How does management differ for cannabinoid hyperemesis syndrome?

Management of Cannabinoid Hyperemesis Syndrome

The definitive management of cannabinoid hyperemesis syndrome (CHS) requires complete cessation of cannabis use, with supportive treatments focused on symptom control during acute episodes. 1

Diagnosis Criteria

Before discussing management, it's important to recognize CHS based on these diagnostic criteria:

1. Clinical features:

   • Stereotypical episodic vomiting (≥3 episodes annually)
   • Cyclic pattern resembling cyclic vomiting syndrome
   • Relief with hot showers/baths (reported in 71% of patients)

2. Cannabis use patterns:

   • Duration >1 year before symptom onset
   • Frequency >4 times per week
   • Often daily use (reported in 68% of cases)

3. Resolution with abstinence:

   • Symptoms resolve after cannabis cessation for at least 6 months or duration equal to 3 typical vomiting cycles

Acute Management (Emergency Department)

First-Line Therapies

• Topical capsaicin (0.1%): Apply to abdomen with monitoring for efficacy and adverse effects 1
• Haloperidol or droperidol: More effective than conventional antiemetics 2, 3
• Benzodiazepines: May be effective for acute symptom control 4
• Olanzapine: Shown benefit in case series 1

Second-Line Therapies

• Ondansetron: May be tried but often less effective than antipsychotics 1, 2
• Promethazine: Limited evidence of efficacy 1

Therapies to Avoid

• Opioids: Should be avoided due to:
  • Worsening of nausea
  • High risk of addiction
  • Not recommended as first-line therapy 1, 2

Non-Pharmacological Management

• Hot showers/baths: Encourage as a temporary relief measure
• Intravenous fluid rehydration: For dehydration from persistent vomiting
• Rule out life-threatening conditions: Immediate evaluation for acute abdomen, bowel obstruction, mesenteric ischemia, pancreatitis, and myocardial infarction 1

Long-Term Management

Primary Intervention

• Cannabis cessation counseling: The definitive treatment and only cure 1, 2, 4
  • Refer to addiction treatment services
  • Provide education about the direct relationship between cannabis use and symptoms

Pharmacological Support

• Tricyclic antidepressants (amitriptyline):
  • Start at 25 mg at bedtime
  • Titrate weekly to reach minimal effective dose (75-100 mg) 1
• Topical capsaicin (0.1%): For ongoing symptom management 1

Psychological Support

• Co-management with psychiatrist/psychologist: Particularly for:
  • Non-responders to standard therapies
  • Patients with psychiatric comorbidities
  • Anxiety and depression (common comorbidities) 1

Common Pitfalls and Caveats

1. Misdiagnosis: CHS is frequently unrecognized, leading to unnecessary testing and inappropriate treatments 4

2. Patient denial: Many patients remain uncertain about the role of cannabis in their symptoms, attributing them to food, alcohol, stress, or other gastrointestinal disorders 1

3. High recidivism: >40% of patients may stop treatments over time, but relapse rates are high 1

4. Unproven strategies: The following lack scientific validation:

   • Switching to lower THC/higher CBD formulations
   • Using edible forms instead of smoking
   • Avoiding THC concentrates 1

5. Differential diagnosis considerations: Rule out rumination syndrome, gastroparesis, cyclic vomiting syndrome, pregnancy, migraine, and functional chronic nausea and vomiting syndrome 1

By following this management approach, clinicians can effectively address both the acute symptoms and underlying cause of cannabinoid hyperemesis syndrome, with the ultimate goal of complete cannabis cessation to prevent recurrence.