Letter to editor

Dear editor

I would like to congratulate the authors of the article entitled, “Optimal management of nausea and vomiting of pregnancy” for the comprehensive review of treatments for a frequent complication of pregnancy.¹ Although this letter arrives well after publication I think it is important for researchers in the future to have clarification on one seemingly minor but important point. In order to avoid confusion it must be pointed out that in the metoclopramide section the statement “subcutaneous metoclopramide is effective in many women with NVP and HG” is supported by one observational trial on continuous subcutaneous metoclopramide.² This distinction is very important because that study reported patients were receiving the drug for 26.7 days on average at a cost of $4432 per patient. Unfavorable cost comparisons have been previously published.³ The recommendation that more studied and less expensive alternatives are explored prior to subjecting the patient to this extreme measure seems prudent.⁴ Perhaps the use of the reference to continuous subcutaneous metoclopramide may have been accidental but the suggestion that “these findings are reassuring, especially for women who experience excessive sleepiness…” implies that women on Diclectin^® who report being tired are advanced to continuous subcutaneous metoclopramide seems like a waste of health care resources and a little reckless.¹

Authors’ responseCorrespondence: Neda Ebrahimi, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G1X8, Canada, Tel [phone]-x4928 mailbox 2, Email [email protected]

Our statement given with respect to metoclopramide, is meant to be an alternative or add-on therapy for patients who don’t respond to Diclectin^®, or suffer from its side effects. In Figure 1 of our article, the algorithm for treatment of nausea and vomiting of pregnancy (NVP) is provided, in which 5–10mg/intramuscular or by mouth, of metoclopramide every 8 hours is suggested. Orally disintegrating tablets, and subcutaneous metoclopramide are both acceptable formulations as well. With respect to the cost/benefit analysis, it was not our intention to encourage the use of the most expensive therapy, but rather the most effective in relieving symptoms and reducing hospitalization and ER visits due to NVP, especially hyperemesis gravidarum (HG). In hue of the costs associated with prolonged hospitalization of HG patients, in some extenuating circumstances, there may even be a favorable cost-benefit ratio. As outlined in your Nausea and Vomiting of Pregnancy Cost Effective Pharmacologic Treatments,¹ we acknowledge that length of therapy may dictate the cost benefit of more expensive drugs, however, the duration of treatment does vary on an individual basis, and hence the cost benefit may still endure.