From the Guidelines
The primary treatment for Cannabinoid Hyperemesis Syndrome (CHS) is complete cessation of cannabis use, which is the only definitive way to resolve symptoms long-term. This is based on the most recent and highest quality study available, which emphasizes the importance of cannabis cessation in managing CHS 1. During acute episodes, supportive care includes intravenous fluids for dehydration, antiemetics such as ondansetron, promethazine, or metoclopramide, and hot showers or baths which many patients report provide temporary relief.
Key Treatment Strategies
- Complete cessation of cannabis use for at least 6 months or equal to the total duration of 3 typical vomiting cycles in the patient 1
- Supportive care with intravenous fluids, antiemetics, and hot showers or baths
- Topical capsaicin cream (0.1%) applied to the abdomen to reduce nausea and vomiting through TRPV1 receptor activation 1
- Benzodiazepines like lorazepam may help with associated anxiety and can reduce nausea
- For pain management, acetaminophen or NSAIDs are preferred over opioids, which can worsen nausea
Long-term Management
For long-term management, counseling to achieve marijuana cessation and tricyclic antidepressants, such as amitriptyline, are the mainstay of therapy, 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. It's also important to note that combining evidence-based psychosocial interventions and pharmacology may be necessary for successful long-term management of CHS 1.
Important Considerations
- Opioids should be avoided due to worsening of nausea and high risk of addiction 1
- Patients should understand that symptoms will recur if cannabis use resumes, as CHS results from chronic cannabinoid stimulation of CB1 receptors, leading to paradoxical effects on the digestive system and thermoregulatory centers
- 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
From the Research
Treatment Options for Cannabinoid Hyperemesis Syndrome (CHS)
- The treatment for CHS is multifaceted and may involve a combination of pharmacological and non-pharmacological therapies 2, 3, 4, 5, 6.
- Cessation of cannabis use is widely accepted as the most effective cure for CHS 3, 5.
- Pharmacological treatments that have shown promise in managing CHS symptoms include:
- Benzodiazepines, which may help decrease the activation of Cannabinoid Type 1 Receptor (CB1) in the frontal cortex and have a sedative and hypnotic effect 2, 3.
- Antipsychotics, such as haloperidol, which may be effective in treating CHS symptoms 3, 5.
- Droperidol, a dopamine antagonist, which has been shown to reduce the length of hospital stay and the total number of antiemetic dosages administered in CHS patients 6.
- Topical capsaicin, which may help alleviate CHS symptoms 3, 4.
- Non-pharmacological therapies that may be beneficial in managing CHS symptoms include:
Considerations for Treatment
- It is essential to consider the patient's history of cannabis use and the effect of hydrothermotherapy on CHS symptoms when diagnosing and treating CHS 3, 4.
- Directed questions about cannabis use and the effect of hydrothermotherapy on CHS symptoms can help confirm the diagnosis and enable appropriate pharmacotherapy and referral to addiction treatment 3.
- Emergency medicine pharmacists should be able to recognize the common presentation of CHS and assist with treatment of these patients in the emergency department 5.