Dr. Eric Prommer is very knowledgeable about serotonin and the serotonin antagonist like ondansetron . Interestingly, serotonin, which is constantly being produced, can overcome the antagonist and this is why these medications may lose effectiveness.

At this time these medications are used for prevention of chemotherapy induce, post-op and radiation induced nausea\ vomiting. Most serotonin activity is increased in the first 24-48 hours after the insult. Therefore this is why these medications are mostly used in theses settings? The issue in palliative medicine is that we are trying to manage the problem of nausea \vomiting in a more chronic setting and not specifically related to a specific event.

Evidence Base is Limited

Opioid Induced Emesis

Ondasnsetron versus reglan may be helpful?

Bowel Obstruction

24 patients granesetron 3mg +dexamethasone 8mg

Highly effective with good control in over 80% of patients

Cancer

280 patients with advance cancer but commonly on opioids the N\V may be in part the cause of nausea\vomiting.

Total Control of N\V which was less than 3 hours of distress a day could be achieved in up 75-85 % of patients with relatively minimal side-effects. However, study flawed in several ways but very suggestive to be highly effective.

Conclusions

1) Serotonin antagonists are not all alike- Therefore it may be that when one is not working that a different drug in this class and or dose may be helpful .

2) Efficacy is studied in Opioid and bowel obstruction

3) Minimal adverse effect

4) Usable in combination with other agents and steroids.

5) The cost of the agents can be extremely high.

6) More studies are needed to use these medications wisely

David is a voice for those people that he has spent so much time to understand, build trust and ultimately to record their suffering end experiences at the end-of-life. With his book and this presentation peole like “Angel” and “Cowboy” have achieved transcedence since capturing their stories such that their lives continue to make a difference.

If you haven’t had a chance to hear this presentation I would recommend that you listen to the recording and/or read his book of the same title. As hospcie/palliative care clinicians it is imperative that we build bridges across the care divide that exist in the USA. There is much controversy about the process of health care insurance reform. David is a voice for those Americans that have the most to lose and the most to gain as we come together to work for justice for all of us.