Does Zofran cause sedation in your experience?

[dozitgetchahi]

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One of the patients I admitted recently was and elderly woman who came in with delirium, constipation, and nausea (among other things). She was retching and had several episodes of vomiting, so while she was being further worked up for the delirium I gave her a couple doses of Zofran to keep her more comfortable and hopefully reduce the chances of her aspirating on vomitus. On rounds the next day, the patient was somewhat somnolent and I was chastised by my senior for using a 'centrally acting' antiemetic on somebody who was delirious. My response was 1) 5-HT3 antagonists were always billed as non-sedating drugs to me (or if nothing else, the very least sedating antiemetics) and 2) if I didn't use Zofran, what else was I going to use? Pretty much any other antiemetic that I am aware of is going to be more sedating and/or anticholinergic etc thus making it less desirable to use in a delirious patient. The patient wasn't on any other medication that would be sedating. We're still not sure why she was so altered on admission - as per the family, she's apparently been like this for at least a couple months. This resident had actually agreed with the idea of trying to manage this woman's nausea phamacologically when we admitted her the night before.

Thoughts? Does anyone find Zofran to be sedating etc? I haven't yet heard patients complain of this as a side effect.

 

[wire]

your "senior" is an idiot.

 

[IM2GI]

Should have just gone with Ativan, works great for nausea and will really set off that delirium.

 

[Instatewaiter]

Of the anti-emetics I find it is one of the least sedating. Especially in the elderly, you're going to have more sedation with the anticholinergic effects of the others. Maybe reglan? I hate reglan though.

 

[Instatewaiter]

Should have just gone with Ativan, works great for nausea and will really set off that delirium.

It does really work well though. I love it for when we have someone with a really long QT and nausea.

 

[IM2GI]

It does really work well though. I love it for when we have someone with a really long QT and nausea.

Haha, yea it really does. I don't reach for it as my go to, but if Zofran isnt doing it I will sometimes use it before phenergan/compazine. "Doc, only Phenergan and Benadryl, IV push, work for me"

 

[gutonc]

I give a LOT of anti-emetics. Zofran can be sedating (and also constipating) but certainly less so than Ativan. I find compazine to generally be more activating, but not always. Something that nobody usually thinks of outside of oncology are Haldol or droperidol and the atypicals like olanzapine which are certainly sedating and centrally acting but tend to have less delirium than benzos and are easier to titrate.

I think that the moral of the story in this case is that pharmacotherapy in the elderly can be a total clusterf*** no matter what you're treating.

 

[jdh71]

As pointed out, it can be sedating in certain patients, for unclear reasons and who the hell knows what the hell is going to happen to "old brain" until its tried in the elderly population. With all that said zofran will generly be the best bang for your buck first try for nausea and usually works and is usually not sedating. I'll try reglan second line. Compazine is my personal favorite third line agent but sometimes it goes into short supply and then I'll use haldol.

Sometimes at the end if the day you need to be a "doctor" and decide which is better at the moment a puking patient or a sleepy one.

 

[Instatewaiter]

As pointed out, I can be sedating in certain patients,

Sometimes at the end if the day you need to be a "doctor" and decide which is better at the moment a puking patient or a sleepy one.

Which certain patients are you in? By "doctor" did you mean sexual preditor. Is that why doctor is in quotes?

 

[jdh71]

Which certain patients are you in? By "doctor" did you mean sexual preditor. Is that why doctor is in quotes?

iphone hates me

let me correct that

 

[immunopath]

Is dronabinol an option?

 

[jdh71]

Is dronabinol an option?

sure, but good luck getting the pharmacy to give you any of that expensive stuff

 

[gutonc]

Is dronabinol an option?

sure, but good luck getting the pharmacy to give you any of that expensive stuff

It's also like my 7th or 8th favorite anti-emetic in terms of efficacy.

 

[jdh71]

It's also like my 7th or 8th favorite anti-emetic in terms of efficacy.

It's definitely no where near as good as just smoking the stuff. I almost never discourage a chronically ill patient from smoking weed if they tell me they get benefit. That probably makes me a bad doctor but I don't give a ****.

 

[gutonc]

It's definitely no where near as good as just smoking the stuff. I almost never discourage a chronically ill patient from smoking weed if they tell me they get benefit. That probably makes me a bad doctor but I don't give a ****.

I don't encourage it per se but I sign a lot of medical weed cards. A lot.

 

[dozitgetchahi]

Interesting points. I have used droperidol before and it's a good drug, but it's not formulary at this particular hospital. Being someone who likes pharm and using 'offbeat' drugs (when appropriate), I actually did think of giving olanzapine but ultimately decided not to because I think I would have gotten even stranger looks the following day ('Zyprexa is not a drug for nausea...' etc etc). Everyone around here seems to be afraid of IV Compazine, which results in a lot of IV promethazine being given (which I prefer not to use as it's a badass vesicant and I've seen the consequences). I've seen a fairly surprising amount of akathesia from both prochlorperazine or promethazine as well.

One interesting option for n/v in the right patient is Remeron (potent 5-HT3 antagonist with a super long half life...available in ODTs...minimal QT prolongation too). It seems to have worked pretty well when I've used it.

 

[DrSnips]

In terms of non-sedating anti-emetics, tigan is a reasonable choice. I haven't found it to be as effective as zofran or the other first line choices, but the frequency of adverse effects seems pretty low. Also, having an IM option is good for situations where PO can't be tolerated and there isn't any access yet.

 

[VA Hopeful Dr]

I second both haldol and ativan. Our palliative folks in residency used those an awful lot - they even had the pharmacy make up a topical cream with them in it that worked wonders.

 

[adnaniqedu]

One of the patients I admitted recently was and elderly woman who came in with delirium, constipation, and nausea (among other things). She was retching and had several episodes of vomiting, so while she was being further worked up for the delirium I gave her a couple doses of Zofran to keep her more comfortable and hopefully reduce the chances of her aspirating on vomitus. On rounds the next day, the patient was somewhat somnolent and I was chastised by my senior for using a 'centrally acting' antiemetic on somebody who was delirious. My response was 1) 5-HT3 antagonists were always billed as non-sedating drugs to me (or if nothing else, the very least sedating antiemetics) and 2) if I didn't use Zofran, what else was I going to use? Pretty much any other antiemetic that I am aware of is going to be more sedating and/or anticholinergic etc thus making it less desirable to use in a delirious patient. The patient wasn't on any other medication that would be sedating. We're still not sure why she was so altered on admission - as per the family, she's apparently been like this for at least a couple months. This resident had actually agreed with the idea of trying to manage this woman's nausea phamacologically when we admitted her the night before.

Thoughts? Does anyone find Zofran to be sedating etc? I haven't yet heard patients complain of this as a side effect.

See here in detail: Zofran Effects in Pregnancy

 

[Crayola227]

Interesting points. I have used droperidol before and it's a good drug, but it's not formulary at this particular hospital. Being someone who likes pharm and using 'offbeat' drugs (when appropriate), I actually did think of giving olanzapine but ultimately decided not to because I think I would have gotten even stranger looks the following day ('Zyprexa is not a drug for nausea...' etc etc). Everyone around here seems to be afraid of IV Compazine, which results in a lot of IV promethazine being given (which I prefer not to use as it's a badass vesicant and I've seen the consequences). I've seen a fairly surprising amount of akathesia from both prochlorperazine or promethazine as well.

One interesting option for n/v in the right patient is Remeron (potent 5-HT3 antagonist with a super long half life...available in ODTs...minimal QT prolongation too). It seems to have worked pretty well when I've used it.

great points, especially about watching out for akathisia from atypicals and prochlorperazine or promethazine
in fact, I saw a case of agitation attributed to delirium (they were delirious in any case, but you can be both or one or the other) that was continually being treated with more and more quetiapine, when it fact we were just giving the patient worse and worse akathisia

I didn't look this up, but I was taught that Zofran shouldn't be thought of as an anti-emetic per se but as anti-nausea, for prophylaxis of emesis, but that once the patient goes status vomitus it's too late for Zofran to be really effective in terminating the cycle and it's actually better to reach for an motility slowing agent like Ativan or promethazine
essentially I was taught to think of these drugs as being 3 categories, anti nausea, anti-emetic terminating, and drugs that can do both like Ativan
I do remember being taught in medical school that the sensation of nausea is distinct and has a distinct mechanism from the vomiting reflex itself, they just usually go together, much as orgasm and ejaculation in men, so I never really questioned this wisdom much further

in our ICU, we actually held Zofran until emesis was under control than used it prophylactically, and I remember we got in trouble just as the OP did, only from the head of the unit not the senior

last point I thought of here, is that you don't really use olanzapine or quetiapine to "treat" or "clear" delirium, in fact they can bring it about themselves
I was taught that the best treatment for delirium is resolution of the primary cause, avoidance of *any* centrally acting med as much as possible including ones mentioned, and my favorite; time, normalization of day/sleep cycle, and re-orientation. I know this is obvious, I state it so I can state the primary purpose of those centrally acting meds, the role of olanzapine or quetiapine is to calm agititation so the patient can be more easily and safely treated for the primary cause, and to help normalize day/sleep. You have to recognize at what point those sedating meds are doing more to prolong the delirium than to promote the conditions for resolution. Pearl: Drugs don't treat delirum. Drugs treat the symptoms.

DISCLAIMER: I did not quote primary or secondary literature, therefore none of the above is evidence based and is purely anecdotal in every way

 

[smartparts]

its easy to develop a reflex of ordering zofran for every patient with "nausea." if you actually ask what patients are feeling rather than take whatever nurse is saying for face value, you'll find that lots of patients don't have nausea at all. a good chunk of them have heartburn or just got a stiff dose of opiates. i once reflexively wrote zofran for a patient who had 'nausea' then while walking past the tele a few hours later noticed they were in afib with RVR.

 

[Raryn]

great points, especially about watching out for akathisia from atypicals and prochlorperazine or promethazine
in fact, I saw a case of agitation attributed to delirium (they were delirious in any case, but you can be both or one or the other) that was continually being treated with more and more quetiapine, when it fact we were just giving the patient worse and worse akathisia

I didn't look this up, but I was taught that Zofran shouldn't be thought of as an anti-emetic per se but as anti-nausea, for prophylaxis of emesis, but that once the patient goes status vomitus it's too late for Zofran to be really effective in terminating the cycle and it's actually better to reach for an motility slowing agent like Ativan or promethazine
essentially I was taught to think of these drugs as being 3 categories, anti nausea, anti-emetic terminating, and drugs that can do both like Ativan
I do remember being taught in medical school that the sensation of nausea is distinct and has a distinct mechanism from the vomiting reflex itself, they just usually go together, much as orgasm and ejaculation in men, so I never really questioned this wisdom much further

in our ICU, we actually held Zofran until emesis was under control than used it prophylactically, and I remember we got in trouble just as the OP did, only from the head of the unit not the senior

last point I thought of here, is that you don't really use olanzapine or quetiapine to "treat" or "clear" delirium, in fact they can bring it about themselves
I was taught that the best treatment for delirium is resolution of the primary cause, avoidance of *any* centrally acting med as much as possible including ones mentioned, and my favorite; time, normalization of day/sleep cycle, and re-orientation. I know this is obvious, I state it so I can state the primary purpose of those centrally acting meds, the role of olanzapine or quetiapine is to calm agititation so the patient can be more easily and safely treated for the primary cause, and to help normalize day/sleep. You have to recognize at what point those sedating meds are doing more to prolong the delirium than to promote the conditions for resolution. Pearl: Drugs don't treat delirum. Drugs treat the symptoms.

DISCLAIMER: I did not quote primary or secondary literature, therefore none of the above is evidence based and is purely anecdotal in every way

Hyperactive (as opposed to hypoactive) delerium is dangerous to the patient. Obviously, treating the underlying cause is ideal, but in the meantime, your options are either to physically or chemically restrain them. Most of the time, a few mg of haldol is less dangerous than putting them in 5 point restraints.

 

[Promethean]

So, necro thread, but whatever...

I have administered a LOT of zofran. It is one of my favorite drugs because of its beautiful activity of relieving nausea with relatively few side effects. Quite a few people I've given it to were able to get some rest shortly after, but I wouldn't describe that as sedation... just blessed relief from discomfort. If misery has kept someone conscious for too long, it isn't a surprise when removal of the noxious stimulus results in sleep, even if the drug effects don't include sedation.

 

[PlutoBoy]

great points, especially about watching out for akathisia from atypicals and prochlorperazine or promethazine
in fact, I saw a case of agitation attributed to delirium (they were delirious in any case, but you can be both or one or the other) that was continually being treated with more and more quetiapine, when it fact we were just giving the patient worse and worse akathisia

I didn't look this up, but I was taught that Zofran shouldn't be thought of as an anti-emetic per se but as anti-nausea, for prophylaxis of emesis, but that once the patient goes status vomitus it's too late for Zofran to be really effective in terminating the cycle and it's actually better to reach for an motility slowing agent like Ativan or promethazine
essentially I was taught to think of these drugs as being 3 categories, anti nausea, anti-emetic terminating, and drugs that can do both like Ativan
I do remember being taught in medical school that the sensation of nausea is distinct and has a distinct mechanism from the vomiting reflex itself, they just usually go together, much as orgasm and ejaculation in men, so I never really questioned this wisdom much further

in our ICU, we actually held Zofran until emesis was under control than used it prophylactically, and I remember we got in trouble just as the OP did, only from the head of the unit not the senior

last point I thought of here, is that you don't really use olanzapine or quetiapine to "treat" or "clear" delirium, in fact they can bring it about themselves
I was taught that the best treatment for delirium is resolution of the primary cause, avoidance of *any* centrally acting med as much as possible including ones mentioned, and my favorite; time, normalization of day/sleep cycle, and re-orientation. I know this is obvious, I state it so I can state the primary purpose of those centrally acting meds, the role of olanzapine or quetiapine is to calm agititation so the patient can be more easily and safely treated for the primary cause, and to help normalize day/sleep. You have to recognize at what point those sedating meds are doing more to prolong the delirium than to promote the conditions for resolution. Pearl: Drugs don't treat delirum. Drugs treat the symptoms.

DISCLAIMER: I did not quote primary or secondary literature, therefore none of the above is evidence based and is purely anecdotal in every way

You were taught a lot of stuff 🙂