From the Guidelines
The treatment approach for cyclic vomiting syndrome (CVS) involves both preventive and abortive strategies, with a focus on improving quality of life and reducing morbidity and mortality. For prevention, tricyclic antidepressants like amitriptyline (starting at 10-25 mg nightly and titrating up as needed) or anticonvulsants such as topiramate (25-100 mg twice daily) are commonly used, as recommended by the American Gastroenterological Association (AGA) Institute Clinical Practice Update 1. Mitochondrial supplements including coenzyme Q10 (10 mg/kg/day up to 200 mg twice daily), L-carnitine (50-100 mg/kg/day), and riboflavin (400 mg daily) may also help prevent episodes.
During acute attacks, treatment focuses on symptom management with antiemetics like ondansetron (4-8 mg every 6 hours), promethazine, or prochlorperazine; sedatives such as lorazepam (0.5-2 mg every 6 hours); and IV fluids for rehydration. Some patients benefit from triptans like sumatriptan at the onset of symptoms. Identifying and avoiding personal triggers (stress, certain foods, sleep deprivation) is crucial for management, as emphasized in the study by Fleisher et al 1. Patients should establish a "rescue plan" with their healthcare provider that outlines specific medications and steps to take when an episode begins.
The effectiveness of these treatments varies among individuals due to the heterogeneous nature of CVS, which is thought to involve autonomic nervous system dysfunction, mitochondrial abnormalities, and in some cases, may share pathophysiological mechanisms with migraine. Access to care, early recognition of CVS, and appropriate treatment can reduce CVS symptoms, reduce health care utilization, and improve patients’ quality of life, as highlighted in the AGA clinical practice update 1. Early recognition and treatment of CVS are essential to prevent long-term complications and improve patient outcomes.
From the Research
Treatment Approach for Cyclic Vomiting Syndrome
The treatment approach for cyclic vomiting syndrome (CVS) is multifaceted and involves a combination of pharmacological and non-pharmacological interventions.
- The management of CVS recommends a biopsychosocial approach 2.
- 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.
- Treatment of comorbid conditions is extremely important to improve overall patient outcomes 2.
Pharmacological Therapies
Pharmacological therapies are categorized into abortive, supportive/rescue, and prophylactic treatments.
- The majority of patients respond particularly well to migraine-focused treatment strategies 3.
- Amitriptyline is a better choice to reduce severity of CVS attacks compared to topiramate, in a short-term evaluation 4.
- Novel therapies that have the potential in better treating this disorder in the future include targeting the endocannabinoid system 5.
Non-Pharmacological Interventions
Lifestyle and non-pharmacological interventions play a pivotal role in successful management.
- Early recognition, evaluation, and management will facilitate care and improve outcomes 3.
- CVS episodes are frequently triggered by stressors and intercurrent illnesses, highlighting the importance of stress management and lifestyle modifications 3.
Personalized Treatment
Treatment personalization is essential, adapting it to the individual needs of each patient 6.
- A multidisciplinary approach is typically involved in the management of CVS, including pharmacologic options, behavioral, and psychologic support therapies 6.