What is the treatment for cyclic vomiting syndrome?

Treatment of Cyclic Vomiting Syndrome

Tricyclic antidepressants are strongly recommended as first-line prophylactic medications for moderate-severe cyclic vomiting syndrome (CVS), with a combination of abortive therapies including sumatriptan and ondansetron for acute episodes. 1, 2

Diagnostic Considerations Before Treatment

• Confirm CVS diagnosis and rule out conditions that can mimic CVS:
  • Addison's disease
  • Hypothyroidism
  • Hepatic porphyria
  • Neurological conditions 1, 2
• Distinguish from cannabinoid hyperemesis syndrome (CHS), which requires cannabis cessation for resolution 1, 2
• Avoid excessive diagnostic testing during acute episodes; focus on hydration and symptom control 2

Treatment Approach Based on Phase

1. Prophylactic Treatment (Inter-episodic Phase)

For patients with moderate-severe CVS (>4 episodes per year, each lasting >2 days, with ED visits/hospitalizations):

• First-line: Tricyclic antidepressants 1, 2
• Second-line options:
  • Topiramate
  • Aprepitant
  • Zonisamide
  • Levetiracetam 1

2. Abortive Therapy (Prodromal Phase)

• Most effective when administered early in the prodromal phase 1
• Recommended combination:
  • Sumatriptan (nasal spray or subcutaneous injection)
  • Antiemetic (ondansetron 8mg every 6-8 hours) 1, 2
• Additional options:
  • Olanzapine (5-10mg daily) for breakthrough nausea/vomiting 2

3. Active Episode Management (Emetic Phase)

• Medication "cocktail":

  • Antiemetics: ondansetron (8mg every 6-8 hours), metoclopramide (10-20mg every 6 hours)
  • Sedatives: lorazepam (0.5-2mg every 4-6 hours)
  • Analgesics: ketorolac 2
  • For refractory cases: haloperidol (0.5-2mg every 4-6 hours), aprepitant (125mg day 1, 80mg days 2-3) 2

• Hydration and environment:

  • IV fluids containing 10% dextrose (crucial to prevent dehydration) 2
  • Place patient in quiet, dark room
  • Allow hot water bathing/showering (effective in 48% of non-cannabis using CVS patients) 2

4. Recovery Phase

• Transition to electrolyte-rich oral fluids (sports drinks)
• Gradual reintroduction of nutrition with nutritious beverages 2

Lifestyle Modifications

• Identify and avoid personal triggers 1, 2
• Maintain regular sleep patterns
• Avoid prolonged fasting
• Implement stress management techniques 1, 2
• Address comorbid conditions:
  • Anxiety/depression
  • Migraines
  • Sleep disorders 1

Common Pitfalls to Avoid

• Delayed treatment: Early intervention is critical for effective management 2
• Overuse of opioids: Can worsen symptoms and lead to dependency 2
• Ignoring comorbidities: Addressing underlying conditions improves outcomes 1, 2
• Misdiagnosing as CHS: Proper distinction is crucial as management differs 2
• Inadequate hydration: Dehydration can perpetuate the cycle 2
• Misinterpreting self-soothing behaviors: Behaviors like drinking large amounts of water or inducing vomiting are not signs of malingering 2

Special Considerations

• Cannabis use in CVS patients requires careful evaluation:

  • CHS is considered when prolonged (>1 year) and heavy cannabis use (>4 times weekly) precedes symptom onset
  • Cannabis cessation for 6 months or 3 typical cycle lengths is needed to rule out CHS
  • Patients with ongoing cannabis use can still benefit from standard CVS treatments 1

• For refractory cases, consider:

  • Alternative supplements: coenzyme Q10 and riboflavin 2
  • Referral to specialists (neurologist, psychiatrist, sleep specialist) 1
  • Psychotherapy and cognitive behavioral therapy 1