Are antipsychotics (anti-psychotic medications) part of the management of cyclical vomiting syndrome?

Antipsychotics in the Management of Cyclic Vomiting Syndrome

Sedating antipsychotic medications such as droperidol and haloperidol are part of the management of cyclic vomiting syndrome (CVS), particularly for acute episodes that cannot be aborted at home and require emergency department intervention. 1

Role of Antipsychotics in CVS Management

• Antipsychotics are typically reserved for use in the emergency department setting during the acute emetic phase of CVS 1
• They function primarily as sedating agents, which is an important treatment goal for CVS episodes 1
• Haloperidol and droperidol are the most commonly used antipsychotic medications for CVS management 1

When to Use Antipsychotics in CVS

• Antipsychotics are indicated when:
  • Patients cannot abort a CVS episode at home with first-line abortive therapies 1
  • Patients present to the emergency department with uncontrolled retching and vomiting 1
  • Sedation is needed as part of the treatment strategy 1

Mechanism and Benefits

• Antipsychotics provide sedation, which helps break the cycle of vomiting 1
• They have antiemetic properties through dopamine receptor antagonism 2
• Sedation is considered a treatment goal in itself for CVS episodes, particularly in the emergency department setting 1

Antipsychotics in the Treatment Algorithm

• First-line abortive therapy typically includes:

  • Sumatriptan (nasal spray or subcutaneous) 1, 3
  • Antiemetics like ondansetron (sublingual) 1, 3
  • Sedating agents like promethazine or benzodiazepines 1

• If home management fails and patients present to the emergency department:

  • IV fluids with dextrose 1, 3
  • IV antiemetics 1
  • Sedating antipsychotics like haloperidol or droperidol 1
  • Non-narcotic pain management with IV ketorolac 1
  • Placement in a quiet, darker room 1

Evidence for Other Antipsychotics

• Beyond haloperidol and droperidol, there is limited evidence for other antipsychotics:
  • Chlorpromazine has been mentioned in literature for CVS treatment 2
  • Case reports suggest risperidone may be effective in refractory cases, particularly in combination with amitriptyline 2
  • Olanzapine has shown benefit in cannabinoid hyperemesis syndrome, which shares features with CVS 1

Important Considerations and Precautions

• Antipsychotics should be used cautiously due to potential side effects:

  • Extrapyramidal symptoms 1
  • QT prolongation 1
  • Sedation and central nervous system depression 1

• Antipsychotics are not typically used for prophylactic management of CVS, which relies primarily on:

  • Tricyclic antidepressants (first-line) 1, 3
  • Anticonvulsants (second-line) 1

Clinical Pearls

• Sedation is a key treatment goal for CVS episodes, making sedating antipsychotics valuable in the acute setting 1
• Patients with CVS often appear agitated during episodes and may have difficulty communicating, which can lead to misunderstanding of their needs 1
• Treatment plans should be individualized based on CVS severity (mild vs. moderate-severe) 1, 3
• Antipsychotics should be considered part of a comprehensive approach that includes IV hydration, antiemetics, and appropriate pain management 1