What is the treatment for Cannabinoid Hyperemesis Syndrome (CHS)?

Treatment for Cannabinoid Hyperemesis Syndrome (CHS)

The definitive treatment for cannabinoid hyperemesis syndrome is complete cessation of cannabis use, which is the only intervention that leads to long-term resolution of symptoms. 1

Diagnosis of CHS

CHS should be diagnosed based on:

• Stereotypical episodic vomiting resembling cyclic vomiting syndrome (≥3 episodes annually) 2, 1
• Cannabis use patterns: >1 year of use before symptom onset, frequency >4 times weekly 2, 1
• Resolution of symptoms after abstinence for at least 6 months or duration equal to 3 typical vomiting cycles 2, 1
• Presence of compulsive hot bathing behavior (reported in 71% of cases) as a characteristic feature 3, 1

Acute Management

First-line treatments:

• Topical capsaicin (0.1%) applied to the abdomen for symptom relief 2, 1
• Benzodiazepines have shown efficacy in resolving symptoms in the acute setting 4, 1
• Antipsychotics such as haloperidol, promethazine, and olanzapine can effectively manage acute symptoms 1, 5
• Hot showers or baths (hydrothermotherapy) provide temporary symptomatic relief 1, 3

Second-line treatments:

• Ondansetron may be tried but often has limited efficacy compared to conventional antiemetic use in other conditions 1, 3

Treatments to avoid:

• Opioids should be strictly avoided as they may worsen nausea and carry addiction risk 2, 1

Long-term Management

Essential components:

• Cannabis cessation counseling is the cornerstone of treatment 1, 6
• Patients should be advised that complete abstinence for at least 3 months is necessary to confirm diagnosis and achieve symptom resolution 6, 1
• Tricyclic antidepressants (particularly amitriptyline) are the mainstay of prophylactic therapy 2, 1
  • Start at 25 mg at bedtime
  • Titrate weekly to reach minimal effective dose of 75-100 mg

Supportive care:

• Psychological support for anxiety and depression which are common comorbidities 1, 7
• Co-management with psychiatry for patients with extensive psychiatric comorbidity or treatment resistance 1

Emergency Department Approach

• Rule out life-threatening conditions first (acute abdomen, bowel obstruction, mesenteric ischemia, pancreatitis, myocardial infarction) 1, 8
• Consider CHS in patients with regular cannabis use presenting with cyclic vomiting 8, 2
• Provide IV hydration for dehydration 8, 3
• Administer acute treatments as outlined above 1, 8

Common Pitfalls and Caveats

• CHS is often underdiagnosed or misdiagnosed due to limited awareness among clinicians 8
• Patients may report that cannabis helps relieve their symptoms, leading to continued use and worsening of the underlying condition 8, 7
• Many patients remain uncertain about the role of cannabis in their symptoms and may attribute them to other factors 8
• The prevalence of CHS is increasing with the rise in cannabis legalization and higher THC concentrations in modern cannabis products 8, 7
• Conventional antiemetics are often ineffective for CHS, leading to unnecessary treatments and investigations 4, 3