Droperidol vs ondansetron vs placebo for nausea

The Gist: In the United States, droperidol has been hard to come by in many locations for years. Many lament the loss for a myriad of indications - agitated delirium, nausea, vomiting, and migraines.  Meek et al found that in nauseated emergency department (ED) patients, droperidol 1.25 mg IV did not outperform ondansetron 8 mg IV or placebo IV in a randomized, blinded trial in 3 Australian EDs [1]. Common anti-emetics or placebo, reduce nausea scores by similar amounts; however, more patients receiving ondansetron or droperidol reached the desired effect and did not receive rescue medications.

Nausea is a common condition in the emergency department; yet ED-based studies of anti-emetics have not found consistent benefit [2-5]. Droperidol received a controversial black box warning in the US in 2001 after 71 adverse events were reported on a single day. Since that time, many providers have lamented to lack of availability of droperidol in the US and thought...this would be the clear winner for our nauseated patients. Hence Meek and colleagues aimed to settle the debate as to whether any of these drugs were superior to placebo in nauseated ED patients. Details pictured below.

Unfortunately, this trial leaves several questions unanswered. It's not all bad news in anti-emetic therapy. Recent trials of inhaled isopropyl alcohol have been promising and this intervention appears to be more effective than oral ondansetron alone [6,7]. It's uncertain how long these effects last and how this therapy would perform compared with intravenous therapies.

References:

1. Meek R, Mee MJ, Egerton-Warburton D, et al. Randomized placebo-controlled trial of droperidol and ondansetron for adult emergency department patients with nausea. Acad Emerg Med. 2018;In Press. doi: 10.1111/acem.13650 
2. Braude D, Soliz T, Crandall C, Hendey G, Andrews J, Weichenthal L. Antiemetics in the ED: a randomized controlled trial comparing 3 common agents. Am J Emerg Med 2006; 24: 177–82. 
3. Barrett TW, DiPersio DM, Jenkins CA et al. A randomized, placebo-controlled trial of ondansetron, metoclopramide, and promethazine in adults. Am J Emerg Med 2011; 29: 247– 55.
4. Egerton-Warburton D, Meek R, Mee MJ, Braitberg G. Antiemetic use for nausea and vomiting in adult emergency department patients: randomized controlled trial comparing ondansetron, metoclopramide, and placebo. Ann Emerg Med 2014; 64: 526–32.
5. Furyk JS, Meek R, Egerton-Warburton D. Drugs for the treatment of nausea and vomiting in adults in the emergency department setting (Review). Cochrane Database Syst Rev 2015: CD010106. 
6. Beadle KL, Helbling AR, Love SL, April MD, Hunter CJ. Isopropyl Alcohol Nasal Inhalation for Nausea in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2016;68(1):1-9.e1.
7. April MD, Oliver JJ, Davis WT, et al. Aromatherapy Versus Oral Ondansetron for Antiemetic Therapy Among Adult Emergency Department Patients: A Randomized Controlled Trial. Ann Emerg Med. 2018;