From the Guidelines
The primary goal in treating the acute phase of cyclical vomiting syndrome (CVS) is to terminate the episode, and this can be achieved through a combination of symptom control, hydration, and breaking the vomiting cycle, as outlined in the 2024 AGA clinical practice update on diagnosis and management of cyclic vomiting syndrome: commentary 1.
Treatment Approach
The treatment approach for the acute phase of CVS involves:
- Intravenous fluids to correct dehydration and electrolyte imbalances
- Antiemetics, such as ondansetron (4-8mg IV/PO every 6 hours), as the cornerstone of treatment
- Sedatives, like lorazepam (0.5-2mg IV/PO every 6 hours), to reduce anxiety and nausea
- Pain control with NSAIDs or low-dose opioids in severe cases
- Proton pump inhibitors, such as omeprazole (20-40mg daily), to reduce gastric acid and prevent complications
Key Considerations
It is essential to initiate treatment at the earliest signs of an episode and continue until symptoms resolve completely. A dark, quiet environment can help reduce stimuli that may worsen symptoms. The goal is to interrupt the brain-gut dysregulation that perpetuates the vomiting cycle, as CVS involves abnormal activation of central pathways that control nausea and vomiting, often triggered by stress, infections, or hormonal changes 1.
Additional Guidance
While the evidence for CHS management may not be directly applicable to CVS, it is worth noting that opioids should be avoided due to the risk of worsening nausea and addiction, as highlighted in the 2024 AGA clinical practice update on diagnosis and management of cannabinoid hyperemesis syndrome: commentary 1.
From the Research
Treatment for Acute Phase of Cyclical Vomiting Syndrome
The treatment for the acute phase of cyclical vomiting syndrome (CVS) involves a combination of pharmacological and non-pharmacological interventions.
- Abortive therapy consists of triptans, antiemetics (ondansetron), and sedation 2.
- Supportive therapy includes hydration and rest.
- Pharmacological therapies are categorized into abortive, supportive/rescue, and prophylactic treatments 3.
- Prophylactic therapy consists of tricyclic antidepressants (amitriptyline), antiepileptics (topiramate), and aprepitant in refractory patients 2.
Management Approach
A biopsychosocial approach is recommended for the management of CVS, taking into account the physical, emotional, and social aspects of the disorder 2.
- Treatment of comorbid conditions, such as anxiety and depression, is extremely important to improve overall patient outcomes 2.
- Lifestyle and non-pharmacological interventions, such as stress management and relaxation techniques, play a pivotal role in successful management 3.
- A multidisciplinary approach, involving healthcare professionals from different specialties, is essential for effective management of CVS 4.
Personalized Treatment
Treatment personalization is essential, adapting it to the individual needs of each patient 4.