From the Guidelines
Cyclic vomiting syndrome (CVS) should be managed with a combination of abortive therapies, including sumatriptan and antiemetic agents like ondansetron, to terminate episodes and prevent future occurrences, as recommended by the most recent guidelines 1. The goal of treatment is to completely avoid the emetic phase or drastically reduce its severity. Recognizing the various CVS phases is essential, and earlier intervention is associated with a higher probability of successfully aborting an episode.
Key Treatment Strategies
- Abortive therapy: sumatriptan and antiemetic agents like ondansetron, which can be administered via nasal spray, sublingual tablet, or rectal suppository form 1
- Prevention: tricyclic antidepressants like amitriptyline or anticonvulsants such as topiramate, starting at a low dose and titrating up as needed
- Symptom management: intravenous fluids for rehydration, antiemetics, and sedatives like lorazepam to help with anxiety and nausea
- Patient education: identifying and avoiding personal triggers, maintaining regular sleep patterns and meals, and recognizing the prodromal phase to deliver abortive therapies early
Important Considerations
- The prodromal phase is the ideal time to deliver abortive therapies, and patient education on this point is imperative to optimal care 1
- Opioids should be avoided due to worsening of nausea and high risk of addiction, as noted in the management of cannabinoid hyperemesis syndrome, which shares some similarities with CVS 1
- Sedating agents like diphenhydramine or benzodiazepines may be needed in an “abortive cocktail” of medications to induce sedation and terminate episodes 1
From the Research
Definition and Prevalence of Cyclic Vomiting Syndrome
- Cyclic vomiting syndrome (CVS) is a chronic disorder of gut-brain interaction characterized by recurrent disabling episodes of nausea, vomiting, and abdominal pain 2.
- CVS affects both children and adults with a prevalence of approximately 2% in the United States, and is more common in female individuals 2.
- The pathophysiology of CVS is unknown, but a combination of genetic, environmental, autonomic, and neurohormonal factors is believed to play a role 2.
Diagnosis of Cyclic Vomiting Syndrome
- The diagnosis of CVS is based on the Rome criteria, and minimal recommended testing includes an upper endoscopy and imaging studies of the abdomen 2.
- CVS is frequently associated with anxiety, depression, and autonomic dysfunction, and patients with CVS commonly use cannabis therapeutically for symptom relief 2.
Treatment Options for Cyclic Vomiting Syndrome
- The treatment approach to a patient with CVS should include consideration of lifestyle changes, prophylactic drug therapy, abortive and/or supportive care treatment during acute episodes, and support of the family 3.
- Prophylactic therapy consists of tricyclic antidepressants (amitriptyline), antiepileptics (topiramate), and aprepitant in refractory patients 2.
- Abortive therapy consists of triptans, antiemetics (ondansetron), and sedation 2.
- Sumatriptan has potential efficacy in treating patients with CVS, particularly in those with a family history of migraine 4.
Management and Prognosis of Cyclic Vomiting Syndrome
- A biopsychosocial approach is recommended for the management of CVS, and treatment of comorbid conditions is extremely important to improve overall patient outcomes 2.
- CVS has a significant negative impact on patients, families, and the healthcare system, and future research to understand its pathophysiology and develop targeted therapies is needed 2.
- Most cases of cyclic vomiting syndrome are reversible by managing risk factors and starting on appropriate treatment, but there is often a significant delay in initiation of treatment 5.