Expert Discusses How Pharmacists Can Treat PONV With Medication, Other Therapies

In an interview with Pharmacy Times® at the American Society of Health-System Pharmacists Midyear Meetings and Exhibition, Jawad Saleh, PharmD, BSPharm, BCCCP, BCPS, clinical manager of Pharmacy Services at the Hospital for Special Surgery, discusses how pharmacists can treat postoperative nausea and vomiting.

Q: How can a pharmacist determine whether postoperative nausea and vomiting should be treated with medication or non-pharmacological therapies?

Jawad Saleh: If we can utilize other mechanisms, safer mechanisms or agents or treatments to help with anything, that's usually the route to go, but as long as it's evidence-based, so utilizing anything evidence-based. There's acupuncture, there's aromatherapy. Acupuncture is becoming a bigger move in my organization specifically with pain management, and aromatherapy is something we've been utilizing specifically, there's specific ingredients to utilize for aromatherapy, but when to use them is important.

A lot of these PONV medications, although it's indicated for postoperative nausea and vomiting, the strength is really in the vomiting portion. The nausea portion of that definition is pretty weak, so we're keeping that in mind. Patients who are nauseous postoperatively, we utilize aromatherapy as a first line. If the patient's high risk or has a history of high risk, based on risk factors, we may want to jump to another agent, but we utilize aromatherapy. We see if that works within you know, 15 to 30 minutes, sometimes up to an hour, if it doesn't work, we'd go on to give an agent.

Q: What is refractory postoperative nausea and vomiting, and is treatment any different for it?

Jawad Saleh: Refractory PONV is almost similar to what I was discussing regarding some of the biggest challenges we have with PONV when it comes to treatment. So again, if a patient comes out in that 6-hour window, and let's say they were a high-risk patients and patient in which you've given 2,3,4 agents, when the patient comes out within that 6 hours, they really shouldn't be getting any of those agents. The agents become limited, and they're limited for rescue based on a few factors. One is, maybe the agent was already given, then you're limited to what you have already. Then you start looking into the onset of action of some agents, you may have 5 agents you can give, but some of those agents are really not for treatment. They're really for prevention given prior to surgery, or prior to induction or pre-op, and that limits what you're giving when a patient's actually vomiting or nauseous. It limits what you're going to give.

When you begin giving agents, you really have to keep in mind and consideration with adverse effects as well. So that also limits the treatment. So now you have agents, you might have 2 or 3 agents you could use. The patient’s QT is prolonged, or the patient might have X pyramidal symptoms or have some sort of underlying comorbidity where we cannot give that agent so you're stuck, and we have to be creative. We have to think of ways to treat these patients.

Q: Any closing thoughts?

Jawad Saleh: I'm a big advocate, of course, I'm a pharmacist, but with these, whether you're experienced and seasoned, or whether you're new and graduating again, we need to take hold of things we know that we specialize in and we're really the ones that are experts in these fields, especially with pharmacotherapy. I don't like seeing interdisciplinary committees, or meetings where pharmacists are absent, or if they're present, they are not really stakeholders. They really have no say or they're not contributing.

With that being said, we are the experts. I think that pharmacists should help guide the evidence based behind this evidence-based decision-making, we should go through the evidence-based decision-making create a policy or a guideline based on the evidence-based guidelines that do exist, and then try to integrate your EMR, EHR to what the protocol or guidelines states, because listen, physician burnout is real. It's becoming a huge deal on a national and international level. We have to find ways to guide but using the EHR without over be over involving BPAs and alerts and overstressing the information that a prescriber has to input deterring them from patient care. That process, that cycle is really pharmacy based. I mean, it's interdisciplinary, but it's really pharmacy based and if we can be large stakeholders in this and get that going and also monitoring, so implementing is one thing, guiding is one thing, but monitoring is really, really important and trending and making sure there's no outliers and that we are actually working in sync and in a very standardized fashion.