Efficacy and Safety of Pharmacologic Therapies for Nausea and Emesis in the Emergency Department: A Systematic Review and Bayesian Network Meta-analysis

Objectives We conducted a systematic review and Bayesian network meta-analysis to identify the most effective and safest therapies for nausea/emesis in adult patients presenting to the emergency department (ED). Methods We searched PubMed, Embase, Cumulated Index to Nursing and Allied Health Literature, and Web of Science from inception to November 22, 2023. Eligible studies were randomized controlled trials in adult participants presenting to ED with nausea or emesis and compared one pharmacologic therapy with another or placebo. Outcomes were as follows: (1) change in nausea intensity at 30 minutes, (2) need for rescue drug, and (3) significant adverse reaction. We extracted data according to Preferred Reporting Items for Systematic Reviews and Network Meta-Analysis and appraised studies using Cochrane RoB 2. We performed Bayesian network meta-analysis to calculate odds ratios with 95% credible intervals and frequentist network meta-analysis to calculate mean differences with 95% confidence intervals. We assessed confidence using Confidence in Network Meta-analysis. We ranked agents using surface under the cumulative ranking curve (SUCRA). Results Intravenous tropisetron (SUCRA=93.9%) is most likely superior for “need for rescue drug” (not needing rescue drug) (11 trials; n=1,465). Intravenous ondansetron (SUCRA=78.6%) is most likely superior for “significant adverse reaction” (not causing adverse reaction) (9 trials; n=1,267). The network for change in nausea intensity demonstrated statistically significant incoherence at the overall level. Conclusion Within a minimally contextualized framework, as single agents, intravenous tropisetron and intravenous prochlorperazine are definitely among the most effective, intravenous metoclopramide and intravenous droperidol are possibly among the most effective, and oral ondansetron is definitely among the least effective; considering certain adverse reactions, intravenous metoclopramide, intravenous droperidol, and intravenous promethazine are definitely among the most harmful.