Cost-Effective Use of Antiemetics

ABSTRACT: Direct comparison of intravenous and oral 5-HT3 antagonists has shown equivalent efficacy if appropriate doses are given, thus allowing widespread use of the more convenient and economical oral route. Effective antiemesis generates additional cost savings by decreasing the resources necessary for salvage antiemetic preparation and administration, additional physician and nursing evaluation, clean-up and maintenance of the patient area, and possible additional hospitalization necessitated by uncontrolled emesis. If ondansetron and metoclopramide are compared strictly on an acquisition cost basis, ondansetron is 4 to 15 times more expensive. However, if the additional savings attributable to better antiemetic control are taken into account, ondansetron is only 2 to 3 times more expensive and quality of life is markedly improved. In cost-utility analysis such improvement in quality of life is taken into account through the use of a utility score. Utility scores for antiemetic protection, however, have not been well defined. We recently performed a pilot study asking patients receiving chemotherapy to rate globally their quality of life (utility score) over the preceding chemotherapy cycle, assuming that a small amount of nausea and vomiting either had or had not occurred. An incremental utility score of 0.52 based solely on the presence or absence of nausea and vomiting was identified. Further careful investigations to identify the incremental utility resulting from use of various modes of oncologic supportive care are required.[ONCOLOGY(Suppl 4):38-42, 1998]

Over the last 40 years, there have been marked advances in the development of chemotherapeutic agents effective against numerous tumor types. This increase in efficacy, however, has been accompanied by an increase in toxicity. Of all the toxicities of chemotherapy, the toxicity most feared by patients has been nausea and vomiting.[1] Thus, prevention and control of emesis has been an important goal both to maintain patient quality of life and to allow delivery of full courses of curative and palliative chemotherapy.

Numerous families of antiemetic agents are now available. Under appropriate circumstances, one may obtain excellent antiemetic control with phenothiazines, butyrophenones, substituted benzamides, cannabinoids, corticosteroids, or serotonin (5-HT₃) antagonists. However, these agents differ in terms of efficacy, toxicity, and cost. Effective antiemetic control should never be sacrificed as a cost-cutting measure. However, cost-effective use of modern antiemetics requires selection of the correct drug to be administered by the correct route at the correct dose in the correct clinical setting.

The first antiemetic agent to provide effective antiemetic control against the highly emetogenic chemotherapeutic agent cisplatin (Platinol) was high-dose metoclopramide,[2] which was introduced in the early 1980s. In contrast to the previous clinical reality where virtually all patients had severe vomiting within the first 24 hours after receiving cisplatin, high-dose metoclopramide completely protected against acute vomiting in up to 40% of patients, with even greater protection when corticosteroids were added.[3] Introduction of the 5-HT₃ antagonists in the early 1990s represented an additional advantage since these agents provided at least equivalent efficacy while eliminating the potentially severe antidopaminergic toxicity that had limited the use of high-dose metoclopramide. Furthermore, the 5-HT₃ antagonists had the added advantage in some comparisons of actually increasing the rate of antiemetic protection. In a direct comparison of a 5-HT₃ antagonist and metoclopramide, Marty et al[4] demonstrated complete or major protection from cisplatin-induced acute vomiting in 75% of patients treated with ondansetron (Zofran), compared with 42% of those treated with high-dose metoclopramide. Complete and major control of nausea was also improved by ondansetron; 58% of patients had no more than mild nausea, compared with 42% receiving high-dose metoclopramide. Even greater protection against cisplatin-induced vomiting was achieved through the addition of a corticosteroid. Roila et al[5] demonstrated an increase in complete antiemetic protection from 64% using ondansetron alone to 91% using ondansetron plus dexamethasone.

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