Costly overuse of anti-nausea drug in children with gastroenteritis

Despite its increased use, ondansetron has not decreased IV rehydration.
Ondansetron has not decreased IV rehydration as originally intended.
Acute gastroenteritis is one of the leading causes of emergency department (ED) visits for children, accounting for more than 1.7 million trips each year. Its standard treatment has traditionally been rehydration by giving fluids orally or intravenously. Though both methods are equally effective, oral rehydration is preferred as it results in less discomfort and helps stop diarrhea sooner. The IV route is often employed in children who are vomiting and unable or unwilling to drink a large amount of liquids.

About a decade ago, ED physicians began orally administering the anti-nausea medication ondansetron to vomiting patients with gastroenteritis who were unable to hold down oral fluids. Once the ondansetron has stemmed their nausea, children have a much easier time with oral rehydration.

However, the lack of standardized use of this drug has led to its overuse. Though intended to reduce the use of IV rehydration, ondansetron proved so effective at reducing vomiting that its use skyrocketed in the course of just a few years.

Concerned about this trend, Boston Children’s Hospital’s Mark Neuman, MD, MPH, and a team of researchers led by Alberta Children’s Hospital Research Institute’s Stephen Freedman, MDCM, MSc, conducted an in-depth examination of ondansetron use in 18 hospitals across the U.S. The study, published this week by JAMA Pediatrics, asked whether increased usage was indeed reducing the rates of IV fluid administration.

Neuman, Freedman and their fellow researchers looked at 804,000 ED cases of gastroenteritis, noting each time a child received ondansetron. Usage rates at each study site were separated into years of low, medium and high usage. Over a 10-year period, ondansetron use increased from 0 to 42 percent. Despite this spike, there was no accompanying reduction in IV rehydration, indicating the drug wasn’t actually reducing IV rehydration as intended.

Moreover, only 13 percent of children administered IV rehydration received oral ondansetron, while 54 percent received the drug intravenously. The researchers also discovered that during years of high ondansetron usage, the overall cost of care was higher.

“We saw that the widespread use of ondansetron hasn’t done much to alter clinically relevant outcomes but has led to a cost increase,” Neuman says. “Clearly, the drug works, but I believe it’s used so liberally now that it’s not being given to the right patients.”

In an era when runaway health care spending is under close scrutiny, these findings are another example of how employing an effective medication as originally intended—in this case to enabled dehydrated children to receive oral rehydration—can protect both patient health and hospital budgets.

“If EDs across the country reevaluated their protocols to ensure ondansetron is only being administered to the right patient population, it could optimize care delivery for a disease that affects millions of American children annually,” Freedman says. “It adds to growing research showing that standardizing certain types of care is a crucial component of reducing health care costs.”