What are the discharge instructions for a patient diagnosed with cannabinoid hyperemesis syndrome?

From the Guidelines

Discharge instructions for a patient diagnosed with cannabinoid hyperemesis syndrome (CHS) should prioritize 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 this is the only definitive treatment for resolution of symptoms. The management of CHS is primarily focused on supportive care and symptom management. For acute and short-term care, topical capsaicin, benzodiazepines, haloperidol, promethazine, olanzapine, and ondansetron may be used, but opioids should be avoided due to the risk of worsening nausea and addiction 1.

Key Discharge Instructions:

• 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, to achieve resolution of symptoms 1
• Use of topical capsaicin (0.1%) cream applied to the abdomen with close monitoring of efficacy and adverse effects for symptom management
• Benzodiazepines, such as lorazepam, may be used for nausea control as needed
• Maintain hydration with frequent small sips of clear fluids and follow a bland diet until symptoms improve
• Patients should be instructed to return to the emergency department if they experience persistent vomiting, inability to keep fluids down for more than 24 hours, severe abdominal pain, or signs of dehydration

Long-term Management:

• Counseling to achieve marijuana cessation is crucial for long-term management
• Tricyclic antidepressants, such as amitriptyline, starting at 25 mg and titrating the dose with increments each week to reach a minimal effective dose of 75–100 mg at bedtime, may be used for long-term management 1
• Long-term follow-up with a primary care provider or addiction specialist is recommended to support cannabis cessation efforts and prevent recurrence of symptoms.

From the Research

Discharge Instructions for Cannabinoid Hyperemesis Syndrome

Overview

• Cannabinoid hyperemesis syndrome (CHS) is a condition characterized by cyclic vomiting, abdominal pain, and relief with hot showers, associated with chronic cannabis use 2, 3, 4, 5.
• The pathophysiology of CHS remains unclear, but cannabis cessation appears to be the best treatment 2, 3, 4.

Treatment and Management

• Supportive care with intravenous fluids, dopamine antagonists, topical capsaicin cream, and avoidance of narcotic medications has shown some benefit in the acute setting 2, 4.
• Antipsychotics, such as haloperidol, and benzodiazepines may be effective in treating CHS symptoms 3, 4.
• Droperidol has been shown to reduce the length of hospital stay and the number of antiemetic dosages administered in patients with CHS 6.
• Hot water baths and capsaicin cream may provide relief from symptoms 2, 3, 4, 5.

Patient Education

• Patients should be educated on the need for cannabis cessation to achieve complete symptom relief 2, 3, 4.
• Patients should be advised to avoid opioid medications, as they may worsen symptoms and lead to unnecessary testing and treatment 4, 5.
• Patients should be encouraged to seek medical attention if symptoms persist or worsen after discharge.

Follow-up Care

• Patients should be scheduled for follow-up appointments to monitor their symptoms and adjust treatment as needed.
• Patients should be referred to addiction treatment services to address underlying cannabis use disorder 3, 4.