What is the diagnosis and treatment for Hyperemesis Cannabinoid Syndrome (Cannabinoid Hyperemesis Syndrome)?

From the Guidelines

The only definitive treatment for hyperemesis cannabinoid syndrome is complete cessation of cannabis use, with resolution of symptoms after a period of abstinence for at least 6 months, or at least equal to the total duration of 3 typical vomiting cycles in that patient. This is based on the most recent evidence from the 2024 study published in Gastroenterology 1. The management of hyperemesis cannabinoid syndrome involves a multi-faceted approach, including:

• Symptom management during acute episodes with IV fluids, anti-emetic medications such as ondansetron, and hot showers or baths
• Use of topical capsaicin cream (0.1%) to improve symptoms by activation of transient receptor potential vanilloid type 1 receptors
• Avoidance of opioids due to worsening of nausea and high risk of addiction
• Counseling to achieve marijuana cessation and consideration of tricyclic antidepressants, such as amitriptyline, for long-term management, with a minimal effective dose of 75-100 mg at bedtime.

It is essential to note that the clinical approach in the emergency department (ED) is different, requiring immediate evaluation for life-threatening disorders, such as acute abdomen, bowel obstruction, mesenteric ischemia, pancreatitis, and myocardial infarction, among others 1. In the outpatient setting, differential diagnosis includes rumination syndrome, gastroparesis, CVS, pregnancy, migraine, and functional chronic nausea and vomiting syndrome. The phases of cyclical vomiting syndrome, as described by Fleisher et al, include prodromal, interepisodic, emetic, and recovery phases 1.

Co-management with a psychologist or psychiatrist may be helpful for patients who have a lack of response to standard therapies or extensive psychiatric comorbidity, as anxiety and depression are common associated conditions 1. Combining evidence-based psychosocial interventions and pharmacology may be necessary for successful long-term management of CHS. However, it is crucial to prioritize complete cessation of cannabis use as the primary treatment goal, as supported by the most recent and highest quality evidence 1.

From the Research

Definition and Characteristics of Hyperemesis Cannabinoid Syndrome

• Hyperemesis cannabinoid syndrome (CHS) is a condition characterized by cyclic vomiting, abdominal pain, and alleviation of symptoms via hot showers in chronic cannabinoid users 2, 3, 4.
• The syndrome is often preceded by daily to weekly cannabis use and is usually accompanied by symptom improvement with hot bathing 2.
• The frequency of major characteristics includes: history of regular cannabis use (100%), cyclic nausea and vomiting (100%), resolution of symptoms after stopping cannabis (96.8%), compulsive hot baths with symptom relief (92.3%), male predominance (72.9%), abdominal pain (85.1%), and at least weekly cannabis use (97.4%) 2.

Pathophysiology of Hyperemesis Cannabinoid Syndrome

• The pathophysiology of CHS remains unclear, with a dearth of research dedicated to investigating its underlying mechanism 2, 3.
• Prolonged high-dose cannabis use may disrupt the normal functioning of the endocannabinoid system, leading to changes in stress and anxiety responses, thermoregulation, and neurotransmitter systems 3.
• The endocannabinoid system changes can dysregulate stress and anxiety responses, thermoregulation, the transient receptor potential vanilloid system, and several neurotransmitter systems, which are potential candidates for mediating the pathophysiology of CHS 3.

Treatment Options for Hyperemesis Cannabinoid Syndrome

• Cannabis cessation appears to be the best treatment for CHS, with supportive care including intravenous fluids, dopamine antagonists, topical capsaicin cream, and avoidance of narcotic medications showing some benefit in the acute setting 2, 4.
• Other treatments that have demonstrated symptom relief include hot water hydrotherapy, haloperidol, droperidol, benzodiazepines, propranolol, and aprepitant administration 4.
• Capsaicin has been recommended as a reasonable first-line treatment approach for CHS, despite limited clinical evidence regarding its use 5.
• Benzodiazepines, followed by haloperidol and capsaicin, were most frequently reported as effective for acute treatment, and tricyclic antidepressants for long-term treatment 6.