Is droperidol (antiemetic) a first-line treatment for hyperemesis (excessive vomiting) associated with Cannabinoid Hyperemesis Syndrome (CHS)?

Droperidol for Cannabinoid Hyperemesis Syndrome

Droperidol is an effective second-line treatment for cannabinoid hyperemesis syndrome (CHS) after first-line therapies have failed, but should not be used as first-line therapy due to its FDA black box warning. 1

Diagnosis of Cannabinoid Hyperemesis Syndrome

CHS is characterized by:

• Stereotypical episodic vomiting
• History of cannabis use for >1 year before symptom onset
• Cannabis use frequency >4 times per week
• Resolution of symptoms after cannabis cessation 1

Treatment Algorithm for CHS

First-Line Treatments

1. Complete cannabis cessation - The definitive management approach 1
2. IV fluid rehydration - For correction of dehydration and electrolyte imbalances
3. Non-pharmacological approaches:
   • Hot showers/baths
   • Topical capsaicin cream (readily available and effective) 2
4. First-line pharmacological options:
   • Haloperidol (butyrophenone class, similar to droperidol)
   • Olanzapine
   • Benzodiazepines (use with caution due to potential drug interactions) 1

Second-Line Treatments

1. Droperidol (0.625mg IV is the most common effective dose) 3

   • Consider when first-line treatments fail
   • Significantly reduces length of hospital stay (6.7 vs 13.9 hours) compared to conventional antiemetics 3
   • Contraindicated in patients with prolonged QTc interval (>440ms in males, >450ms in females) 4
   • Should be avoided in patients at risk for QT prolongation (heart failure, bradycardia, diuretic use, cardiac hypertrophy, hypokalemia, hypomagnesemia, elderly, alcohol abuse) 4

2. Other second-line options:

   • Serotonin receptor antagonists (ondansetron)
   • Corticosteroids 1

Important Considerations

Efficacy

• Droperidol has been shown to be more effective than conventional antiemetics for CHS 3
• Patients treated with droperidol require fewer total antiemetic doses and have shorter hospital stays 3

Safety Concerns

• FDA black box warning (2001) indicates droperidol should be used only when first-line drugs are unsuccessful 4
• ECG monitoring is recommended before administration due to risk of QT prolongation 4
• Hypotension is the most common side effect 4

Medications to Avoid

• Opioids should be avoided as they can worsen nausea and carry addiction risk 1, 2
• Conventional antiemetics like ondansetron and metoclopramide have limited effectiveness in CHS 2, 5

Special Patient Populations

For patients with significant cannabis consumption (defined as >1.5g/day smoked cannabis, >300mg/day CBD oil, >20mg/day THC oil, or unknown cannabis product >2-3 times per day), consider additional antiemetic prophylaxis 4

Patient Education

Emphasize that complete cannabis cessation is the only definitive treatment for CHS 1, 2

Follow-up

Monitor for symptom recurrence, which typically happens with cannabis resumption, even after prolonged periods of recovery 1

Droperidol represents an effective option in the treatment arsenal for CHS, but its use should be reserved for cases where first-line treatments have failed, and appropriate precautions regarding QT prolongation are taken.