You Decide: Anti-Nausea Medicine #2 – Zofran

Have you heard of this medication?  If not, I am sure you soon will as most people (especially doctor-types) are touting it as the latest and greatest thing since sliced bread.  While it certainly has a role as an anti-nausea medication, many are now advocating its routine use for common pediatric problems.  In particular it has recently become in-vogue to use this medication just about any time a child vomits.  However, if you have read my page on understanding vomiting, there are certain times when it may not be  a good idea to stop the vomiting.  In this post I will examine the pros and cons of using this medication and offer a rational set of suggestions for when it might be useful for your child.

What is Zofran?

Zofran, also called ondansetron, is a relatively new medication that is used for the treatment of nausea and vomiting.  In the early stages of its development it was used primarily in cancer patients to help control the nausea and vomiting associated with chemotherapy.  This is why the medication was developed, and for this use, it is invaluable.  Gradually the use of Zofran was extended to the OR for post-operative nausea and vomiting, where it has been shown to be invaluable as well.  Now the scope of use is looking to be expanded to just about every scenario where vomiting occurs – like when your child has a stomach virus or food poisoning.

Should I use it for routine vomiting in my child?

Remember most cases of vomiting in children are caused by a stomach virus or food poisoning.  In both cases, children generally vomit for a brief period of time (less than 24 hours) and then may or may not go on to develop diarrhea.  When your child is vomiting, this is a GOOD thing.  This means that your child is eliminating the stomach virus or the food poisoning from their body.  Beware the consequences of interfering with this normal body process.

Why not stop the vomiting?

If you stop the vomiting, the stomach virus or food poisoning will likely pass through into the intestines where it will cause diarrhea.  The more stomach virus or food poisoning that is eliminated through vomiting, the less that will make it into the intestines causing diarrhea.  Now this is not just my opinion.  This is well supported by the medical literature.  In many studies looking at this, children are divided into two groups.  One group gets the anti-nausea medicine and the other does not.  In the group that gets the anti-nausea medicine, there is generally less vomiting.  However, there is MORE diarrhea.  In some studies the diarrhea lasts as much as 4 days longer.  Since most cases of vomiting mostly resolve in 12-24 hours, I am not sure trying to stop the vomiting is worth the 4 extra days of diarrhea.

Is it ever a good idea to use this medicine?

Perhaps.  When there is concern for dehydration, this medication might be useful.  For example, if your child has been unable to keep any fluids down for more than 24 hours, then you might consider using this medication.  In studies that look at using this medication in the ER, there is a suggestion that it decreases the need for IV fluids.   Thus, if you find yourself in the ER and the nurse is coming at your child with an IV, you might request a trial of the Zofran medication first.  When using this medication your child is roughly half as likely to need IV fluids and half as likely to require admission to the hospital.  This is because about half of the kids who get Zofran are able to keep fluids down and the vomiting stops.

What I Do in the ER.

  1. If the child is over 3 months of age, does not have any worrisome symptoms, and has been vomiting for less than 12 hours, I do not use this medication.  I instruct the family on the proper use of pedialyte (or other means of oral rehydration) and have them follow-up in 12-24 hours if the vomiting has not resolved.  No child over the age of 3 months is going to get dehydrated just from vomiting for 12-24 hours.
  2. If the child has been vomiting for close to 24 hours, I will often give a trial of Zofran to see if it will make things better.  I then instruct the family on the proper use of home oral rehydration therapy.
  3. For those patients who are still vomiting despite a trial of Zofran, I will consider IV fluids.  However, in many cases if they are not clinically dehydrated, I will send them home with a second dose of the Zofran medication to take in 6-12 hours.  I will have them continue home oral rehydration therapy and follow-up again in 12-24 hours if not better.
  4. Children who are less than 3 months, have profuse vomiting and diarrhea at the same time, or have other worrisome signs of serious illness generally get some lab tests.  Thus if I feel like lab tests are indicated, I generally go ahead and have the nurses put in an IV and give some IV fluids.  Remember though, lab tests are NOT indicated in most children.

What do I have against IV Fluids?

I see this all the time in the ER.  An 18-month old child comes in who has been vomiting for 6-12 hours.  For whatever reason the decision is made to give the child IV fluids.  These children are VERY difficult to get an IV on.  It often takes 4, 5, even 6 or more attempts to get an IV in these children.  It is truly torturous.  Hey… if they need the IV, then sure bring on the torture – but if they can avoid it, then let’s spare everyone the trouble.

Close to 99% of kids in this country can adequately rehydrate at home with simple Oral Rehydration Therapy.

Can my doctor call this medicine in?

Probably.  It has recently been made generic in an orally dissolving tablet.  Thus it is relatively inexpensive and easy to take.  So you decide… Zofran or no Zofran?

Related Posts:

Myths & Facts: Vomiting

Understanding Vomiting

Understanding Oral Rehydration Therapy (ORT)

Anti-Nausea Medicine #1: Phenergan


Archives of Pediatric and Adolescent Medicine: 2008

This is a review of 11 different studies looking at the benefit of Zofran for the treatment of gastorenteritis (stomach virus).  They found that Zofran reduced the need for IV fluids and reduced the need for hospital admission.

Annals of Emergency Medicine: 2008

This study addresses the idea that oral rehydration therapy should be attempted before the use of medication.  Those patients who failed oral rehydration therapy (ie. vomit the pedialyte) were broken down into 2 groups.  One group got the zofran and the other group got a placebo (fake zofran).  The group who got Zofran had a 2/3 reduction in the need for IV fluids and were 1/2 as likely to be admitted to the hospital.

New England Journal of Medicine: 2006

This is one of the original studies looking at the utility of using Zofran for kids in the ER.  Again breaking the patients into two groups, the group that got Zofran had less vomiting, was able to keep more fluid down, and needed less IV fluids.  Their conclusions: “In children with gastroenteritis and dehydration, a single dose of oral ondansetron reduces vomiting and facilitates oral rehydration and may thus be well suited for use in the emergency department.”

Cochrane Review: 2006

This study reviewed many other studies that looked at zofran and vomiting.  Their conclusions:

The small number of included trials provided some, albeit weak and unreliable, evidence which appeared to favor the use of ondansetron and metoclopramide over placebo to reduce the number of episodes of vomiting due to gastroenteritis in children. The increased incidence of diarrhea noted with both ondansetron and metoclopramide was considered to be as a result of retention of fluids and toxins that would otherwise have been eliminated through the process of vomiting.

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7 Responses to You Decide: Anti-Nausea Medicine #2 – Zofran

  1. Leigh Anne Rushing says:

    Dr. Reynolds~
    I found your blog from a link on your wife’s blog. I’m a college friend of hers and also now a pharmacist. I have enjoyed reading your blog. I completely agree with your recent phenergan and zofran posts. I see these meds over-prescribed so often. But, I wanted to let you know that the Zofran tabs and liquid are now generic so they are much cheaper. The tabs run about $1.50-$2.00 per tablet depending on the pharmacy, quantity, strength, etc…..
    Keep up the good work!
    Leigh Anne Rushing, Pharm.D

  2. katrin schenk says:

    Your comments about vomiting being “good for you” when you have food poisoning or the stomach flu are ridiculous. In the case of food poisoning, once you vomit one time, all the bacteria laden food stuffs that can come out of your stomach will come out. Any further vomiting, like the dry heaves that often accompany food poisoning or viral gastroenteritis, DOES NOT help rid your body of pathogens, it just greatly increases suffering and contributes to the possibility of dehydration. My 6 year old spent an entire night dry heaving every 5 minutes, then in the morning our doctor called in a prescription for generic Zofran (Ondansetron) ODT (orally distintegrating tablet). This stopped the dry heaves within 5 minutes of him taking it. He did not through up again and was able to drink and eat some crackers.

  3. DrReynolds says:

    Hey I do not make up the studies, I just report them. On average, when you stop the vomiting prematurely, kids tend to have longer bouts of diarrhea. When I try to make educated decisions about how I will treat my own kids, I weigh putting up with 12-24 hours of vomiting against potentially prolonging the diarrhea for 3-5 days. For my kids I would choose the former.

    You also may well have fallen victim to the medicine “illusion.” Most vomiting from a stomach virus lasts 12-24 hours. Sure, maybe it was the medicine that stopped the vomiting. Another possibility is that the vomiting was about to stop on its own anyway… it just happened that you gave your kid the medicine about the same time.

  4. Jessica says:

    I just wanted to thank you for posting this. I took my 2 yr old daughter to the doctor today for a stomach virus. She had been vomiting on and off all weekend, usually in the middle of the night, and the diarrhea was ridiculous. By this morning though, Monday, she is doing better. The nurse practitioner called in a script for Zofran, not because she thought my daughter needed it now, but just in case she ever vomits again I can give it to her. Who hands out a “just in case” script for a child. I didn’t go get it and now I’m definitely not going to.

  5. DrReynolds says:

    Way to go! You are a smart mommy.

  6. Jody says:

    Dr. Reynolds,

    My 5 year old daughter has been diagnosed with stomach migraines and was prescribed zofran. It has kept her out of the hospital twice now. Once she starts to vomit, it is every 15 minutes around the clock, with out the zofran she becomes so dehydrated that she is hospitalized for several days. So for us it is a life saver, but is there anything to worry about using zofran so often?

  7. DrReynolds says:

    Probably not. Zofran for migraine may be reasonable. However, treating the underlying cause should be the primary goal.

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