Aprepitant (Emend) is a potent, oral antiemetic used to prevent chemotherapy-induced nausea and vomiting (CINV) and postoperative nausea and vomiting (PONV). Fosaprepitant is a prodrug of aprepitant, with the benefit that it can be administered intravenously for patients who are too nauseous to reliably take oral aprepitant.

Aprepitant specifically targets and inhibits NK1 receptors, effectively preventing the emetic signals from being transmitted. This mechanism is distinct from other antiemetics like serotonin (5-HT3) receptor antagonists and dopamine receptor antagonists, providing a synergistic effect when used in combination.

In the perioperative setting, aprepitant is often administered as part of a multimodal approach to manage PONV. Its efficacy in reducing the incidence and severity of nausea and vomiting makes it a valuable addition, especially in patients with a high risk of PONV. For CINV, aprepitant is typically part of a three-drug regimen alongside a 5-HT3 receptor antagonist and dexamethasone. This combination has been shown to significantly improve the control of both acute and delayed phases of CINV.

Common side effects of aprepitant include fatigue, dizziness, and hiccups. Aprepitant is generally well-tolerated, but caution is advised in patients with hepatic impairment due to its metabolism in the liver.

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  1. Hi Dr. Kumar,
    Does your institution carry aprepitant? Do you find it to be effective? I tried ordering it as a CA-2 after reading more about PONV prophylaxis!! but was embarrassed shortly after as the periop nurse called me to say our hospital doesn’t carry aprepitant…

    Also do you ever give dexamethasone as 8mg instead of 4mg for PONV?

    • Yes, we have aprepitant and fosaprepitant (which I’m more likely to give). Personally, I don’t give 8 mg of dex (not sure what the data is based on varying doses for PONV). 4 mg of dex is a LOT (~100 mg hydrocortisone… basically a stress dose of steroids not taking into different gluco/mineralcorticoid potencies).


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