From the Guidelines
The primary treatment for Cannabis Hyperemesis Syndrome (CHS) is complete cessation of cannabis use, which typically leads to symptom resolution within 1-2 weeks. For acute episodes, hot showers or baths provide temporary relief, likely by correcting dysregulation of the body's thermoregulatory system caused by cannabinoid effects, as noted in the management of CHS 1. Intravenous fluids are essential to address dehydration from persistent vomiting. 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) often have limited effectiveness in CHS.
Key Considerations for Treatment
- Haloperidol (0.5-2mg IV) or droperidol (0.625-1.25mg IV) can be more effective for severe symptoms, as supported by evidence from case series and small clinical trials 1.
- Topical capsaicin cream (0.075% or 0.1%) applied to the abdomen may help by activating TRPV1 receptors, which are affected by cannabinoids, with the dose and application to be determined based on patient response and side effects 1.
- Benzodiazepines like lorazepam (1-2mg IV/PO) can reduce anxiety and provide sedation during severe episodes.
- For long-term management, patients should be referred to substance use counseling to support cannabis cessation, as this is the only definitive treatment, with tricyclic antidepressants such as amitriptyline considered for some cases, starting at a low dose (25mg) and titrating up to the minimal effective dose of 75-100mg at bedtime 1.
Approach to Diagnosis and Management
The clinical approach involves immediate evaluation for life-threatening disorders and differential diagnosis to exclude other conditions such as rumination syndrome, gastroparesis, and functional chronic nausea and vomiting syndrome, as outlined in the commentary on the diagnosis and management of cannabinoid hyperemesis syndrome 1. Opioids should be avoided due to worsening of nausea and high risk of addiction. Symptoms typically do not return unless cannabis use is resumed, and patients should understand that continued use will likely lead to recurrent episodes, emphasizing the importance of cessation for long-term management.
From the Research
Treatment Options for Cannabis Hyperemesis Syndrome
- The treatment of Cannabis Hyperemesis Syndrome (CHS) often involves a combination of pharmacological and non-pharmacological approaches 2, 3, 4.
- Classic antiemetics may be tried initially but often fail to alleviate CHS, while antipsychotics (such as haloperidol), benzodiazepines, and/or capsaicin cream appear to be the most efficacious in the treatment of this unique disorder 2, 4, 5.
- Hot showers and baths have been consistently reported as effective in reducing symptoms of CHS, and are often used as a first-line treatment 2, 3, 4, 6.
- The only known way to permanently end CHS is abstinence from cannabinoids, highlighting the importance of addressing the underlying cannabis use in the treatment of this syndrome 2, 3, 6.
Pharmacological Treatment
- Haloperidol has been shown to be superior to ondansetron in the acute treatment of CHS, with significant improvements in abdominal pain and nausea 5.
- Benzodiazepines, such as lorazepam, have also been reported as effective in the treatment of CHS, particularly in the short-term management of symptoms 4.
- Capsaicin cream has been used as an adjunctive treatment for CHS, with some studies suggesting its efficacy in reducing symptoms 2, 4.
Challenges and Future Directions
- The diagnosis of CHS can be challenging due to its similarity to other disorders, such as cyclical vomiting syndrome, and the lack of awareness among healthcare providers 3, 6.
- Further research is needed to fully understand the pathophysiology of CHS and to develop effective treatment strategies, including the evaluation of pharmacological and non-pharmacological interventions 2, 3, 4, 6.