# Best alternative to zofran?



## Aidey

With all the drug shortages going on we are looking at an alternative to zofran. I'm curious what other people are using and what people think is the best/safest alternative while being cost effective. Are their any drugs you strongly object to being used prehospital?

I believe zofran is currently around $15 per 4mg vial, but I'm not 100% sure.


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## NomadicMedic

Look at Anzemet. Works great.


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## Aidey

I'm personally pushing for one of the other -setron meds, but I know as a class they are more expensive than the others so I have to be prepared to push for one of the cheaper alternatives.


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## NomadicMedic

Droperidol works well, too. But, I bet you'd be hard pressed to find a doc that'll let you use it as an antiemetic prehospital. 

I haven't experienced the Zofran shortage yet. We still give it out like candy. 

Now fentanyl. That's a different story.


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## Handsome Robb

n7lxi said:


> I haven't experienced the Zofran shortage yet. We still give it out like candy.



Seconded. Easily the most used med on the unit.

Aidey, I don't have any experience with it first hand but my old partner among many of the other older medics I have worked with swear by phenergan, especially for someone who is actively vomiting. Just have to be ready for the possibility of a dystonic reaction.


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## STXmedic

I've got both phenergan and zofran. Phenergan seems to work much better from my personal experience. You just have to be smart about giving it. Only side effect that I've seen is the sedation.


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## NYMedic828

FDNY just got zofran about 4 months ago and I am yet to give it once. 

Do you guys give it if a patient complains of being nauseous or vomits whatsoever?


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## Handsome Robb

NYMedic828 said:


> FDNY just got zofran about 4 months ago and I am yet to give it once.
> 
> Do you guys give it if a patient complains of being nauseous or vomits whatsoever?



Yep pretty much. It depends on the severity and it is up to us as the provider to make that call. Most medics give it pretty freely.

It's been my soapbox recently, but I'm here to help make patients more comfortable wether it be helping with their nausea or their pain.

When I'm on the ski car we give it to everyone who gets narcotic analgesia for the most part since the road we have to wind down has a tendency to really make people ski with narcotics onboard. Hell it makes some people sick with nothing on board.


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## Aidey

n7lxi said:


> Droperidol works well, too. But, I bet you'd be hard pressed to find a doc that'll let you use it as an antiemetic prehospital.



That is what we had before Zofran, and what they are threatening to go back to. My reaction was something along the lines of "oh _*HELL *_no!". It has the worst safety profile of all of them.

I've used promethazine before and I am comfortable with it, but I can see people objecting because some idiot won't dilute it and the patient will file a complaint. I also prefer something non-sedating, and I know the docs like non-sedating also. This especially applies if I am giving anti-emetics with fentanyl.


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## Aidey

NYMedic828 said:


> FDNY just got zofran about 4 months ago and I am yet to give it once.
> 
> Do you guys give it if a patient complains of being nauseous or vomits whatsoever?



Pretty much. I will also give it to people highly likely to get nauseous, like MI patients or people I am giving activated charcoal to.


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## NomadicMedic

I think I give Zofran to at least 50% of my calls. Our dose here is 8mg, and we carry it in both the ODT and IV. 

I really do miss Phenergan for when I used to give Morphine. It was the perfect pain management/antiemetic/sedation mix for little old ladies with femoral head fractures. (or almost anyone with a traumatic injury) 12.5 of Phenergan and 2 to 4mg of morphine made extrication and PT movement easy. 

Like most kind and caring medics, I really like to mitigate my patients complaints. If I can do that with an antiemetic and pain management, then I've done my job.


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## Medic Tim

Gravol


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## Tigger

Sports medicine job only stocks phenergan, and it works very well for the athlete that gets ill and nauseous pre-game. We'll have hour medics give it IV and then get them back out on the ice if they pass inspection.


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## mycrofft

Don't eat the green hamburger no matter how well it's cooked.:wacko:


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## Aidey

n7lxi said:


> I think I give Zofran to at least 50% of my calls. Our dose here is 8mg, and we carry it in both the ODT and IV.
> 
> I really do miss Phenergan for when I used to give Morphine. It was the perfect pain management/antiemetic/sedation mix for little old ladies with femoral head fractures. (or almost anyone with a traumatic injury) 12.5 of Phenergan and 2 to 4mg of morphine made extrication and PT movement easy.
> 
> Like most kind and caring medics, I really like to mitigate my patients complaints. If I can do that with an antiemetic and pain management, then I've done my job.



I told my boss I would rather have the ODT than Inapsine. I admit I do miss promethazine for those cases. I was more thinking of the people I don't want to sedate. This is one of those situations were I wish we had more than one option so we could pick what is most appropriate.


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## R99

Well it isn't metaclopramide there for darn sure

Promethazine is top notch but too sedating

Both were withdrawn here in 2009


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## Shishkabob

R99 said:


> Promethazine is top notch but too sedating



"Too" sedating?


Shoot, most of the people with nausea/vomiting could use a little sedation.


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## R99

Linuss said:


> "Too" sedating?
> 
> 
> Shoot, most of the people with nausea/vomiting could use a little sedation.



We used 12.5mg IV and that knocked most people down a couple pegs, for smaller people it was way too much


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## usalsfyre

6.25 of promethazine works awesome without nearly as much sedation or  as bad of a risk profile.

Why ODTs rather than Inapsine? The black box warning was WAY overblown. Don't forget the FDA just put out a warning about ondansetron for essentially the same thing.

Ondansetron works ok till they start vommitting. After that I've found you can push 8mgs and it MIGHT work.


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## socalmedic

Zofran is all we use here, and we use a ton of it. we haven't experienced a shortage or a price change (we have a supplier price contract). we haven't actually experienced any shortages that would change out clinical practice. morphine got low for a bit, but never dipped below 40mg per truck.


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## MediMike

In regards to the narcotic discussions on here, we have the option to utilize Zofran 4-8mg or Benadryl 12.5-25mg.  The narcotics produce a histamine release leading to the nausea, so rather than making them nauseated then resolving it, giving the Benadryl concurrent with the Narc prevents the issue from occurring, along with the sedative effects of Benadryl.  I'm a pretty big fan


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## jwk

MediMike said:


> In regards to the narcotic discussions on here, we have the option to utilize Zofran 4-8mg or Benadryl 12.5-25mg.  The narcotics produce a histamine release leading to the nausea, so rather than making them nauseated then resolving it, giving the Benadryl concurrent with the Narc prevents the issue from occurring, along with the sedative effects of Benadryl.  I'm a pretty big fan



Now THAT is the best post of the thread so far.


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## jwk

Aidey said:


> That is what we had before Zofran, and what they are threatening to go back to. My reaction was something along the lines of "oh _*HELL *_no!". It has the worst safety profile of all of them.



How much droperidol were you giving?  Most anesthetists that have used it swear by it, but many hospitals won't carry it because of concerns with QT changes (way overblown near-bogus issue).  It's far superior to anything else we have available.


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## Aidey

usalsfyre said:


> 6.25 of promethazine works awesome without nearly as much sedation or  as bad of a risk profile.
> 
> Why ODTs rather than Inapsine? The black box warning was WAY overblown. Don't forget the FDA just put out a warning about ondansetron for essentially the same thing.



The studies I read indicated that the negative cardiac affects of Zofran  appear when the doses of Zofran being used were significantly higher  than what we use pre-hospital (~40mg IV), and along the lines of zero with oral zofran. With Inapsine the negative affects were seen with lower doses. I also read something (which of course I can't find now grrrrrr.)  that indicated that Inapsine potentiates the QT prolongation affect of  other medications more strongly than Zofran does. The list of  medications that both medications can interact with is long and includes  many common meds that a lot of our patients are on and I know very few  people who work under our protocols are aware of all of this.

I'm frankly factoring in the lowest common denominator. The current  recommendation is that anyone given Inapsine has a 12 lead first, and  cardiac monitoring for 2-3 hours after. This is not going to happen. Is  it necessary? Possibly not, but it is the current recommendation and  since I know it is not going to be followed I do not believe it is a  wise choice. It is basically setting ourselves up for huge trouble if  something goes wrong, even if it isn't necessarily related to the  Inapsine. 




MediMike said:


> In regards to the narcotic discussions on here, we have the option to utilize Zofran 4-8mg or Benadryl 12.5-25mg.  The narcotics produce a histamine release leading to the nausea, so rather than making them nauseated then resolving it, giving the Benadryl concurrent with the Narc prevents the issue from occurring, along with the sedative effects of Benadryl.  I'm a pretty big fan





jwk said:


> Now THAT is the best post of the thread so far.



Promethazine is also an antihistamine, which is part of the reason it complements opiates so well. 



jwk said:


> How much droperidol were you giving?  Most anesthetists that have used it swear by it, but many hospitals won't carry it because of concerns with QT changes (way overblown near-bogus issue).  It's far superior to anything else we have available.



I say "we" as in my agency. I wasn't here when it was in the protocols and I don't know what the dose was.  There was apparently some sort of 'incident' when it was in the  protocols but I didn't get any of the story aside from the fact that  someone "slammed" it and then something bad happened. It was mentioned  in passing before I knew of the proposal to use Inapsine as a back up,  so I didn't ask any details. It was apparently the reason we switched to Zofran though.


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