What is the management of THC (tetrahydrocannabinol)-induced abdominal pain, nausea, and vomiting with relatively negative workup?

From the Guidelines

The management of THC-induced abdominal pain, nausea, and vomiting with a negative workup primarily involves complete cessation of cannabis use, as this is the definitive treatment for cannabinoid hyperemesis syndrome (CHS), which is likely the underlying diagnosis. For acute symptom relief, pharmacologic management includes intravenous fluids for dehydration, antiemetics such as ondansetron or promethazine, and topical capsaicin cream (0.1%) applied to the abdomen, as supported by the 2024 study 1. Notably, traditional antiemetics may have limited efficacy, and haloperidol or droperidol may be considered for severe symptoms.

Key Management Strategies

• Complete cessation of cannabis use for at least 6 months, or at least equal to the total duration of 3 typical vomiting cycles in that patient, as recommended by the 2024 study 1
• Topical capsaicin (0.1%) cream applied to the abdomen with close monitoring of efficacy and adverse effects
• Antiemetics such as ondansetron or promethazine for acute symptom relief
• Avoidance of opioids due to potential worsening of nausea, and instead use of acetaminophen or NSAIDs for pain control
• Patient education about CHS and the direct relationship between cannabis use and symptoms is crucial for long-term management, as symptoms typically resolve within 24-48 hours of cannabis cessation but may recur with resumed use, as noted in the 2024 study 1

Additional Considerations

• The clinical approach in the ED requires immediate evaluation for life-threatening disorders, such as acute abdomen, bowel obstruction, mesenteric ischemia, pancreatitis, and myocardial infarction, among others, as highlighted in the 2024 study 1
• Differential diagnosis in the outpatient setting after exclusion of structural abnormalities includes rumination syndrome, gastroparesis, CVS, pregnancy, migraine, and functional chronic nausea and vomiting syndrome, as discussed in the 2024 study 1

From the FDA Drug Label

Nausea, vomiting, or abdominal pain can occur during treatment with synthetic delta-9-tetrahydrocannabinol (delta-9-THC), the active ingredient in dronabinol capsules. In some cases, these adverse reactions were severe (e.g., dehydration, electrolyte abnormalities) and required dose reduction or drug discontinuation. Symptoms are similar to cannabinoid hyperemesis syndrome (CHS), which is described as cyclical events of abdominal pain, nausea, and vomiting in chronic, long-term users of delta-9-THC products Consider dose reduction or discontinuing dronabinol capsules if a patient develops worsening nausea, vomiting, or abdominal pain while on treatment.

The management of THC-induced abdominal pain, nausea, and vomiting includes dose reduction or discontinuation of the drug, especially if symptoms worsen or become severe 2.

• Monitor patients for signs of dehydration and electrolyte abnormalities.
• Assess for symptoms similar to cannabinoid hyperemesis syndrome (CHS).
• Consider alternative treatments if symptoms persist or worsen after dose reduction or discontinuation.

From the Research

Management of THC-Induced Abdominal Pain, Nausea, and Vomiting

• The management of THC-induced abdominal pain, nausea, and vomiting, also known as Cannabinoid Hyperemesis Syndrome (CHS), typically involves a combination of pharmacological and non-pharmacological interventions 3, 4, 5, 6, 7.
• CHS is characterized by recurrent episodes of severe nausea, vomiting, and abdominal pain, often accompanied by compulsive hot showers or baths, in individuals with a history of chronic cannabis use 3, 4, 5, 6, 7.

Pharmacological Management

• Topical capsaicin cream has been shown to be effective in alleviating symptoms of CHS, possibly due to its antiemetic effects produced by activation of TRPV1 receptors 3, 5, 7.
• Droperidol, an antipsychotic medication, has also been used to treat CHS, with studies showing reduced length of hospital stay and decreased use of antiemetics 4.
• Other medications, such as haloperidol, benzodiazepines, and antiemetics, may also be tried, although their effectiveness can vary 5.

Non-Pharmacological Management

• Cessation of cannabis use is the most effective way to resolve CHS symptoms, with recurrence of symptoms often occurring when cannabis use is reinitiated 3, 5, 6.
• Hydrothermotherapy, or hot water bathing, can provide temporary relief from symptoms, possibly due to its effects on TRPV1 receptors 5, 7.

Diagnosis and Treatment Approach

• A diagnosis of CHS should be considered in individuals with a history of chronic cannabis use and symptoms of cyclic nausea, vomiting, and abdominal pain, particularly if other diagnostic tests are negative 3, 4, 5, 6, 7.
• A thorough medical history, physical examination, and laboratory tests should be conducted to rule out other potential causes of symptoms 3, 4, 5, 6, 7.