What is the treatment for cyclic vomiting syndrome?

Treatment of Cyclic Vomiting Syndrome

The treatment of cyclic vomiting syndrome (CVS) requires a medication "cocktail" approach including antiemetics (ondansetron, metoclopramide), sedatives (lorazepam), and analgesics (ketorolac), with tricyclic antidepressants as first-line prophylactic therapy for moderate-severe cases. 1

Acute Episode Management

Initial Assessment

• Confirm CVS diagnosis and rule out complications such as dehydration, electrolyte imbalances, and Mallory-Weiss tears
• Distinguish from cannabinoid hyperemesis syndrome, which requires cannabis cessation
• Avoid excessive diagnostic testing during acute episodes 1

Medication Management for Acute Episodes

1. First-line medications:

   • Antiemetics: Ondansetron 8 mg every 6-8 hours or metoclopramide 10-20 mg every 6 hours
   • Sedatives: Lorazepam 0.5-2 mg every 4-6 hours (reduces anxiety and provides sedation)
   • Analgesics: Ketorolac for pain management 1

2. For refractory vomiting:

   • Haloperidol 0.5-2 mg every 4-6 hours
   • Aprepitant 125 mg day 1,80 mg days 2-3 for severe refractory cases 1

3. Abortive treatments:

   • Sumatriptan (nasal spray or subcutaneous injection)
   • Olanzapine 5-10 mg daily for breakthrough nausea and vomiting 1

Hydration and Environment Management

• Provide aggressive IV hydration with fluids containing 10% dextrose
• Place patient in a quiet, dark room
• Allow hot water bathing/showering (effective in 48% of non-cannabis using CVS patients)
• Transition to electrolyte-rich oral fluids (sports drinks) when tolerated 1

Prophylactic Treatment

First-line Prophylactic Therapy

• Tricyclic antidepressants (TCAs) are recommended as first-line prophylactic therapy for moderate-severe cases 1
• Amitriptyline is the most commonly used TCA for CVS prophylaxis 2

Alternative Prophylactic Options

• Antiepileptics (topiramate)
• Aprepitant for refractory cases
• Nutritional supplements: coenzyme Q10 and riboflavin 1, 2

Lifestyle and Trigger Management

• Maintain regular sleep patterns
• Avoid prolonged fasting
• Implement stress management techniques
• Identify and avoid personal triggers
• Address comorbid conditions (anxiety, depression, migraines, sleep disorders) 1

Common Pitfalls to Avoid

1. Delaying treatment (early intervention is crucial)
2. Overusing opioids (avoid if possible)
3. Ignoring comorbidities
4. Misdiagnosing as cannabinoid hyperemesis syndrome (CHS)
5. Providing inadequate hydration
6. Misinterpreting self-soothing behaviors (drinking large amounts of water or inducing vomiting) as malingering 1

Prognosis and Follow-up

• With specialized care, most adults with CVS show improvement, but only about 20% achieve complete resolution of symptoms 3
• Factors associated with reduced odds of complete resolution include:
  • Non-white race
  • Higher comorbidity count
  • Cannabis use 3

Special Considerations

• Distinguish CVS from cannabinoid hyperemesis syndrome, as the latter requires cannabis cessation
• Monitor for complications including dehydration, electrolyte imbalances, and rarely, hypertension that can lead to neurological complications 1, 4
• Recognize that CVS is frequently associated with migraine headaches and may share pathophysiology 2