What medications can be used to treat cannabis hyperemesis syndrome?

Medications for Cannabis Hyperemesis Syndrome Treatment

Dopamine receptor antagonists like haloperidol (0.5-2 mg IV or PO every 4-6 hours) are the first-line pharmacological treatment for cannabis hyperemesis syndrome, though complete cannabis cessation remains the only definitive cure. 1

First-Line Treatment Options

1. Dopamine receptor antagonists:

   • Haloperidol: 0.5-2 mg IV or PO every 4-6 hours 1
   • Droperidol: effective alternative to haloperidol 1, 2
   • Monitor for QT interval prolongation and acute dystonic reactions 1

2. Non-pharmacological interventions:

   • Hot showers/baths (provide temporary relief) 1
   • Topical capsaicin cream applied to abdomen 1, 3
   • IV fluid rehydration 1
   • Quiet, darker room environment 1

Second-Line Treatment Options

1. Antiemetics:

   • Ondansetron, promethazine, or prochlorperazine 1
   • Note: Traditional antiemetics often have limited efficacy in CHS 3, 4

2. Sedation strategies:

   • Benzodiazepines: lorazepam 0.5-2 mg PO/SL/IV every 6 hours, alprazolam 1, 3
   • Olanzapine: 5-10 mg PO daily 1

3. Pain management:

   • Non-narcotic pain control: IV ketorolac 1
   • Avoid opioids as they may worsen symptoms and are not recommended as first-line therapy 1, 2

4. Other options:

   • Corticosteroids 1

Treatment Algorithm

1. Initial management:

   • Confirm diagnosis (cyclic vomiting in cannabis user >1 year, use >4 times/week, relief with hot showers) 1
   • Rule out life-threatening conditions
   • Basic workup: CBC, electrolytes, glucose, liver function tests, lipase, urinalysis 1

2. Acute symptom management:

   • Start IV fluid rehydration
   • Administer haloperidol 0.5-2 mg IV or PO every 4-6 hours 1
   • Apply topical capsaicin cream to abdomen 1
   • Encourage hot showers/baths for temporary relief 1

3. If inadequate response:

   • Add benzodiazepines (lorazepam 0.5-2 mg) 1, 3
   • Consider olanzapine 5-10 mg 1
   • Try conventional antiemetics (ondansetron, promethazine) 1

4. Long-term management:

   • Complete cannabis cessation for at least 3-6 months 1
   • Patient education about recurrence with resumed cannabis use 1

Important Clinical Considerations

• CHS is frequently unrecognized, leading to unnecessary testing and treatment 3
• Recovery typically takes 1-2 days after appropriate treatment and cannabis cessation 1
• Symptoms almost always recur if cannabis use is reinitiated 1
• Benzodiazepines and antipsychotics appear most efficacious due to their sedating effects 5
• Avoid narcotic pain medications as they may worsen symptoms 1
• Patients should be counseled that complete cannabis cessation is the only definitive treatment 1, 4

Pitfalls to Avoid

• Failing to recognize CHS, leading to extensive unnecessary testing
• Relying solely on traditional antiemetics, which often fail in CHS 3, 4
• Using opioids as first-line therapy, which may worsen symptoms 2
• Not emphasizing cannabis cessation as the definitive treatment 1, 4
• Overlooking the effectiveness of simple measures like hot showers and topical capsaicin 1