Helsinn Healthcare Exhibit 2037
`Dr. Reddy's Laboratories, Ltd., et al. v. Helsinn Healthcare S.A.
`Trial PGR2016-00007
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`Page 1 of 5
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`Anti-ernetics in development
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`Despite these advances ir1 drug therapy, N &V remains a
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`difficult clinical problem in several areas of medicine. For
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`CINV, room for improvement in efficacy rates appears evi-
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`dent given that 21 — 45% of patients may still experience
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`CINV despite contemporary 5-HT3 antagonist plus corti-
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`costeroid therapy [6,7]. More specifically, delayed CINV
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`(emesis beginning > 24 h after chemotherapy), which occurs
`most commonly with cisplatin and cyclophosphamide,
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`occurs in up to 40% of cisplatin recipients despite ondanset-
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`ron therapy [8]. The 5—HT3 antagonists have no advantage
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`over traditional anti—emetics, such as metoclopramide "or
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`prochlorperazine, in delayed emesis [8]. Although vigorous
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`research into optimising combinations of agents already
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`available is ongoing, the overall rate of PONV, despite phar-
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`macological prophylaxis,
`remains at 40 — 60% or even
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`higher for some surgeries [4]. Related to both CINV and
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`PONV is opioid-induced N&V, against which no drug ther-
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`apy has proven to be particularly effective.
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`Not surprisingly, researchers have been actively developing
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`compounds, aimed at achieving superior anti—emetic efficacy
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`to those currently available. The numerous neurotransmitters,
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`including dopamine, serotonin, histamine and acetylcholine
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`and probably others, believed to be important in modulating
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`N&V have fuelled efforts to either antagonise multiple recep-
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`tors with one drug or to identify a ‘final common pathway’
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`which could be antagonised. The majority of these efforts
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`have been focused on development of substance P (SR neuro-
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`kinin—1 or NK1) receptor antagonists. Other pharmacological
`approaches currently in development are aimed at modulating
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`the endocannabinoid nervous system, modulating serotonin
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`receptors and broad spectrum approaches which interact with
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`multiple receptor types.
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`review will
`summarise the rationale for
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`approaches and describe the current status of anti—emetic
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`compounds in development. The focus will be on agents
`which are undergoing clinical trials in humans.
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`these
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`2. Neurokinin-1 antagonists
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`SP has been implicated in the control of the vomiting reflex
`since the 1980s [9]. Induction of retching in ferrets by SP and
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`anti—emesis achieved using the SP neurotoxin resinferatoxin
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`led to the hypothesis that non—peptide NK1 antagonists could
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`produce meaningful anti—emesis in humans [10]. Further ani-
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`research confirmed that NK1 antagonists
`injected
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`directly into the nucleus tractus solitarius attenuated cispla-
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`tin-induced emesis [11]. If NK1 antagonists which cross the
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`human blood—brain barrier could be developed,
`they may
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`represent a unique therapeutic target for anti-emetics. More-
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`over, potential clinical utility in pain, migraine, depression,
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`rheumatoid arthritis,
`imflammatory bowel disease, asthma
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`and bronchitis were also foreseen [12].
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`Numerous highly-selective non-peptide NK1 antagonists
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`have now been synthesised. Early development of these com-
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`pounds was complicated by inter-species variability in NK1
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`receptor affinity, binding to L—type calcium channels in the
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`(a predictor of potential cardiovascular
`toxicity in
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`humans) and poor oral bioavailability. Despite these chal-
`lenges, at least 16 molecules showing promise have under-
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`gone efficacy and toxicity evaluation in animal models [12].
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`This work has elucidated the probable mechanism of action
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`of NK1 antagonists, which is believed to be mainly central
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`blockade of NK1 receptors in the NTS near the area pos-
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`trema [13,14]. Other central sites of action, such as the dorsal
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`motor vagal nucleus [15,16], may also be involved [16-18]. The
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`possible contribution of a peripheral site of action has not
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`been ruled out [19], but is likely to be of minor importance in
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`comparison to the central mechanism.
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`Several clinical trials of NK1 antagonists have been pub-
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`lished and many others are ongoing.
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`3. Neurokinin-1 antagonist trials in
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`chemotherapy-induced nausea and vomiting
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`In the first published clinical trial of an NK1 antagonist for
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`emesis, Kris et al. described an open—label dose ranging study
`where CP—l22,721 was added to a regimen of dexamethasone
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`and a 5-HT3 antagonist in patients receiving cisplatin chemo-
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`therapy [20]. A single dose of CP—lZ2,721 given before cispla-
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`tin resulted in control of delayed emesis in 83% of patients
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`compared to 17% among CP-122,721 non—recipients.
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`In clinical
`trial of oral aprepitant
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`754,030), Navari at al. compared three regimens of aprepi-
`tant added to a background anti—emetic regimen of graniset-
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`ron plus dexamethasone in 159 women receiving cisplatin for
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`the first time [21]. Patients received, in double—blind fashion,
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`either aprepitant prior to cisplatin on day 1 and on days 2 -5,
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`aprepitant on day 1 only or placebo on days 1 — 5. Only 7%
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`of patients receiving aprepitant vomited during the first 24 h
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`compared to 33% of placebo recipients (p < 0.001). During
`days 2 — 5, 20% of patients who received aprepitant vomited,
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`while 56% of placebo recipients vomited (p < 0.001). There
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`was no significant difference between groups where aprepi-
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`tant was given on days 1 — 5 versus those who received only a
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`single dose on day 1; This trial suggests that aprepitant has
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`an important additive effect to granisetron against both acute
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`and delayed cisplatin-induced emesis and that repeated dos-
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`ing to prevent delayed CINV may not be necessary.
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`A subsequent double—blind trial directly compared oral
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`aprepitant to intravenous granisetron in 351 cisplatin-naive
`patients receiving dexamethasone as a background anti-
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`emetic [22]. Patients were randomised to receive either grani-
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`setron alone on day 1 followed by placebo on days 2 — 5
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`(group 1), granisetron plus aprepitant on day 1 followed by
`aprepitant on days 2 — 5 (group 2), aprepitant alone on the
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`night before cisplatin and on day 1 and on days 2 — 5
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`(group 3) or aprepitant alone on day 1 and on days 2 — 5
`(group 4). In the acute the c_ombination of graniset-
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`ron and aprepitant was superiorwtorgranisetron alone (80 ver-
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`sus 57% emesis—free, p < 0.01). Those who received only
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`Page 2 of 5
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`Expert Opin. /nvestig. Drugs (2002) 11(1)
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`Page 2 of 5
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`aprepitant (groups 3 & 4) had emesis-free rates of 46 and
`43%, respectively, which was not statistically different from
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`the granisetron alone rate of 57% (group 1). Against delayed
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`emesis, all three groups who received aprepitant had a lower
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`incidence of emesis than the granisetron-only recipients
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`(group 22 53%, group 3: 51%, group 43 57% versus group 12
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`29% emesis free, p < 0.01). This trial suggests similar efficacy
`between aprepitant and granisetron against acute emesis and
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`an additive effect when they are combined, as well as superior
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`efficacy of aprepitant compared to granisetron versus delayed
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`cisplatin—induced emesis.
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`A prodrug of MK-869, L—758,298, which is suitable for
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`intravenous administration, was compared to intravenous
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`ondansetron in a double-blind study involving 53 cisplatin-
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`naive patients [23]. Patients received either 100 mg i.v. L-
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`758,298 (the first 9 patients received 60 mg) or 32 mg i.v.
`ondansetron prior to cisplatin. During the first 24 h there was
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`no significant difference between the groups in the 'emesis-
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`free' rate (37 versus 52% respectively, p > 0.05) or in nausea
`scores over this period. During days 2 — 7, however, more
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`patients were emesis-free in the L—758,298 group than among
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`ondansetron recipients (72 versus 30%, p = 0.005). Nausea
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`scores over this period did not conclusively favour L-758,298.
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`This small trial neither supports nor refutes a similarity in
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`efficacy between L-758,298 and granisetron versus acute cis-
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`platin—induced emesis but does suggest superiority of L-
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`758,298 against delayed emesis.
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`Adverse effects occurring more commonly than with pla-
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`cebo in the three aprepitant trials were limited to diarrhoea
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`[22] and transient changes in liver transaminases [21—23]. No
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`serious toxicities have yet been identified; however, the trials
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`conducted to date are not large enough to detect rare and
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`potentially serious adverse events.
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`Hesketh er al. compared ezlopitant (CJ-11,974) to placebo in
`a double-blind randomised trial of cisplatin—naive patients receiv-
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`ing grar1isetron plus dexamethasone as background anti—emesis
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`[24]. Sixty one patients were randomised to receive 100 mg oral
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`ezlopitant prior to cisplatin, 12 h afterward and twice—daily on
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`days 2 — 5 following cisplatin or placebo. For the primary end
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`point of delayed emesis, ezlopitant was more efficacious than pla-
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`cebo on days 2 — 5 (63 versus 37% emesis-free, p = 0.043). A
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`recent report indicated that due to the unsatisfactory nausea
`results in this trial, Pfizer has decided to halt development of
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`ezlopitant as an anti—emetic and concentrate on its potential use
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`in irritable bowel syndrome [25].
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`4. Neurokinin-1 antagonist trials in other
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`nausea and vomiting states
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`At present, few published trials evaluating NK1 antagonists
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`for non—CINV indications are available.
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`Gesztesi eta]. evaluated CP-122,721 given intraoperatively
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`for prevention of PONV in 243 women undergoing abdominal
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`hysterectomy [26]. In the first phase of the study, oral CP-
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`122,721 doses of 100 or 200 mg given 60 — 90 min prior to the
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`Loewen
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`induction of anaesthesia were compared to placebo in a ran-
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`domised, double-blind design. Only 10% of CP-122,72l_
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`recipients experienced PONV during the first 8 h postopera-
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`tively compared to 50% in the placebo group. However, only
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`the 200 mg dose was superior to placebo at 24 h (p < 0.01) and
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`CP—122,72l had no beneficial effect on nausea scores com-
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`pared to placebo during the entire 72 h observation period. In
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`the second phase of the study, CP—122,721 was compared to i.v.
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`4 mg ondansetron given intraoperatively and the combination
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`of both agents. Emesis within 24 h of surgery was 6% in the
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`CPA-122,721 group versus 24% in the ondansetron alone arm
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`versus 4% with combination therapy. However, at 24 h, there
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`were no differences between the groups in need for rescue med-
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`ication or in nausea scores. The only adverse effect occurring
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`more commonly than with placebo was headache, in 22% of
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`CP-122,721 recipients. Although this trial suggests anti-emetic
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`efficacy of CP—l22,72l which may be superior to ondansetron
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`in PONV, the lack of improvement in nausea scores suggests
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`the need for further characterisation of the effects of CP-
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`l22,721 in PONV.
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`Diemunsch et a1. studied the efficacy of vofopitant (GR-
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`205l7l) in the treatment of PONV following major gynaeco-
`logical surgery [27], a situation in which other anti—emetics
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`have not been rigorously evaluated. The investigators
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`observed that among the 36 patients randomised, blinded
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`intravenous vofopitant produced superior anti—emetic efficacy
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`to placebo over the 24 h assessment period.
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`(GR-
`Reid et a1. evaluated the efficacy of vofopitant
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`20517l) against motion sickness in 16 healthy volunteers
`[28]. Participants were exposed to an experimental motion-
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`sickness stimulus and received either vofopitant, vofopitant
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`and ondansetron, hyoscine or placebo in this double-blind
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`randomised crossover study. The only treatment which
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`attenuated motion-induced nausea compared to placebo
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`was hyoscine.
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`5. Serotonin receptor modulators
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`The role of 5-HT3 receptor antagonists in various N&V states
`is well-established and has been discussed. Numerous agents
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`in this class are currently marketed worldwide and their effi-
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`cacy and safety are indistinguishable. Most development in
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`this area is aimed at bringing drugs to market which have
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`advantages of marginal clinical importance (e.g., renal versus
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`hepatic excretion and longer duration of action). Although
`some efforts have been made to develop compounds with
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`both 5—HT3 and 5—HT4 antagonist activity (e.g., itasetron and
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`palonosetron), clinical trials have demonstrated efficacy simi-
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`lar to or inferior to available 5—HT3 antagonists [29,30].
`It is
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`unknown how other agents of this type (e.g., lerisetron and
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`N3389) will perform in clinical trials.
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`2 5—HT1A receptor agonism has been identified as a potential
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`anti—emetic target [31]. Although none have yet resulted in clini-
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`cal trial reports, compounds, such as 8—OH—DPAT [32], SUN-
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`8399 [33] and LY-228729 [32], have shown promise in animal
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`Anti-emetics in development
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`models of anti-emesis. Similarly, 5-1-ITZNZC antagonists demon-
`strate some anti—emetic activity in animal models [34].
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`6. Cannabinoid receptor modulators
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`Agonism of the CB1 cannabinoid receptor may produce
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`useful anti—emetic effects. A beneficial effect of the CB1 ago-
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`nist WIN55,Zl2—2 on opioid—induced emesis has been dem-
`onstrated in ferrets [35], but no clinical trial data are available
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`at present.
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`7. Broad spectrum receptor antagonists
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`An appealing option is to combine the established and effec-
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`tive receptor activities of several drugs into a single agent. AS-
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`8112 is a dopamine D2, D3 and 5-HT3 receptor antagonist
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`which has shown anti—emetic efficacy in several animal models
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`[37] and is expected to proceed to early clinical evaluation.
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`8. Expert opinion and conclusions
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`The NK1 receptor antagonists are the most promising and vig-
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`orously studied agents in development for the management of
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`nausea and vomiting. Head-to—head clinical trials in patients
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`receiving cisplatin ‘suggest
`their possible inferior efficacy
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`against acute emesis compared to 5-HT3 antagonists. How-
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`ever, NK1 antagonists combined with 5-1-IT3 antagonists are
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`superior to 5-HT3 antagonists alone in this scenario. NK1
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`antagonists are superior to 5—HT3 antagonists in preventing
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`delayed cisplatin—induced emesis. There is also preliminary
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`evidence of their efficacy in PONV.
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`inefficacy versus
`Despite their promise, NK1 antagonist
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`motion sickness and their possible lack of superiority to 5-
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`HT3 antagonists in acute CINV and PONV suggest that they
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`may not block the ‘final common pathway’ of nausea and
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`vomiting as was hoped by some.
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`Much more clinical research is required to clarify the role of
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`these agents against other aspects of CINV, including as mon-
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`otherapy, their role in comparison to other effective agents for
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`PONV and their utility against opioid-induced N&V. Since
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`contemporary strategies for CINV and PONV management
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`are increasingly focused on combinations of drugs and max-
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`imising cost-effectiveness. it will be important to determine
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`the efficiency of VNKI antagonists in this context before their
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`ultimate role can be defined.
`
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`
`All of this research is conducted against the backdrop of
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`what, so far, appears to be an excellent safety profile. How-
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`
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`
`
`
`ever, it is possible that exposure to these agents by thousands
`
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`
`
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`more patients
`in clinical
`trials may reveal previously
`
`
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`
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`
`
`
`unknown and potentially serious adverse effects.
`
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`Other strategies for reducing emesis, such as 5—HT1A
`receptor agonism, CB1 receptor agonism and broad spec-
`
`
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`
`
`
`trum receptor antagonists, have yet to be evaluated in clini-
`
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`cal trials.
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`dexamethasone, in the prevention of
`
`
`
`
`
`cisplatin—induced delayed emesis. _/I Clin.
`
`
`
`
`Once]. (1997) 15:124-130.
`
`
`
`CARPENTER DO, BRIGGS DB,
`
`
`
`
`STROMINGER N: Peptide induced emesis
`
`
`
`
`in dogs. Behéw Brain Res. (1984) 11.277-_
`
`
`
`
`
`
`23L
`.
`
`10 ANDREWS PLR BHANDARI P.
`
`
`
`
`
`-
`1
`.
`-
`I
`1
`.
`.
`
`
`
`Re:]mferat:lxm, all ultrelpotent Ca1.)Sa1Cm
`
`
`
`
`
`:11
`igxy as a1:memet‘1,C
`
`
`
`Beg: '
`"’”””’ ‘"*’”""‘” °gy
`
`A seminal "proof of concept" paper
`
`
`
`
`
`
`supporting the role of neurokinins in N&V.
`
`
`
`
`
`
`
`
`TATTERSALL FD RYCROFT W
`'
`’
`
`
`
`FRANCIS B at31. Tachykinin NK1 receptor
`
`
`
`
`
`'
`' h'b't
`t
`anta onists act central]
`
`
`
`
`
`yoiniiemesis
`g
`‘
`induced by the chemotherapeutic agent
`
`
`
`
`
`_
`_
`I
`
`
`
`
`cisplatin in ferrets. ]\/europlzarmacology
`(1996) 35:1121—1129.
`
`
`
`9.
`
`
`"
`
`11
`
`'
`
`
`
`
`Bibliography
`Papers of special notevhave been highlighted as
`
`
`
`
`
`
`
`
`either of interest (') or of considerable interest (")
`
`
`
`
`
`
`
`
`to readers.
`
`
`
`
`
`
`
`
`l.
`
`2'
`
`
`.
`
`
`3‘
`
`
`
`
`
`
`ASHP COMMISSION ON
`THERAPEUTICS: ASHP therapeutic
`
`
`
`
`
`
`
`
`
`guidelines on the management of nausea and ‘
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`
`
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`
`Vomiting 1" aduk and pediatric patients
`receivmg Chemotherapy °r radiation therapy
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`
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`Pharm. (1999) 56:729-764.
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`GRALLA R1’ OSOBA D' KRIS MG ata1‘:
`
`
`
`
`
`
`
`
`
`
`
`
`Recommendations for the use of antiemetics:
`
`
`
`
`evidence—based, clinical practice guidelines.
`f Cl‘
`' al O
`.
`A
`'
`S
`'
`l
`.
`
`
`
`
`
`Cr1i;<:ng:]r:0lo<(::t;tS};I9(; 17;12n91;1 2£?;p 03)’ f
`
`
`
`
`'
`'
`'
`'
`-
`_dl_
`_
`d
`_b
`A
`,1 _d
`
`
`
`
`
`f typuia 8“ _enCe
`ase _ Pracflce gm e_u.1e
`or anti—emetic therapy in patients receiving
`
`
`
`
`
`chemotherapy-
`
`
`
`
`
`
`
`
`
`
`
`ANTIEMETIC SUBCOMMITTEE OF
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`
`
`OF SUPPORT“/E CARE 1N CANCER
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`DOMINO KB, ANDERSON EA,
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`efficacy and safety of ondansetron,
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`droperidol, and metoclopramide for
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`Preventing postoperafive nausea and
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`vomiting: a meta—analysis. /lnertli. Analg.
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`LOEWEN PS’ MARRA CA‘ ZED P]. 5_
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`
`
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`HT receptor antagonists versus traditional
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`agerjts for the prophylaxis of postoperative
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`nausea and vomiting. Can. f Anaesthesia
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`efficacy of two antiemetic regimens on acute
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`.
`.
`.
`.
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`C1111’ 017501‘ 1993 11123962404‘
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`HERON JF, GOEDHALS L, JORDAAN JP
`
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`
`
`
`_
`.
`.
`
`
`
`
`
`
`
`et aI.. Oral granisetron alone and in
`combination with dexamethasone: a double—
`
`
`
`blind randomized comparison against high-
`
`
`
`
`dose metocloprarnide plus dexamethasone in
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`'
`'
`prevention of cisplatin—induced emesis /lnn
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`OHM]. (1994) 5:579_584_
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`THE ITALIAN GROUP FOR
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`ANTIEMETIC RESEARCH‘ Ondansetron
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`versus metocloprarnide, both combined with
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`804
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`Page 4 of 5
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`Expert Opin. /nvestig. Drugs (2002) 11(1)
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`‘
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`'
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`
`
`12' ESOT.
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`
`
`
`an eme ics.
`ru
`:
`—
`.
`ti
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`gs
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`13- RUPNIAK NM» TATTERSALL FD»
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`
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`
`V1"-‘Wand in V179
`WILLIAMS AR 5" 31-3
`predictors of the antiemetic efficacy of
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`tachykjnin NK1 receptor antagonists, Elm I
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`Page 4 of 5
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`

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`Control of emesis following cisplatin by CP-
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`Z8.
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`
`
`MK-896, in combination with granisetron
`
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`
`
`
`and dexamethasone or with dexamethasone
`
`
`
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`
`alone.I Clin. Oncol. (2001) 1911759—1767.
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`Well-conducted clinical trial.
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`COCQUYT V, VANBELLE S,
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`
`ondansetron for the prevention of cisplatin-
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`
`
`
`induced emesis. Eur. I Cancer (2001)
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`
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`Well-conducted clinical trial.
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`HESKETH P], GRALLA R], WEBB RT:
`
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`
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`
`Randomized Phase II study of the neurokinin
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`
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`011601. (1999) 17:338-343.
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`Well-conducted clinical trial.
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`EVANGELISTA s: Ezlopitant Pfizer. Curr‘.
`
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`
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`
`0p1'n. Investig. Drugs (2001) 211441-1443.
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`GESZTESI Z, SCUDERI PE, WHITE PF
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`
`
`
`et al.1 Substance P (neurokinin-1) antagonist
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`
`
`
`
`prevents postoperative vomiting after
`I
`
`
`
`
`abdominal hysterectomy procedures.
`
`
`
`Anesthesiology (2000) 93:931-937.
`
`
`Well-conducted clinical trial.
`
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`Affiliation
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`Peter S Loewen BSc (Pharm), Pharm D
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`Pharmacotherapeutic Specialist — lntemal
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`Medicine, Pharmaceutical Sciences Clinical Service
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`Unit, Vancouver Hospital & Health Sciences
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`Center, Clinical Assistant Professor of Pharmacy,
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`University of British Columbia‘, Canada.
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`Page 5 of 5
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`Expert Opin. Investig. Drugs (2002) 11(1)
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