From the Guidelines
Cannabinoid hyperemesis syndrome (CHS) is best managed through cannabis cessation as the primary treatment, with patients completely stopping all cannabis products, which typically leads to symptom resolution within 1-2 weeks, as supported by the most recent evidence from 2024 studies 1.
Key Management Strategies
- Cannabis cessation is the primary treatment, with a recommended cessation period of at least 6 months or equal to the total duration of 3 typical vomiting cycles in that patient, as suggested by the AGA clinical practice update on diagnosis and management of cannabinoid hyperemesis syndrome: commentary 1.
- For acute episodes with severe vomiting, supportive care includes:
- Intravenous fluids for rehydration
- Antiemetics, with haloperidol (2.5-5mg IV/IM) or benzodiazepines like lorazepam (1-2mg IV) often being more effective than traditional antiemetics like ondansetron
- Hot showers or baths provide temporary symptom relief
- Capsaicin cream (0.1%) applied to the abdomen can mimic this effect through TRPV1 receptor activation, as mentioned in the study 1
- Proton pump inhibitors like omeprazole (20-40mg daily) may help with associated gastric symptoms
Long-term Management
- Patients should be counseled about the direct relationship between cannabis use and symptoms, as many are reluctant to accept this connection
- Psychological support and substance use counseling are important components of treatment, as relapse rates are high
- 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, as suggested by the study 1
Pathophysiology and Epidemiology
- CHS is a disorder of gut–brain interaction, characterized by cyclic vomiting, nausea, and abdominal pain, and is associated with prolonged bathing behavior (long hot baths or showers) 1
- The endocannabinoid system plays a crucial role in the pathophysiology of CHS, with CB1 receptors being the primary receptors involved in the effects of THC resulting in nausea or vomiting 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, with a significant association with cannabis use patterns, particularly daily or multiple times per day use 1
From the Research
Management of Cannabinoid Hyperemesis Syndrome (CHS)
Cannabinoid hyperemesis syndrome (CHS) is a condition characterized by cyclic severe vomiting, abdominal pain, and compulsive hot showers or baths in individuals with a history of long-term cannabis use. The management of CHS can be challenging, but several treatment options have been identified:
- Complete abstinence from cannabis consumption is considered the most effective long-term treatment option for CHS 2
- Pharmacological therapies, such as dopamine antagonists (e.g., haloperidol and droperidol), conventional antiemetics (e.g., ondansetron and metoclopramide), and topical capsaicin, may be used to manage symptoms 3, 4, 5, 6
- Droperidol has been shown to be effective in reducing the length of hospital stay and the total number of antiemetic dosages administered in patients with CHS 3
- Topical capsaicin has been found to be effective in reducing pain scores and the number of episodes of emesis in patients with CHS, and may be associated with a shorter time to discharge after administration of the reference agent 5, 6
Treatment Options
The following treatment options may be considered for the management of CHS:
- Dopamine antagonists:
- Haloperidol
- Droperidol
- Conventional antiemetics:
- Ondansetron
- Metoclopramide
- Topical capsaicin
- Hot showers or baths
Important Considerations
- Opioids and benzodiazepines should not be used as first-line therapy for CHS due to the risk of dependence and worsening of symptoms 4
- The use of capsaicin cream has been associated with a modest pain score reduction and may be a useful adjunctive therapy in the emergency department 5, 6
- Further research is needed to determine the efficacy of capsaicin when used earlier in therapy, ideally upon initial diagnosis of CHS, and before additional adjunct medications are administered 5