What is the treatment for acute cannabinoid hyperemesis?

Treatment of Acute Cannabinoid Hyperemesis Syndrome

For acute cannabinoid hyperemesis syndrome, use haloperidol 5 mg IV as first-line treatment, add topical capsaicin 0.1% to the abdomen, provide IV fluids for rehydration, and avoid opioids entirely. 1, 2

Immediate Acute Management

First-Line Pharmacologic Treatment

• Haloperidol 5 mg IV is the most effective acute treatment, reducing hospital length of stay by nearly 50% (6.7 vs 13.9 hours) compared to standard antiemetics 2, 3
• Add lorazepam 2 mg IV for anxiolysis and enhanced symptom control, as benzodiazepines address the stress-mediated component of CHS 2, 3
• Apply topical capsaicin 0.1% cream to the abdomen, which activates TRPV1 receptors and provides consistent symptom relief 1, 2, 3

Alternative Antiemetic Options (if haloperidol unavailable or contraindicated)

• Droperidol (another butyrophenone) shows similar efficacy to haloperidol 3, 4
• Promethazine 12.5-25 mg IV can be used as a second-line agent 2
• Olanzapine 5-10 mg PO daily is another antipsychotic option 2
• Ondansetron has limited efficacy in CHS compared to its effectiveness in other conditions and should not be relied upon as monotherapy 1, 5

Supportive Care

• Provide IV fluids for rehydration, assessing for dehydration by skin turgor, mucous membrane moisture, capillary refill, and mental status 2
• Allow hot showers or baths (hydrothermotherapy) for temporary symptomatic relief—this is universally effective and can serve as a diagnostic clue 1, 5, 6

Critical Medications to Avoid

Absolutely avoid opioids as they worsen nausea, carry high addiction risk, and are contraindicated in CHS treatment 1, 2, 3, 4

Safety Considerations

• Monitor for haloperidol's risk of extrapyramidal effects and QT prolongation 2
• Ensure life-threatening conditions are ruled out first: acute abdomen, bowel obstruction, mesenteric ischemia, pancreatitis, and myocardial infarction 1, 2

Definitive Treatment Counseling

Cannabis cessation is the only definitive cure and must be strongly recommended before discharge 1, 2, 3, 5, 7, 6

Long-Term Prevention Strategy

• Initiate amitriptyline 25 mg at bedtime, titrating weekly to reach 75-100 mg for prevention of recurrent episodes 1, 2
• Provide cannabis cessation counseling and consider referral to addiction treatment services 5
• Co-manage with psychiatry for patients with extensive psychiatric comorbidity, as anxiety and depression are common 1

Diagnostic Confirmation

Confirm CHS diagnosis based on:

• Cannabis use pattern: >1 year of use before symptom onset, frequency >4 times weekly 1, 2
• Stereotypical episodic vomiting: ≥3 episodes annually with acute onset and duration <1 week 1, 2, 3
• Pathognomonic hot water bathing behavior: compulsive use of hot showers/baths for relief (present in 44-71% of cases) 2, 3
• Resolution with abstinence: symptoms resolve after at least 6 months of cannabis cessation 1

Common Pitfalls

• CHS is frequently underdiagnosed due to limited clinician awareness, leading to extensive unnecessary testing 1, 2, 5, 6
• Patients often report that cannabis helps relieve their symptoms, leading to continued use and paradoxical worsening 2
• Standard antiemetics commonly fail in CHS, necessitating the mechanistically different approach with antipsychotics and capsaicin 5, 7
• The prevalence is increasing with cannabis legalization and higher THC concentrations in modern products 2, 3