From the Guidelines
The most effective treatment for Hyperemesis Cannabinoid Syndrome (CHS) is complete cessation of cannabis use, which is essential for long-term resolution, as supported by recent studies 1.
Treatment Approach
The treatment approach for CHS involves a combination of supportive care and pharmacological interventions. During acute episodes, supportive care includes:
- Intravenous fluids for rehydration
- Antiemetics such as ondansetron 4-8mg IV/PO every 8 hours or promethazine 12.5-25mg IV/PO every 6 hours for nausea control
- Hot showers or baths provide temporary symptom relief due to the effect of heat on TRPV1 receptors
- Topical capsaicin cream (0.075%) applied to the abdomen every 4-6 hours can also help by activating the same receptors
Pharmacological Interventions
For severe cases, the following pharmacological interventions may be used:
- Benzodiazepines like lorazepam 1-2mg IV/PO every 6 hours for anxiety and symptom management
- Haloperidol 2.5-5mg IV/IM has shown effectiveness in some patients
- Proton pump inhibitors like pantoprazole 40mg daily can help with associated gastritis
- Tricyclic antidepressants, such as amitriptyline, are the mainstay of therapy for long-term management, with the minimal effective dose being 75–100 mg at bedtime, starting at 25 mg and titrating the dose with increments each week to reach minimal effective dose 1
Counseling and Support
Patients should be counseled that symptoms will recur with resumed cannabis use, and addiction treatment resources should be offered to support long-term abstinence. Combining evidence-based psychosocial interventions and pharmacology may be necessary for successful long-term management of CHS 1. Co-management with a psychologist or psychiatrist may be helpful for patients who have a lack of response to standard therapies or extensive psychiatric comorbidity 1.
Key Considerations
- Opioids should be avoided due to worsening of nausea and high risk of addiction 1
- Other frequently suggested strategies lack scientific validation, such as switching to a lower D9 THC/higher CBD formulation, use of edible forms, and avoiding D9THC concentrates 1
- The prevalence of CHS is rising, and it is becoming a frequent clinical problem, leading to visits to the emergency department (ED) and gastroenterology clinics 1
From the Research
Treatment for Hyperemesis Cannabinoid Syndrome
The treatment for Hyperemesis Cannabinoid Syndrome (CHS) involves a combination of pharmacological and nonpharmacological therapies. Some of the key treatment options include:
- Cessation of cannabis use, which is considered the most effective cure for CHS 2, 3
- Dopamine antagonists such as haloperidol and droperidol, which have been shown to be effective in alleviating symptoms of CHS 2, 4, 5, 6
- Conventional antiemetics such as ondansetron and metoclopramide, although they may not be as effective as dopamine antagonists 2, 5, 6
- Topical capsaicin, which has been reported to be effective in alleviating symptoms of CHS 2, 4, 6
- Hot baths or showers, which can provide relief from symptoms, although this is not a cure for CHS 2, 3, 6
Pharmacological Therapies
Pharmacological therapies play a crucial role in the treatment of CHS. Some of the key pharmacological therapies include:
- Haloperidol, which has been shown to be superior to ondansetron in alleviating symptoms of CHS 5
- Droperidol, which has been reported to be effective in alleviating symptoms of CHS 2, 6
- Lorazepam, which has been used in combination with haloperidol to alleviate symptoms of CHS in adolescents 4
Nonpharmacological Therapies
Nonpharmacological therapies also play a crucial role in the treatment of CHS. Some of the key nonpharmacological therapies include: