Droperidol undermining gastroparesis symptoms (DRUGS) in the emergency department

Abstract

Background/purpose

Gastroparesis is a syndrome of delayed gastric emptying without obstruction. There are high rates of Emergency Department (ED) visits due to gastroparesis, and this chronic disease is difficult to treat which often leads to hospital admissions. This study aimed to evaluate the impact droperidol administration has on opioid therapy, symptom relief, co-administration of antiemetic and prokinetic medications, disposition, cost, and length of stay (LOS) of patients presenting to the ED.

Results

A total of 431 patients were identified and 233 met the inclusion criteria. Droperidol administration reduced the number of patients requiring opioid therapy (108/233 [46%] vs 139/233 [60%], P -value 0.0040), reduced patient-reported pain scales by 4 points, and reduced antiemetic therapy requirement (140/233 [60%] vs 169/233 [73%], P -value 0.0045). No differences were found in terms of ED LOS (Median 6 h [IQR 4–8] vs 5 h [IQR 4–9], P -value 0.3638), hospital LOS (Median 6 h [IQR 4–30 vs 7 h [IQR 4–40], P-value 0.8888), hospital admission rates (67/233 [29%] vs 71/233 [31%], P -value 0.6101), ED cost to the facility (Median $1462 [IQR $1114 – $1986] vs $1481 [IQR $1034 – $2235], P-value 0.0943), or hospital cost (Median $4412 [IQR $2359 – $9826] vs $4672 [IQR $2075 – $9911], P-value 0.3136).

Conclusion

In patients with gastroparesis presenting to the ED, droperidol reduced opioid use, improved pain control, and decreased antiemetic use without any differences in MME per dose, length of stay, hospital admission rate, or cost.

1 Introduction

Gastroparesis is a syndrome characterized by an objective delay in gastric emptying without mechanical obstruction. This disorder presents with a range of symptoms, including nausea, vomiting, bloating, abdominal pain, early satiety, and postprandial fullness, often significantly impacting the patient’s quality of life [ ]. The severity of these symptoms frequently leads to a high number of emergency department (ED) visits and subsequent hospital admissions, posing substantial clinical challenges. In the United States, approximately 200,000 ED visits are related to gastroparesis, and the hospital admission rate is around 80% [ ]. The prevalence of gastroparesis is approximately four times higher in women than in men, with approximately 10 men and 40 women per 100,000 people affected by the condition [ ]. While gastroparesis is commonly associated with diabetes mellitus, it can also arise due to surgical procedures or the use of specific medications, such as opioids, tricyclic antidepressants, calcium channel blockers, and antipsychotics [ ].

Currently approved therapies for gastroparesis include metoclopramide and electrical stimulation devices [ , ]. Off-label therapies include the use of opioids for abdominal pain, antiemetics, other prokinetic medications such as erythromycin, as well as onabotulinumtoxinA injection and surgical procedures. It is notable that domperidone, a medication demonstrating efficacy in gastroparesis treatment, remains unavailable in the United States [ ].

Antipsychotics that antagonize dopamine receptors, such as haloperidol, have shown promise for treating both pain and nausea [ , ]. Previous studies focusing on ED patients with gastroparesis presenting with abdominal pain, nausea, and vomiting have demonstrated that haloperidol reduces pain and nausea, leading to a decrease in the administration of morphine milligram equivalents (MME) and lower admission rates [ , ].

Haloperidol and droperidol, both belonging to the butyrophenone class of antipsychotics, exhibit antiemetic properties. Droperidol, by acting on central dopamine receptors implicated in nausea regulation, has exhibited efficacy surpassing that of ondansetron, promethazine, metoclopramide, and prochlorperazine in managing undifferentiated nausea and vomiting [ , ]. However, the specific effectiveness of droperidol in addressing the constellation of symptoms—nausea, vomiting, and abdominal pain—associated with gastroparesis has not yet been investigated.

To bridge this knowledge gap, the present retrospective study aims to evaluate the impact of droperidol administration on symptom relief, concurrent use of antiemetic, prokinetic, and analgesic medications, patient disposition, healthcare costs, and length of stay in ED patients presenting with gastroparesis-related symptoms. By delving into this unexplored aspect of droperidol’s potential utility, the study contributes valuable insights into enhancing the therapeutic approach to gastroparesis and potentially alleviating the considerable burden it places on patients and healthcare systems alike.

2 Materials and methods

This study was a single-center, retrospective chart review of patients 18 years or older who presented to the ED for gastroparesis symptoms and received droperidol between January 1, 2015, and August 31, 2021, approved by the Institutional Review Board. Patients were identified with an International Classification of Diseases (ICD) code for gastroparesis, cyclic vomiting, chronic abdominal pain, nausea, vomiting, and/or abdominal pain and had at least one ED visit where droperidol was administered while in the ED. Patients’ visits were matched to their most recent ED visit >7 days prior where droperidol was not administered.

Patients were excluded if there was no comparison visit available for comparison more than seven days before the index visit; if transferred from another facility; if intubated; if symptoms were felt to be caused by a condition other than gastroparesis as documented by the treating clinician’s note; or if records were inadequate for review. Milligrams of Morphine Equivalents (MME) were calculated using an online opioid equivalence calculator [ ].

The primary objective of the study was to determine the number of patients requiring opioid therapy during their ED visits. Secondary objectives included evaluating the number of total opioids administered in MME, assessing patient self-reported pain levels, measuring ED and hospital length of stay (LOS), examining ED disposition, calculating total ED and hospital cost, and analyzing the use of additional antiemetic or prokinetic medications.

Descriptive statistics were employed to summarize the data collected in this study. Categorical variables were analyzed using the Chi-Squared test, while continuous variables were analyzed using the Wilcoxon Signed Rank test. A two-sided P -value of <0.05 was considered statistically significant.

3 Results

A total of 431 patients were initially evaluated for inclusion. Among them, 233 patients met all inclusion criteria ( Fig. 1 ). One patient was excluded due to being under 18 years old, 3 patients were excluded due to evidence of intubation, and 194 patients were excluded due to inappropriate comparison encounters or missing data. Out of the 233 included patients, a majority of patients were female, 51% identifying as Black or African American, and the median age was 40 years old ( Table 1 ). Notably, 80 patients had documented cannabis use in their electronic health records (EHR).

Table 1

Demographics summary.

Demographics Summary
	Total Patients ( n = 233)
Sex
Female	158 (68%)
Age, years
Median Age	40
18–30	63 (27%)
31–45	80 (34%)
46–65	78 (33%)
66+	12 (5%)
Race
Black or African-American	120 (51%)
White	104 (45%)
Other	9 (4%)
Documented Cannabis Use
Yes	80 (34%)

The doses of droperidol administered were up to the provider’s discretion, ranging from 0.625 mg to 2.5 mg via intravenous or intramuscular routes. The most common given dose and route of droperidol was 1.25 mg intravenous.

The utilization of droperidol was linked to a statistically significant decrease in the proportion of patients who were administered opioid therapy (108 out of 233 [46%] compared to 139 out of 233 [60%], p = 0.0040) ( Table 2 ). There was not a difference in MME/Dose between droperidol and no droperidol (7.5 [IQR 5–15] vs 7.5 [5–15], p = 0.0653). The median pain level decreased from 9 [IQR 7–10] before droperidol compared to 5 [IQR 0–8] after droperidol ( p < 0.0001) ( Table 3 ). Droperidol was associated with a significant decrease in patient self-reported pain on the Wong-Baker FACES pain scale. Hydromorphone was the most commonly administered opioid, followed by oxycodone and morphine as shown in Table 4 .

Table 2

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