From the Guidelines
Cyclic vomiting syndrome (CVS) is a disorder that requires a comprehensive treatment approach, focusing on prevention and symptom management, with tricyclic antidepressants like amitriptyline and anticonvulsants such as topiramate being commonly used for prevention, as recommended by the most recent study 1.
Treatment Overview
The treatment of CVS involves a multifaceted approach, including:
- Prevention of episodes using tricyclic antidepressants like amitriptyline (starting at 10-25mg daily, gradually increasing if needed) or anticonvulsants such as topiramate (25-100mg twice daily) 1
- Symptom management during acute episodes, including intravenous fluids for dehydration, antiemetics like ondansetron (4-8mg every 6 hours) or promethazine (12.5-25mg every 4-6 hours), and sedatives such as lorazepam (0.5-2mg every 6 hours) for associated anxiety 1
- Identification and avoidance of personal triggers like stress, lack of sleep, or certain foods
- Maintaining regular sleep patterns, eating schedules, and stress management techniques to help reduce episode frequency
Key Considerations
- CVS may be related to migraine pathways, autonomic nervous system dysfunction, or mitochondrial disorders, which explains why antimigraine medications and supplements targeting mitochondrial function can be effective in some patients 1
- Some patients benefit from supplementation with L-carnitine (50-100mg/kg/day divided into 2-3 doses) or coenzyme Q10 (10mg/kg/day divided into 2-3 doses), particularly if there's suspicion of mitochondrial dysfunction 1
- The clinical approach in the ED is totally different, as it requires immediate evaluation for life-threatening disorders, such as acute abdomen, bowel obstruction, mesenteric ischemia, pancreatitis, and myocardial infarction, among others 1
Diagnosis and Management
- The diagnosis of CVS is based on the recognition of the various phases of the disorder, including the prodromal, interepisodic, emetic, and recovery phases 1
- The management of CVS involves a comprehensive approach, including prevention, symptom management, and lifestyle modifications to reduce episode frequency and improve quality of life 1
- The goal of treatment is to terminate the episode and prevent future episodes, with a focus on improving the patient's quality of life, as emphasized in the most recent study 1.
From the Research
Definition and Characteristics of Cyclic Vomiting Syndrome
- Cyclic vomiting syndrome (CVS) is a disorder characterized by recurrent and unpredictable episodes of intense vomiting, interspersed with periods of apparent wellbeing 2.
- CVS is a chronic disorder of gut-brain interaction characterized by recurrent disabling episodes of nausea, vomiting, and abdominal pain 3.
- The syndrome affects both children and adults, with a prevalence of approximately 2% in the United States, and is more common in female individuals 3.
Pathophysiology and Triggers
- The exact etiology of CVS remains unknown, but genetic factors, nervous system alterations, autonomic dysregulation, and environmental factors (such as the use and abuse of cannabinoids) are postulated as possible triggers 2.
- A combination of genetic, environmental, autonomic, and neurohormonal factors is believed to play a role in the pathophysiology of CVS 3.
- CVS is closely associated with migraine headaches and likely shares a similar pathophysiology 3, 4.
Diagnosis and Diagnostic Challenges
- The diagnosis of CVS is based on the Rome criteria, and minimal recommended testing includes an upper endoscopy and imaging studies of the abdomen 3.
- Thorough evaluation of symptoms and the ruling out of other possible causes of recurrent vomiting are required for diagnosis 2.
- CVS has significant diagnostic challenges due to the lack of a specific test for confirming its presence 2.
Management and Treatment
- Management of CVS typically involves a multidisciplinary approach, including pharmacologic options, behavioral, and psychologic support therapies 2.
- Prophylactic therapy consists of tricyclic antidepressants (amitriptyline), antiepileptics (topiramate), and aprepitant in refractory patients 3, 5.
- Abortive therapy consists of triptans, antiemetics (ondansetron), and sedation 3, 5.
- Treatment of comorbid conditions, such as anxiety, depression, and autonomic dysfunction, is extremely important to improve overall patient outcomes 3, 5.