine to stop COVID‐19 in 3346 adults who had been exposed to the virus but had no symptoms of infection. We did not find any completed studies of these medicines to stop COVID‐19 in people who were at risk of exposure to the virus; studies are still under way.\ The studies took place in China, Brazil, Egypt, Iran, Taiwan, North America, and Europe; one study was worldwide. Some studies were partly funded by pharmaceutical companies that manufacture hydroxychloroquine.\ What are the main results of our review?\ Treating COVID‐19\ Compared with usual care or placebo, hydroxychloroquine:\ · clearly did not affect how many people died (of any cause; 9 studies in 8208 people);\ · probably did not affect how many people needed mechanical ventilation (3 studies; 4521 people);\ · may not affect how many people still tested positive for the virus after 14 days (3 studies; 213 people).\ We are uncertain whether hydroxychloroquine affected the number of people whose symptoms improved after 28 days.\ Compared with other antiviral treatment (lopinavir plus ritonavir), chloroquine made little or no difference to the time taken for symptoms to improve (1 study; 22 people).\ Compared with usual care in one study in 444 people, hydroxychloroquine given with azithromycin (an antibiotic) made no difference to:\ · how many people died;\ · how many needed mechanical ventilation; or\ · time spent in hospital.\ Compared with febuxostat (a medicine to treat gout), hydroxychloroquine made no difference to how many people were admitted to hospital or to changes seen on scans of people's lungs; no deaths were reported (1 study; 60 people).\ Preventing COVID‐19 in people exposed to it\ We are uncertain whether hydroxychloroquine affected how many people developed COVID‐19, or how many people were admitted to hospital with COVID‐19, compared with those receiving a placebo treatment (1 study; 821 people).\ Compared with usual care, hydroxychloroquine made no difference to the risk of developing COVID‐19, or antibodies to the virus, in people exposed to it (1 study; 2525 people).\ Unwanted effects\ When used for treating COVID‐19, compared with usual care or placebo, hydroxychloroquine:\ · probably increases the risk of mild unwanted effects (6 studies; 1394 people);\ · may not increase the risk of serious harmful effects (6 studies; 1004 people).\ When given along with azithromycin, hydroxychloroquine increased the risk of any unwanted effects, but made no difference to the risk of serious unwanted effects (1 study; 444 people).\ Compared with lopinavir plus ritonavir, chloroquine made little or no difference to the risk of unwanted effects (1 study; 22 people).\ When used for preventing COVID‐19, hydroxychloroquine probably causes more unwanted effects than placebo, but may not increase the risk of serious, harmful unwanted effects (1 study; 700 people).\ How confident are we in our results?\ We are confident about our results for how many people died and moderately confident about how many needed mechanical ventilation. We are moderately confident about the unwanted effects of hydroxychloroquine treatment, but less confident about our results for serious unwanted effects; these results might change with further evidence.\ How up‐to‐date is this review?\ We included evidence published up to 15 September 2020.](https://app.figure1.com/case-detail/47eaf351-8332-42a9-9ffc-cd099dc20b03)
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\ \ Why are people sick after an operation?\ Feeling sick (nausea) or being sick (vomiting) is a common unwanted effect of general anaesthesia—medicine that makes people unconscious and unresponsive so they don't move or feel pain during an operation.\ Most unwanted effects of general anaesthesia, including feeling or being sick, happen immediately and stop after a few hours, although some people may continue to feel sick for up to a day. If people carry on feeling or being sick, they might have to stay in hospital longer than expected and may experience other unwanted effects or complications.\ Women are more likely to be sick after an operation, as are people taking opioid painkillers, those who have had motion sickness, and those who have been sick after previous operations.\ Medicines to prevent people from being sick\ Medicines called antiemetics are given to prevent people from feeling or being sick. These medicines may be given before or during anaesthesia.\ Antiemetic medicines are grouped into six main classes based on how they act. Combining medicines from different classes sometimes makes them work better.\ Why we did this Cochrane Review\ We wanted to find out which medicines work best to prevent people from being sick after an operation and cause the fewest unwanted effects. Some unwanted effects of antiemetic medicines include headache, constipation, movement disorders such as tremors, sleepiness, irregular heartbeat, and wound infection.\ What did we do?\ We searched for studies that looked at the use of antiemetic medicines in adults having general anaesthesia to prevent people from being sick afterwards.\ \ We looked for randomized controlled studies, in which the treatments people received were decided at random. This type of study usually gives the most reliable evidence about the effects of a treatment.\ Search date\ We included evidence published up to November 2017; in April 2020, we found another 39 studies, which are not yet included in the analysis.\ What we found\ We found 585 studies in 97,516 people who were given antiemetic medicines before or during general anaesthesia. People included in the studies were more likely to be sick after anaesthesia, as 83% were women and 88% were taking opioid painkillers. Most studies were conducted in Asia, Europe, or North America.\ These studies either measured how many people were sick in the first 24 hours after their operation or how many unwanted effects were reported, or both of these outcomes. Most studies compared medicines (given alone or in combination) with a dummy (placebo) treatment.\ We compared all antiemetic medicines with each other using a mathematical method called network meta‐analysis.\ What were our main results and how reliable are these results?\ Compared with placebo treatment, 10 out of 28 single medicines and 29 out of 36 combinations of medicines prevented people from being sick in the first 24 hours after their operation (282 studies). Combinations of antiemetic medicines generally worked better than single medicines given alone. However, aprepitant, casopitant, and fosaprepitant worked as well alone as most combinations of antiemetics. The single medicine that worked best in the ranking of all medicines was fosaprepitant, followed by casopitant, aprepitant, ramosetron, granisetron, dexamethasone, tropisetron, ondansetron, dolasetron, and droperidol.\ We are confident that aprepitant, ramosetron, granisetron, dexamethasone, and ondansetron prevent people from being sick. We are moderately confident about how well fosaprepitant and droperidol work, but this finding may change when further evidence becomes available. We are uncertain about how well casopitant, tropisetron, and dolasetron work.\ Not all studies looked at serious, life‐threatening unwanted effects. We are uncertain how many of these effects were reported when taking an antiemetic medicine and whether serious, life‐threatening unwanted effects occur at a similar rate or are reduced compared to placebo (28 studies).\ Of the best medicines with most reliable evidence for preventing being sick, granisetron and ondansetron probably made little to no difference in the occurrence of unwanted effects compared to placebo, whereas dexamethasone and droperidol may cause fewer unwanted effects than placebo. We are uncertain about unwanted effects with aprepitant and ramosetron (61 studies). We found no studies looking at unwanted effects for fosaprepitant.\ We are less confident about unwanted effects of other antiemetic medicines because we found little reliable evidence about this. Our results for unwanted effects are likely to change when further evidence is available.\ Conclusions\ For people at higher risk, we found that some antiemetic medicines work well to prevent them from being sick after general anaesthesia. The best antiemetic medicines with reliable evidence were aprepitant, ramosetron, granisetron, dexamethasone, and ondansetron, followed by fosaprepitant and droperidol.\ However, we did not find enough reliable evidence about potential unwanted effects to rank these medicines reliably according to how well they are tolerated.](https://app.figure1.com/case-detail/873bcda9-d75c-43b0-b074-95e3803b85e2)
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