What is the treatment for cannabinoid hyperemesis syndrome?

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

Acute Management

• Topical capsaicin (0.1%) applied to the abdomen can provide symptom relief by activating transient receptor potential vanilloid type 1 receptors 2, 1
• Antipsychotics are effective for acute symptom management:
  • Haloperidol 2, 1, 3
  • Droperidol 3
  • Promethazine 2, 1
  • Olanzapine 2, 1
• Benzodiazepines can be effective for symptom control 2, 4
• Ondansetron may be tried but often has limited efficacy compared to conventional antiemetic use in other conditions 2, 1
• Hot showers or baths (hydrothermotherapy) provide temporary symptomatic relief and can be a diagnostic clue 1, 5
• Avoid opioids as they may worsen nausea and carry addiction risk 2, 1, 3

Emergency Department Approach

• Rule out life-threatening conditions first (acute abdomen, bowel obstruction, mesenteric ischemia, pancreatitis, myocardial infarction) 2, 6
• Consider CHS in patients with:
  • Regular cannabis use (especially >4 times weekly for >1 year) 1, 6
  • Cyclic vomiting episodes (≥3 episodes annually) 2, 1
  • Relief with hot showers/baths 6, 5
• Conventional antiemetics and proton pump inhibitors often fail to provide relief 4, 5
• Dopamine antagonists such as haloperidol and droperidol are more effective than traditional antiemetics 3, 5

Long-term Management

• Cannabis cessation counseling is essential and the only definitive treatment 1, 3
• Tricyclic antidepressants (particularly amitriptyline) are the mainstay of therapy:
  • Start at 25 mg at bedtime
  • Titrate weekly to reach minimal effective dose of 75-100 mg 2, 1
• Psychological support is beneficial as anxiety and depression are common comorbidities 1, 7
• Brief interventions (5-30 minutes) incorporating individualized feedback and advice on reducing or stopping cannabis consumption 7
• Follow-up to monitor progress and adjust treatment as needed 7

Diagnostic Criteria for CHS

• Stereotypical episodic vomiting (≥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
• Hot water bathing behavior is reported in 71% of CHS cases and helps distinguish it from other causes 2, 6

Common Pitfalls and Caveats

• CHS is often underdiagnosed or misdiagnosed due to limited awareness among clinicians 6, 8
• Patients may report that cannabis helps relieve their symptoms, leading to continued use and worsening of the underlying condition 6, 9
• Many patients remain uncertain about the role of cannabis in their symptoms and may attribute them to other factors like food, alcohol, stress, or pre-existing GI disorders 6
• The prevalence of CHS is increasing with the rise in cannabis legalization and higher THC concentrations in modern cannabis products 6, 9
• Monitor for depression or psychosis during withdrawal, which can occur less commonly 7