Ondansetron use not reaching its target audience in children with gastroenteritis

Issue: March 2014

Children at greatest risk for oral rehydration failure may benefit from oral ondansetron, however the children at greatest risk of oral rehydration failure are not receiving the medicine, according to recent study findings published in JAMA Pediatrics.

“Ondansetron use in children with [acute gastroenteritis] has increased dramatically in pediatric centers during the past decade without a concomitant reduction in IV rehydration or hospitalizations,” the researchers wrote. “However, more than 85% of patients who received IV rehydration for [acute gastroenteritis] were not given oral ondansetron, suggesting an opportunity to better target its use to children at greatest risk for failing [oral rehydration therapy].”

Stephen B. Freedman, MDCM, MSc, of the sections of emergency medicine and gastroenterology, department of pediatrics at Alberta Children’s Hospital and Research Institute, and colleagues evaluated 804,000 children aged 0 to 18 years diagnosed with gastroenteritis from 18 EDs across the United States. The researchers conducted the study to determine if increasing ED ondansetron use resulted in a decrease in IV rehydration rates. Low ondansetron use was defined as less than 5% and high ondansetron use was defined as more than 25%.

Stephen B. Freedman

The mean number of acute gastroenteritis (AGE) visits increased among participating sites between 2002 and 2006 (P=.05) but stabilized between 2006 and 2011 (P=.98). In 2002, the median institutional rate of oral ondansetron use was 0.11% compared with 42.2% in 2011 (P<.001). Overall, 18% of patients received IV rehydration; however, only 13.5% of those received oral ondansetron, while 54.1% received IV ondansetron.

Although during the high ondansetron use period, IV rehydration rates were lower (17.8%) compared with the low-use period (18.7%), this was not statistically significant after adjustment for other variables. Moreover, there was a greater rate of hospitalization in the high-use category compared with the low-use category (percentage change=0.7%; 95% CI, 0.6-0.8). During the high-use period, children presenting were less likely to return to the ED within 3 days after discharge or have a revisit associated with hospitalization.

“The available evidence indicated that children with vomiting and mild to moderate dehydration are less likely to have ongoing vomiting, require IV rehydration and hospitalization if they are administered an oral dose of ondansetron followed by an appropriate oral rehydration period,” Freedman told Infectious Diseases in Children. “Although we found that ondansetron use has increased dramatically, there was no reduction in IV rehydration or hospitalization. On further analysis, we also found that very few children administered IV rehydration received oral ondansetron (in fact many received it intravenously). Thus, we believe that clinicians are missing an opportunity to improve outcomes in children; they are providing ondansetron to children at low risk for requiring IV rehydration while avoiding its use in the target population. This situation should be a target for future knowledge translation as we know what needs to be done, now clinicians simply need to do it.”

In an accompanying editorial, Vice President of Quality and Chief Quality Officer at the Children’s Hospital of Philadelphia, Ron Keren, MD, MPH, wrote that some EDs have discovered which patients may benefit from ondansetron and how to incorporate it into care for those patients.

Ron Keren

“If we are to achieve maximum return on our investment in this therapy, research is needed to understand how those hospitals got the desired results,” he wrote. “Failure to do so is a lost opportunity to leverage an inexpensive drug to prevent outcomes (eg, need for IV rehydration and admission to hospital) that are both costly (to the health system and families) and disruptive (to children and their families). This will require qualitative research to tease out the best practices used by successful hospitals in deciding how to use a medicine known to be efficacious and implementation science research to figure out how to disseminate that knowledge and implement it in a variety of unique clinical settings.” — by Amber Cox

For more information:

Freedman SB. JAMA Pediatr. 2014;doi:10.1001/jamapediatrics.2013.4906.

Keren R. JAMA Pediatr. 2014;doi:10.1001/jamapediatrics.2013.5378.

Stephen B. Freedman, MDCM, MSc, can be reached at stephen.freedman@albertahealthservices.ca.

Disclosure: Freedman reports financial ties with GlaxoSmithKline. Keren reports financial ties with the Children’s Hospital Association.