fbpx

Charleston, SC

jimmy@pharmacyfridaypeals.com

Cannabinoid Hyperemesis Syndrome (CHS)

Introduction 

1. Commonly identified as symptoms, including nausea, cyclic vomiting and abdominal pain, that are refractory  to available antiemetics and analgesics.  

2. Patients tend to take compulsive hot baths/showers for symptom relief. 

3. Characteristically distinguished from cyclic vomiting syndrome, these symptoms are usually preceded by years  of chronic cannabis use and symptoms are typically resolved with cessation of cannabis use 

4. Patients often present with severe abdominal pain. Opioids should be avoided for analgesic pain if CHS is  suspected as it may induce/worsen nausea and vomiting symptoms  

Pharmacology

Capsaicin Haloperidol Benzodiazepines
Mechanism Hot water stimulates a G-protein  coupled receptor on peripheral tissue, transient receptor potential vanilloid-1  (TRPV1), that interacts with  endocannabinoid system causing  relief of nausea and vomiting. This is  the only known capsaicin receptor.Postsynaptic dopaminergic  blockade at D2 receptors in the  gastrointestinal tract and the  chemoreceptor trigger zoneStimulation of inhibitory  neurotransmitter gamma aminobutyric acid (GABA) to  reduce anticipation of  nausea and vomiting.  Additionally, decreased  activation of the cannabinoid  type receptor 1 (CB1)  receptor in the frontal cortex.
Dose 0.075%: 3-4 times per day1-5mg Doses from 1 – 2.5mg are often enough  for symptom improvement and should  be tried first Clonazepam 0.5mg *other benzos are likely  appropriate too
AdministrationTopical application to abdomen or  back of arms (prioritize treatment to a  certain area in which hot water  provides symptom reliefIV, PO PO, ODT
Formulations (recommended  for use)Topical Cream 0.075% IV, PO PO, ODT
Adverse Effects Burning/uncomfortable on skin on  initial applicationExtrapyramidal reaction (low risk) Drowsiness, confusion,  respiratory depression
Drug  Interactions and  warningsBurns and CNS depression are possible Avoid touching eyes mouth and  genitalsCaution use in psychiatric disorders QT prolonging agentCaution in hepatic/renal  dysfunction
THE ONLY CURRENT DEFINITIVE TREATMENT IS CESSATION OF CANNABIS USE
Standard of care prophylaxis and treatment of nausea/vomiting should be provided prior to ruling ineffective  and moving on to above therapies

Overview of Evidence

Author, year Design/  sample size Intervention & Comparison Outcome
Inayat 2016Case Report  N =1 • Haloperidol 1-2mg IV No relief of symptoms at 2 days with ondansetron,  lorazepam and IV hydration. Patient responded to 1mg IV  haloperidol with decreased gastrointestinal symptoms and  compulsive hot bathing. Subsequent doses of 2mg were  given.
Jones  2016Case Report N=1 • Haloperidol 5mg PO dailyTreated in the outpatient setting with oral haloperidol 5mg  daily. Symptom relief was reported after 1 day of  haloperidol use. Patient self-discontinued after 3 weeks  without recurrence of symptoms but unable to determine  how long this effect lasted due to patient being lost to follow  up 
Witsil 2017Case Series N=4 • Haloperidol 5mg IVAll 4 patients failed standard of care therapy. All were given  a dose of haloperidol 5mg IV with reported resolution of  nausea and vomiting within 1-2 hours. 
Dezieck  2017Case series N=13 • Topical CapsaicinAll 13 patients, who used cannabis daily, experienced relief  of symptoms with topical capsaicin cream in the  emergency department when other standard treatments  failed to provide relief from nausea/vomiting 
Moon 2018Case Report N =1 • Topical Capsaicin 0.075% Failed treatment of: ondansetron, metoclopramide, and  prochlorperazine. 0.075% capsaicin cream applied to  periumbilical region, repeated every 4 hours. Complete  resolution of symptoms was seen after 3 doses. 
Kheifets 2019Case Series N=4 • Clonazepam 0.5mg PO q8hAll 4 patients were refractory to conventional IV antiemetics.  2 patients used cannabis chronically on a weekly basis and  2 patients on a daily basis. Patients were treated with  clonazepam 0.5mg PO q8h. 2 patients had symptom relief  after 1 dose and 2 patients within 24 hours. 
In the works HaVOC trialProspective N= estimate 80• Haloperidol 0.05mg/kg IV • Haloperidol 0.1mg/kg IV • Ondansetron 8mg IVResults pending

References 

– Micromedex [Electronic].Greenwood Village, CO: Truven Health Analytics.  . Retrieved July 19, 2019 from http://www.micromedexsolutions.com/  – Lapoint J, et al. West J Emerg Med. 2018;19(2):380-86. 

– Sorensen CJ, et al. J. Med. Toxicol. 2017;13:71-87. 

– Venatesan T, et al. Neurogastroenterology & Motility. 2019; 31(Suppl. 2): e13606. 

– Galli JA, et al. Curr Drug Abuse Rev. 2011;4(4):241-49. 

– Moon AM, et al. ACG Case Rep J. 2018; 5:e3. 

– Dezieck L, et al. Clin Toxicol (Phila). 2017;55(8):908-13.

– Inayat F, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2016-21823.

– Jones JL, et al. Case Reports in Psychiatry. 2016. doi:10.1155/2016/3614053.

– Kheifets M, et al. IMAJ. 2019;21:404-7.

SHARE:

Share on facebook
Share on twitter
Share on linkedin
Share on whatsapp

Subscribe to our Newsletter

Want to learn more?

Join PHARMACY & ACUTE CARE UNIVERSITY

An e-learning platform that empowers healthcare providers with knowledge and skills so they can provide evidence-based, safe care for these types of patients.

Subscribe to our Newsletter

Be the first to read our articles and updates

GET IN TOUCH