What is the management of Cannabinoid Hyperemesis Syndrome (CHS)?

Management of Cannabinoid Hyperemesis Syndrome (CHS)

The definitive management of Cannabinoid Hyperemesis Syndrome requires complete cessation of cannabis use for at least 6 months, as this is the only truly effective long-term solution. 1 In the acute setting, a combination of supportive care, specific pharmacological interventions, and patient education is necessary to manage symptoms and prevent recurrence.

Diagnosis and Assessment

• Confirm diagnosis using established criteria:

  • Stereotypical episodic vomiting
  • Cannabis use for >1 year before symptom onset
  • Cannabis use frequency >4 times per week
  • Relief with hot showers/baths
  • Resolution of symptoms after cannabis cessation 1

• Initial workup should include:

  • Complete blood count
  • Electrolytes
  • Glucose
  • Liver function tests
  • Lipase
  • Urinalysis 1

Acute Management

First-Line Interventions

1. Nonpharmacological approaches:

   • Hot showers or baths (hydrothermotherapy) 1, 2
   • Topical capsaicin (0.1%) cream applied to the abdomen 1, 3
   • IV fluid rehydration for dehydration 1

2. Pharmacological options:

   • Dopamine antagonists:

     • Haloperidol (2.5-5mg IV/IM) 1, 3, 2
     • Droperidol 3, 2

   • Benzodiazepines:

     • Shown to be effective in resolving symptoms 1, 2, 4
     • May work by decreasing activation of CB1 receptors in the frontal cortex 4
     • Use with caution due to potential drug interactions 1

   • Other options:

     • Olanzapine 1
     • Promethazine 1

Second-Line/Adjunct Therapies

• Tricyclic antidepressants (e.g., amitriptyline 25mg at bedtime, titrating weekly to 75-100mg) 1
• Conventional antiemetics (ondansetron, metoclopramide) may be tried but often have limited efficacy 1, 3, 2

Treatments to Avoid

• Opioids should be avoided as they can worsen nausea and carry addiction risk 1, 3
• Standard antiemetics like 5-HT3 or D2-receptor antagonists have been shown to be ineffective in many cases 5

Long-Term Management

1. Cannabis cessation:

   • Complete abstinence from cannabis is the only definitive treatment 1, 3, 2, 5
   • Refer to addiction specialist 1
   • Provide counseling and support for cannabis discontinuation 1

2. Address comorbidities:

   • Co-management with psychiatrist or psychologist for psychiatric comorbidities 1
   • Treatment of anxiety and depression, which are common associated conditions 1

Patient Education

• Explain that many patients remain skeptical about cannabis as the cause of symptoms 1
• Discuss the pathophysiology of CHS and the paradoxical nature of symptoms
• Emphasize that symptom resolution only occurs with cessation of cannabis use 6
• Warn about driving risks (avoid driving within at least 6 hours of cannabis use) 1

Clinical Pearls and Pitfalls

• CHS is frequently unrecognized by clinicians, leading to extensive and unnecessary testing and treatment 2
• Directed questions about cannabis use and the effect of hot showers on symptoms can confirm diagnosis 2
• The prevalence of CHS will continue to rise with increasing worldwide cannabis use and potency 2
• Patients may present repeatedly to emergency departments before diagnosis is established 5, 6
• A high index of suspicion for CHS allows for rapid, appropriate treatment 4
• Significant cannabis consumption that may warrant clinical concern is defined as >1.5 g/day of smoked cannabis, >300 mg/day CBD oil, >20 mg/day THC oil, or using an unknown cannabis product >2-3 times per day 1