What is the treatment for cyclic vomiting syndrome?

Treatment for Cyclic Vomiting Syndrome

The treatment of cyclic vomiting syndrome (CVS) requires a combination approach with tricyclic antidepressants (TCAs) as first-line prophylactic therapy for moderate-severe cases, and a combination of antiemetics, triptans, and sedating agents for abortive treatment. 1

Diagnosis Considerations

• Confirm diagnosis based on stereotypical episodic vomiting occurring at least 3 times annually
• Distinguish CVS from cannabinoid hyperemesis syndrome (CHS), which requires cannabis cessation for resolution 2
• Basic laboratory workup and one-time upper GI evaluation to exclude structural causes 1

Treatment Approach

Prophylactic Treatment (for moderate-severe CVS)

First-line:

• Tricyclic antidepressants (TCAs):
  • Amitriptyline: Start at 25 mg at bedtime, titrate slowly to 75-150 mg (or 1-1.5 mg/kg) 1
  • For elderly patients: Start at lower doses and titrate more slowly; nortriptyline may be better tolerated 1

Second-line options:

• Anticonvulsants: Topiramate, zonisamide, levetiracetam 1
• NK1 antagonist: Aprepitant 1
• Nutritional supplements: Coenzyme Q10, L-carnitine, riboflavin 1, 3

Abortive Treatment (for all patients)

Key point: Almost all patients require combinations of at least 2 agents to reliably abort CVS attacks 1

1. Antiemetics:

   • Ondansetron (8 mg, 2-3 times daily) 2, 1
   • Metoclopramide (10-20 mg every 4-6 hours) 1
   • Haloperidol (0.5-2 mg every 4-6 hours) 1
   • Promethazine 1

2. Triptans:

   • Sumatriptan (nasal spray or subcutaneous injection) 1

3. Sedating agents:

   • Benzodiazepines (e.g., lorazepam 0.5-2 mg every 4-6 hours) 2, 1
   • Olanzapine (5-10 mg daily) for breakthrough nausea and vomiting 1

4. For severe refractory cases:

   • Aprepitant (125 mg on day 1,80 mg on days 2 and 3) 2, 1

Supportive Care During Episodes

• IV fluids with dextrose for hydration 1
• IV ketorolac for non-narcotic pain management 1
• Quiet, dark room environment 1
• Gradual reintroduction of nutrition with nutrient drinks as tolerated 1
• Avoid opioids as they can worsen nausea and carry addiction risk 2

Management of Comorbid Conditions

• Address anxiety and depression (very common in CVS patients) 2, 1
• Treat associated migraine headaches 4
• Manage sleep disorders 1
• Consider co-management with psychiatry/psychology for patients with extensive psychiatric comorbidity 2

Lifestyle Modifications

• Maintain regular sleep patterns 1
• Avoid prolonged fasting 1
• Implement stress management techniques 1
• Identify and avoid personal triggers 1
• Hot water bathing/showering may provide relief for approximately 48% of non-cannabis-using CVS patients 1

Prognosis and Follow-up

• The prognosis is favorable in the majority of patients 5
• However, only about 19% of adult patients experience complete resolution of symptoms (unlike children who often outgrow CVS) 6
• Deterioration in CVS course is indicated by coalescence of episodes in time 5

Common Pitfalls to Avoid

• Relying on monotherapy for abortive treatment 1
• Confusing CVS with cannabinoid hyperemesis syndrome in cannabis users 1
• Performing repeated endoscopies or imaging studies after initial evaluation 1
• Using narcotics except in the most severe refractory forms of pain 1

The management of CVS requires a comprehensive approach addressing both the acute episodes and prevention of future attacks, with treatment tailored based on symptom severity and response.