Droperidol Dosing for Cannabinoid Hyperemesis Syndrome
For acute treatment of cannabinoid hyperemesis syndrome in the emergency department, administer droperidol 0.625 mg to 2.5 mg intravenously, with 0.625 mg being the most commonly effective dose. 1
Recommended Dosing Strategy
Start with low-dose droperidol (0.625-1.25 mg IV) as initial therapy, as this has demonstrated superior efficacy compared to conventional antiemetics in reducing both length of stay and total antiemetic requirements. 1 The most frequently successful dose in clinical practice is 0.625 mg IV, which achieved symptom resolution while minimizing adverse effects. 1
- If symptoms persist after initial dose, titrate cautiously up to 2.5 mg IV maximum. 2
- Onset of action occurs within 3-10 minutes with duration of effect lasting 2-4 hours. 2, 3
- Administer as intermittent boluses rather than continuous infusion. 3
Route of Administration
Intravenous administration is the preferred route based on available evidence, as all published studies demonstrating efficacy in CHS utilized IV dosing. 1 While IM administration is theoretically possible, no specific data supports its use for CHS, and IV provides more predictable pharmacokinetics for this acute presentation.
Critical Safety Considerations
Screen for QTc prolongation and cardiac risk factors before administration, as droperidol carries an FDA black box warning for QT prolongation and torsades de pointes. 3
Absolute Contraindications:
Relative Contraindications Requiring Caution:
- Congestive heart failure, bradycardia, cardiac hypertrophy 3
- Hypokalemia or hypomagnesemia 3
- Concurrent diuretic use 3
- Age ≥65 years 3
- Alcohol abuse 3
Clinical Context and Alternative Agents
While the 2024 AGA guidelines mention haloperidol (not droperidol specifically) among agents supported by case series for CHS, 4 droperidol has demonstrated superior outcomes in head-to-head comparisons. In a retrospective study, droperidol reduced median length of stay from 13.9 hours to 6.7 hours (p=0.014) and decreased total antiemetic requirements by approximately 50% compared to conventional therapy with ondansetron and metoclopramide. 1
If droperidol is contraindicated or unavailable, consider these alternatives in order of evidence strength:
- Haloperidol (antipsychotic with similar mechanism) 4, 5
- Benzodiazepines (lorazepam or diazepam) 4, 6
- Topical capsaicin 0.1% cream 4
- Olanzapine 4
Avoid opioids entirely as they worsen nausea and carry high addiction risk in this population. 4, 7
Practical Implementation
- Obtain baseline ECG if feasible before first dose 3
- Correct electrolyte abnormalities (potassium, magnesium) prior to administration 3
- Reduce dosage in patients with renal or hepatic dysfunction 2
- Expect discharge readiness approximately 137 minutes after final droperidol dose 1
The evidence strongly supports droperidol as highly effective for acute CHS management, with the 0.625 mg IV dose providing optimal balance between efficacy and safety. 1