What is the management of marijuana hyperemesis?

Management of Cannabinoid Hyperemesis Syndrome (CHS)

The definitive management of cannabinoid hyperemesis syndrome requires complete cannabis cessation for at least 3-6 months, along with supportive care including IV fluid rehydration, dopamine receptor antagonists (particularly haloperidol), and topical capsaicin application. 1

Diagnosis

CHS should be suspected in patients presenting with:

• Stereotypical episodic vomiting (≥3 episodes annually)
• Cannabis use for >1 year before symptom onset
• Cannabis use frequency >4 times per week
• Relief from hot showers/baths (reported in 71% of cases)
• Resolution of symptoms after cannabis cessation 2, 1

Acute Management

First-line interventions:

• IV fluid rehydration to correct dehydration and electrolyte abnormalities
• Dopamine receptor antagonists:
  • Haloperidol 0.5-2 mg IV or PO every 4-6 hours 1
• Topical capsaicin cream (0.1%) applied to abdomen with monitoring for efficacy and adverse effects 2, 1
• Encourage hot showers/baths which provide temporary symptom relief 1

Second-line options:

• Benzodiazepines: Lorazepam 0.5-2 mg PO/SL/IV every 6 hours 1, 3
• Olanzapine: 5-10 mg PO daily 1
• Promethazine for nausea control 4
• Ondansetron may provide some benefit 2

Important cautions:

• Avoid opioids due to risk of worsening nausea and high addiction potential 2
• Provide a quiet, supportive environment with minimal stimulation 1
• Ensure adequate hydration throughout treatment 1

Long-term Management

1. Cannabis cessation counseling - the only definitive treatment 2, 1, 3
2. Tricyclic antidepressants (e.g., amitriptyline):
   • Start at 25 mg at bedtime
   • Titrate weekly to reach minimal effective dose (75-100 mg) 2, 5
3. Patient education about the direct relationship between cannabis use and symptoms
4. Regular follow-up to monitor for symptom recurrence and cannabis use

Clinical Pearls

• CHS is frequently misdiagnosed, leading to unnecessary testing and treatments 4
• The paradoxical relief with hot water bathing/showering is a distinctive feature that helps differentiate CHS from other causes of cyclic vomiting 6
• Symptoms typically resolve completely within 7-10 days of cannabis cessation 1
• Capsaicin may reduce the need for additional medications and decrease opioid requirements 7
• Emergency department differential diagnosis should include life-threatening conditions such as acute abdomen, bowel obstruction, mesenteric ischemia, pancreatitis, and myocardial infarction 2

Treatment Challenges

• Many standard antiemetics show limited efficacy in CHS 5
• Patient resistance to accepting cannabis as the cause of symptoms is common
• High recurrence rate if cannabis use is resumed
• Limited high-quality research on optimal pharmacologic treatment 3, 5

The most recent evidence strongly supports a multifaceted approach with cannabis cessation as the cornerstone of treatment, supplemented by dopamine antagonists, benzodiazepines, and topical capsaicin for symptomatic relief during acute episodes 2, 1.