What is the treatment for metabolic alkalosis due to Cannabis (marijuana) Hyperemesis Syndrome?

From the Guidelines

The primary treatment for metabolic alkalosis due to Cannabis Hyperemesis Syndrome (CHS) involves immediate cessation of cannabis use, alongside fluid resuscitation with normal saline and potassium supplementation as needed, with topical capsaicin and antiemetics like ondansetron or promethazine being used for symptom management. The management of CHS is complex and requires a multifaceted approach, considering both the acute symptoms and the long-term cessation of cannabis use. According to the most recent guidelines 1, cannabis cessation is crucial for the resolution of symptoms, with a recommended abstinence period of at least 6 months or equal to the total duration of 3 typical vomiting cycles in that patient.

Key Components of Treatment

• Fluid resuscitation with normal saline (0.9% NaCl) to address dehydration and electrolyte imbalances, starting with an IV bolus of 1-2 liters, followed by maintenance fluids based on the patient's clinical status.
• Potassium supplementation, typically 10-20 mEq/L added to IV fluids if serum potassium is low, to correct hypokalemia.
• Antiemetics such as ondansetron 4-8 mg IV/PO every 6-8 hours or promethazine 12.5-25 mg IV/PO every 6 hours for symptom management.
• Topical capsaicin cream (0.1%) applied to the abdomen can provide relief through TRPV1 receptor modulation, as suggested by recent clinical practice updates 1.
• Long-term management includes counseling to achieve marijuana cessation and consideration of tricyclic antidepressants like amitriptyline, starting at 25 mg and titrating up to a minimal effective dose of 75-100 mg at bedtime.

Importance of Cannabis Cessation

The resolution of symptoms after a period of abstinence from cannabis use underscores the importance of cessation in the treatment of CHS, as highlighted in the 2024 clinical practice update 1. This approach, combined with appropriate fluid and electrolyte management, and the use of antiemetics and topical capsaicin for symptom control, forms the basis of treating metabolic alkalosis due to CHS.

From the FDA Drug Label

1. 5 Paradoxical Nausea, Vomiting, or Abdominal Pain Nausea, vomiting, or abdominal pain can occur during treatment with synthetic delta-9-tetrahydrocannabinol (delta-9-THC), the active ingredient in dronabinol capsules. In some cases, these adverse reactions were severe (e.g., dehydration, electrolyte abnormalities) and required dose reduction or drug discontinuation. Symptoms are similar to cannabinoid hyperemesis syndrome (CHS), which is described as cyclical events of abdominal pain, nausea, and vomiting in chronic, long-term users of delta-9-THC products Because patients may not recognize these symptoms as abnormal, it is important to specifically ask patients or their caregivers about the development of worsening of nausea, vomiting, or abdominal pain while being treated with dronabinol capsules. Consider dose reduction or discontinuing dronabinol capsules if a patient develops worsening nausea, vomiting, or abdominal pain while on treatment.

The treatment for metabolic alkalosis due to Cannabis (marijuana) Hyperemesis Syndrome is not directly addressed in the provided drug label.

• The label discusses paradoxical nausea, vomiting, or abdominal pain associated with dronabinol capsules, which is similar to cannabinoid hyperemesis syndrome (CHS).
• It recommends considering dose reduction or discontinuing dronabinol capsules if a patient develops worsening nausea, vomiting, or abdominal pain while on treatment 2. However, it does not provide information on the treatment of metabolic alkalosis due to Cannabis (marijuana) Hyperemesis Syndrome.

From the Research

Treatment for Metabolic Alkalosis due to Cannabis (Marijuana) Hyperemesis Syndrome

• The treatment for metabolic alkalosis due to Cannabis (Marijuana) Hyperemesis Syndrome involves fluid resuscitation and antiemetic medications 3.
• Discontinuation of cannabis use is the only assured cure for Cannabinoid Hyperemesis Syndrome, which is the underlying cause of metabolic alkalosis in this context 4, 5.
• Common antiemetic medications are often ineffective in treating Cannabinoid Hyperemesis Syndrome, but some studies have shown that haloperidol and lorazepam can be effective in managing acute symptoms 4.
• Benzodiazepines and antipsychotics represent logical choices for treatment due to their powerful sedating effects, and topical capsaicin may also be a promising option 5.
• Treatment typically involves a combination of:
  • Fluid resuscitation to correct dehydration and electrolyte imbalances
  • Antiemetic medications, such as haloperidol and lorazepam, to manage nausea and vomiting
  • Discontinuation of cannabis use to address the underlying cause of the syndrome
  • Abstinence from cannabis use to prevent relapse 3, 6