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

From the Guidelines

The most effective treatment for THC hyperemesis syndrome is complete cessation of cannabis use, which typically leads to resolution of symptoms within 24-48 hours, though complete recovery may take 7-10 days. For acute symptom management, conventional antiemetics like ondansetron (4-8mg IV/PO every 6 hours), metoclopramide (10mg IV/PO every 6 hours), or promethazine (12.5-25mg IV/PO every 6 hours) may provide limited relief, as suggested by 1. Hot showers or baths often provide temporary symptom relief, likely due to the effect of heat on TRPV1 receptors. Topical capsaicin cream (0.1%) applied to the abdomen every 4-6 hours can mimic this effect, as supported by 1. IV fluids are important to address dehydration from persistent vomiting. Benzodiazepines like lorazepam (1-2mg IV/PO every 6 hours) may help with associated anxiety and can reduce nausea. Haloperidol (0.5-2mg IV/PO every 6 hours) has shown effectiveness in some cases.

For long-term management, patients should be counseled on the importance of cannabis abstinence, as symptoms will recur with resumed use, as noted in 1 and 1. The syndrome results from chronic cannabis use disrupting the endocannabinoid system's regulation of nausea and vomiting, particularly affecting CB1 receptors in the brain and gut. Some key points to consider in management include:

• Avoiding opioids due to worsening of nausea and high risk of addiction, as warned by 1
• Using tricyclic antidepressants, such as amitriptyline, with the minimal effective dose being 75–100 mg at bedtime, starting at 25 mg and titrating the dose with increments each week to reach minimal effective dose, as recommended by 1
• Applying topical capsaicin (0.1%) cream with close monitoring of efficacy and adverse effects, as suggested by 1

From the Research

Treatment Options for Cannabinoid Hyperemesis Syndrome

• Topical capsaicin has been shown to be effective in treating CHS, providing dramatic relief within 24 hours 2, 3, 4, 5
• Hydrothermotherapy, such as hot showers and baths, is also a commonly reported effective treatment for CHS 3, 5, 6
• Pharmacologic treatments, including antiemetics, antipsychotics, and benzodiazepines, may be tried but often have limited efficacy 3, 5
• Tricyclic antidepressants (TCAs) and lorazepam have been discussed as effective long- and short-term treatments, respectively 5
• Ondansetron, promethazine, diphenhydramine, and opioids have also been mentioned as potential treatments, but their efficacy is unclear 5
• Antiepileptics, such as zonisamide and levetiracetam, have been reported as effective in some cases 5
• Benzodiazepines, haloperidol, and capsaicin are the most frequently reported effective treatments for acute CHS 5

Key Findings

• CHS is often resistant to standard antiemetic therapy 2, 3, 5, 6
• Complete resolution of CHS occurs only after cessation of cannabis use 3
• The syndrome is frequently unrecognized by clinicians, leading to extensive and unnecessary testing and treatment 3
• Directed questions about cannabis use and the effect of hydrothermotherapy on CHS symptoms can help confirm the diagnosis 3

Treatment Considerations

• Topical capsaicin may be a useful alternative to antiemetics and narcotics in patients with CHS 2, 4
• The use of capsaicin may reduce the need for additional medications and decrease opioid requirements 4
• Hydrothermotherapy, such as hot showers and baths, can provide temporary relief from symptoms 3, 5, 6