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
|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 zone||Stimulation 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 day||1-5mg 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|
|Administration||Topical application to abdomen or back of arms (prioritize treatment to a certain area in which hot water provides symptom relief||IV, PO||PO, ODT|
|Formulations (recommended for use)||Topical Cream 0.075%||IV, PO||PO, ODT|
|Adverse Effects||Burning/uncomfortable on skin on initial application||Extrapyramidal reaction (low risk)||Drowsiness, confusion, respiratory depression|
|Drug Interactions and warnings||Burns and CNS depression are possible Avoid touching eyes mouth and genitals||Caution use in psychiatric disorders QT prolonging agent||Caution in hepatic/renal dysfunction|
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 2016||Case 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 2016||Case Report N=1||• Haloperidol 5mg PO daily||Treated 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 2017||Case Series N=4||• Haloperidol 5mg IV||All 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 2017||Case series N=13||• Topical Capsaicin||All 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 2018||Case 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 2019||Case Series N=4||• Clonazepam 0.5mg PO q8h||All 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 trial||Prospective N= estimate 80||• Haloperidol 0.05mg/kg IV • Haloperidol 0.1mg/kg IV • Ondansetron 8mg IV||Results pending|
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– 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.