From the Research
For patients with cyclical vomiting syndrome who don't respond to ondansetron, the next step typically involves trying other antiemetic medications or escalating to prophylactic therapies such as tricyclic antidepressants or antiepileptics. According to the most recent and highest quality study 1, a biopsychosocial approach is recommended for the management of CVS, which includes prophylactic therapy with tricyclic antidepressants (amitriptyline), antiepileptics (topiramate), and aprepitant in refractory patients.
Some key points to consider in the management of CVS include:
- Trying other antiemetic medications such as promethazine (12.5-25 mg every 4-6 hours), prochlorperazine (5-10 mg every 6-8 hours), or metoclopramide (10 mg every 6 hours) 1
- Escalating to low-dose tricyclic antidepressants like amitriptyline (starting at 10-25 mg at bedtime and gradually increasing to 50-100 mg daily) for prevention of episodes 1
- Using anticonvulsants like topiramate (25-100 mg twice daily) or zonisamide for prevention in some cases 1
- Addressing triggers is essential, including stress management, regular sleep patterns, and avoiding dietary triggers 2
- Some patients require a multi-modal approach combining several medication classes 1
The rationale behind these treatments relates to the neurological basis of cyclical vomiting syndrome, which involves dysregulation of brain-gut pathways, autonomic nervous system dysfunction, and mitochondrial abnormalities in some patients 1. It's also important to note that 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 1.