From the Guidelines
Cannabis hyperemesis syndrome (CHS) is a chronic disorder that requires complete cessation of cannabis use for effective management, with supportive care including intravenous fluids, antiemetics, and topical capsaicin cream during acute episodes. The condition is characterized by recurrent episodes of severe nausea, persistent vomiting, and abdominal pain in long-term cannabis users 1. CHS is often misdiagnosed as cyclic vomiting syndrome or other gastrointestinal disorders, but the history of chronic cannabis use and temporary relief with hot showers are distinctive diagnostic features.
Diagnostic Criteria
Diagnostic criteria for CHS are based on clinical features, cannabis use patterns, and resolution of symptoms after cannabis cessation 1. The condition is often underdiagnosed, and further understanding of CHS pathophysiology and evidence-based therapies are urgently needed 1.
Management
Management of CHS includes supportive care during acute episodes, such as intravenous fluids for dehydration, antiemetics like ondansetron 4-8mg every 8 hours or promethazine 12.5-25mg every 6 hours, and hot showers or baths 1. Topical capsaicin cream (0.1%) applied to the abdomen can also help reduce symptoms 1. Benzodiazepines like lorazepam 1-2mg may be used for severe cases. For long-term management, counseling to achieve marijuana cessation and tricyclic antidepressants, such as amitriptyline, are the mainstay of therapy, with the minimal effective dose being 75–100 mg at bedtime 1.
Key Considerations
- Opioids should be avoided due to worsening of nausea and high risk of addiction 1.
- The clinical approach in the emergency department requires immediate evaluation for life-threatening disorders 1.
- Differential diagnosis in the outpatient setting includes rumination syndrome, gastroparesis, cyclic vomiting syndrome, pregnancy, migraine, and functional chronic nausea and vomiting syndrome 1.
From the Research
Definition and Symptoms of Cannabis Hyperemesis Syndrome
- Cannabis hyperemesis syndrome (CHS) is a condition that arises in some adolescents and adults who chronically use cannabis, presenting with intractable nausea, vomiting, and abdominal pain 2.
- The Rome IV diagnostic criteria of CHS require cannabinoid use and persistence of nausea and vomiting symptoms for at least the past 6 months 3.
Treatment Options for Cannabis Hyperemesis Syndrome
- Cannabis cessation is noted to be the most successful management of CHS, but other treatments also demonstrated symptom relief, including:
Efficacy of Different Treatments
- Haloperidol was found to be superior to ondansetron in alleviating the acute symptoms of CHS in a randomized controlled trial 6.
- A case series of 6 adolescent patients with CHS found that haloperidol, lorazepam, and/or capsaicin appeared safe and effective in adolescents, but larger studies are required to confirm these findings 2.
- Benzodiazepines, followed by haloperidol and capsaicin, were most frequently reported as effective for acute treatment, and tricyclic antidepressants for long-term treatment 4.