Summary of findings 7. Summary of findings (extrapyramidal symptoms).
| HARM | |||||||
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Patient or population: adults undergoing any type of surgery under general anaesthesia Interventions: antiemetic drugs (monoprophylaxis and combination prophylaxis)* Comparator (reference): placebo (or no treatment) Outcome: extrapyramidal symptoms within 7 days postoperatively Setting: inpatient and outpatient | |||||||
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Total studies: 64 RCTs Total participants: 10,724 Number of treatments: 30 Geometry of the network** |
Relative effect*** (95% CI) |
Anticipated absolute effect **** (95% CI) | Certainty of evidence |
Ranking ***** (P score) |
Interpretation of findings | ||
| Without intervention | With intervention | Difference | |||||
| 5‐HT3 receptor antagonists | |||||||
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Dolasetron (3 RCTs; 288 participants) |
0.67 (0.10 to 4.38) |
8 per 10001 | 5 per 1000 | 3 fewer per 1000 (7 fewer to 27 more) |
⊕⊕⊖⊖ Low Due to imprecision2 |
Rank 5 (0.5860) Rank 3 of 16 single drugs |
Dolasetron may reduce extrapyramidal symptoms |
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Granisetron (5 RCTs; 330 participants) |
0.90 (0.23 to 3.57) |
8 per 10001 | 7 per 1000 | 1 fewer per 1000 (6 fewer to 21 more) |
⊕⊖⊖⊖ Very low Due to study limitations, imprecision3 |
Rank 12 (0.5109) Rank 6 of 16 single drugs |
We are uncertain whether granisetron reduces extrapyramidal symptoms |
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Ondansetron (7 RCTs; 751 participants) |
0.73 (0.39 to 1.38) |
8 per 10001 | 6 per 1000 | 2 fewer per 1000 (5 fewer to 3 more) |
⊕⊖⊖⊖ Very low Due to study limitations, imprecision3 |
Rank 3 (0.6026) Rank 1 of 16 single drugs |
We are uncertain whether ondansetron reduces extrapyramidal symptoms |
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Palonosetron (1 RCT; 60 participants) |
1.00 (0.02 to 48.80) |
8 per 10001 | 8 per 1000 | 0 fewer/more per 1000 (8 fewer to 382 more) |
⊕⊖⊖⊖ Very low Due to study limitations, imprecision3,4 |
Rank 18 (0.4885) Rank 8 of 16 single drugs |
We are uncertain whether palonosetron has no or minimal effect on extrapyramidal symptoms |
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Ramosetron (no direct evidence, indirect evidence only) |
0.73 (0.01 to 37.44) |
8 per 10001 | 6 per 1000 | 2 fewer per 1000 (8 fewer to 292 more) |
⊕⊖⊖⊖ Very low Due to study limitations, imprecision, incoherence5 |
Rank 8 (0.5409) Rank 5 of 16 single drugs |
We are uncertain whether ramosetron reduces extrapyramidal symptoms |
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Tropisetron (3 RCTs; 187 participants) |
0.82 (0.43 to 1.58) |
8 per 10001 | 7 per 1000 | 1 fewer per 1000 (5 fewer to 5 more) |
⊕⊖⊖⊖ Very low Due to study limitations, imprecision6 |
Rank 7 (0.5553) Rank 4 of 16 single drugs |
We are uncertain whether tropisetron reduces extrapyramidal symptoms |
| D2 receptor antagonists | |||||||
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Amisulpride (1 RCT; 689 participants) |
1.00 (0.02 to 50.11) |
8 per 10001 | 8 per 1000 | 0 fewer/more per 1000 (8 fewer to 393 more) |
⊕⊕⊖⊖ Low Due to imprecision2,4 |
Rank 19 (0.4872) Rank 9 of 16 single drugs |
Amisulpride may have little or no effect on extrapyramidal symptoms |
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Droperidol (22 RCTs; 3270 participants) |
1.36 (0.89 to 2.08) |
8 per 10001 | 11 per 1000 | 3 more per 1000 (1 fewer to 9 more) |
⊕⊕⊖⊖ Low Due to imprecision2 |
Rank 29 (0.3456) Rank 15 of 16 single drugs |
Droperidol may increase extrapyramidal symptoms |
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Haloperidol (5 RCTs; 437 participants) |
1.18 (0.37 to 3.73) |
8 per 10001 | 9 per 1000 | 1 more per 1000 (5 fewer to 22 more) |
⊕⊕⊖⊖ Low Due to imprecision2 |
Rank 27 (0.4202) Rank 14 of 16 single drugs |
Haloperidol may increase extrapyramidal symptoms |
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Metoclopramide (12 RCTs; 855 participants) |
1.14 (0.59 to 2.20) |
8 per 10001 | 9 per 1000 | 1 fewer per 1000 (3 fewer to 10 more) |
⊕⊕⊖⊖ Low Due to imprecision2 |
Rank 26 (0.4257) Rank 13 of 16 single drugs |
Metoclopramide may increase extrapyramidal symptoms |
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Perphenazine (1 RCT; 115 participants) |
1.03 (0.05 to 23.02) |
8 per 10001 | 8 per 1000 | 0 fewer/more per 1000 (8 fewer to 176 more) |
⊕⊖⊖⊖ Very low Due to study limitations, imprecision3 |
Rank 23 (0.4774) Rank 12 of 16 single drugs |
We are uncertain whether perphenazine has no or minimal effect on extrapyramidal symptoms |
| NK1 receptor antagonists | |||||||
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Aprepitant (0 RCTs; 0 participants) |
NA | NA | NA | NA | NA | NA | No studies were found that looked at extrapyramidal symptoms |
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Casopitant (0 RCTs; 0 participants) |
NA | NA | NA | NA | NA | NA | No studies were found that looked at extrapyramidal symptoms |
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Fosaprepitant (0 RCTs; 0 participants) |
NA | NA | NA | NA | NA | NA | No studies were found that looked at extrapyramidal symptoms |
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Rolapitant (0 RCTs; 0 participants) |
NA | NA | NA | NA | NA | NA | No studies were found that looked at extrapyramidal symptoms |
| Corticosteroids | |||||||
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Dexamethasone (4 RCTs; 1031 participants) |
0.70 (0.17 to 2.80) |
8 per 10001 | 6 per 1000 | 2 fewer per 1000 (7 fewer to 14 more) |
⊕⊕⊖⊖ Low Due to imprecision2 |
Rank 4 (0.5865) Rank 2 of 16 single drugs |
Dexamethasone may reduce extrapyramidal symptoms |
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Methylprednisolone (0 RCTs; 0 participants) |
NA | NA | NA | NA | NA | NA | No studies were found that looked at extrapyramidal symptoms |
| Antihistamines | |||||||
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Dimenhydrinate (0 RCTs; 0 participants) |
NA | NA | NA | NA | NA | NA | No studies were found that looked at extrapyramidal symptoms |
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Meclizine (0 RCTs; 0 participants) |
NA | NA | NA | NA | NA | NA | No studies were found that looked at extrapyramidal symptoms |
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Promethazine (0 RCTs; 0 participants) |
NA | NA | NA | NA | NA | NA | No studies were found that looked at extrapyramidal symptoms |
| Anticholinergics | |||||||
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Scopolamine (0 RCTs; 0 participants) |
NA | NA | NA | NA | NA | NA | No studies were found that looked at extrapyramidal symptoms |
| Comparator | |||||||
| Placebo | Reference comparator | Not estimable | Not estimable | Not estimable | Reference comparator |
Rank 22 (0.4778) |
Reference comparator |
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NMA‐SoF table definitions: * Certainty of evidence was assessed only for single antiemetic drugs of direct interest. ** Geometry of the network is presented in Figure 18 (netgraph). *** Network estimates are reported as risk ratio (RR) with confidence interval (CI). **** Anticipated absolute effects. The anticipated absolute effect compares two risks by calculating the difference between risk of the intervention group and risk of the control group. ***** Ranking of treatments includes all single drugs and combinations of drugs and is based on the P score (a value on a continuous 0 to 1 scale), which measures the extent of certainty that a treatment is better than another treatment, averaged over all competing treatments (Supplementary Files‐6‐extrapyramidal symptoms). Larger P scores indicate better treatments. In addition, the rank of the treatment out of all single drugs is indicated. | |||||||
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GRADE working group grades of evidence (or certainty of the evidence). High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of effect. Very low certainty: we have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect. | |||||||
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Explanatory footnotes: 1 Baseline risks (assumed control risk) are based on the total events of all placebo groups included in the outcome extrapyramidal symptoms. The general incidence of extrapyramidal symptoms after surgery with placebo is about 0.79%. 2 Very serious concerns for imprecision. 3 Serious concerns for study limitations and very serious concerns for imprecision. 4 Poorly connected to the network. Only direct evidence available. 5 Serious concerns for study limitations and incoherence, and very serious concerns for imprecision. 6 Very serious concerns for study limitations and imprecision. | |||||||