How is cannabinoid hyperemesis syndrome (CHS) best managed?

From the Guidelines

Cannabinoid hyperemesis syndrome (CHS) is best managed through cannabis cessation as the primary treatment, with resolution of symptoms after a period of abstinence from cannabis use for at least 6 months, or at least equal to the total duration of 3 typical vomiting cycles in that patient. For acute episodes with severe vomiting, supportive care includes intravenous fluids for rehydration and electrolyte replacement, as well as hot showers or baths to provide temporary symptom relief due to the effect of heat on TRPV1 receptors 1. Medication options for acute episodes include topical capsaicin cream (0.1%) applied to the abdomen, haloperidol, benzodiazepines, or ondansetron, although conventional antiemetics like ondansetron often have limited effectiveness.

Some key points to consider in the management of CHS include:

• Avoiding opioids due to worsening of nausea and high risk of addiction 1
• Using topical capsaicin cream (0.1%) with close monitoring of efficacy and adverse effects 1
• Considering tricyclic antidepressants, such as amitriptyline, for long-term management, with the minimal effective dose being 75–100 mg at bedtime 1
• Referring patients to addiction counseling to support cannabis abstinence, as relapse to cannabis use typically causes symptoms to return 1

It's also important to note that patient education about the direct relationship between cannabis use and symptoms is crucial for successful management, and 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

Management of Cannabinoid Hyperemesis Syndrome (CHS)

• CHS is a rare condition characterized by cyclic severe vomiting in individuals who have been consuming large doses of cannabis for several years 2.
• The syndrome is often alleviated by hot showers, but standard treatments of vomiting, such as 5-HT3 or D2-receptor antagonists, have been shown to be ineffective in alleviating the symptoms 2.
• The only long-term satisfying treatment option is the complete abstinence from cannabis consumption 2.

Pharmacological Therapies for CHS

• Dopamine antagonists, such as haloperidol and droperidol, have been used to treat CHS, with droperidol showing promise in reducing the length of hospital stay and the total number of antiemetic dosages administered 3.
• Conventional antiemetics, such as ondansetron and metoclopramide, have also been used, but their effectiveness is limited 4, 3.
• Topical capsaicin has been shown to be effective in reducing the severity of CHS symptoms, with some studies demonstrating a decrease in the number of medications administered and a reduction in opioid requirements 5, 6.

Non-Pharmacological Therapies for CHS

• Hot baths or showers are often used to alleviate symptoms of CHS, with some patients experiencing significant relief from these measures 2, 4.
• Abstinence from cannabis use is the most effective long-term treatment for CHS, with cessation of use leading to resolution of symptoms in most cases 2, 4.

Emergency Department Management of CHS

• Emergency medicine pharmacists should be able to recognize the common presentation of CHS and assist with treatment of these patients in the emergency department 4.
• A multidisciplinary approach to management, including pharmacological and non-pharmacological therapies, is often necessary to effectively manage CHS in the emergency department 4, 5, 3, 6.