Cannabinoid hyperemesis relieved by compulsive bathing

The safety of studies with intravenous Δ⁹-tetrahydrocannabinol in humans, with case histories

RATIONALE

Delta-9-tetrahydrocannabinol (THC) is one of the few cannabinoid receptor ligands that can be used to probe the cannabinoid system in humans. Despite increasing interest in the cannabinoid receptor system, use of intravenous THC as a research tool has been limited by concerns about its abuse liability and psychoactive effects.

OBJECTIVES

This study aims to evaluate the safety of all intravenous THC studies conducted at this center for the past 13 years.

METHODS

Included were 11 studies with 266 subjects (14 schizophrenia patients and 252 healthy subjects, of whom 76 were frequent cannabis users), 351 active THC infusions, and 226 placebo infusions. Subjects were monitored for subjective and physical adverse events and followed up to 12 months beyond study participation.

RESULTS

There was one serious and 70 minor adverse events in 9.7% of subjects and 7.4% of infusions, with 8.5% occurring after the end of the test day. Nausea and dizziness were the most frequent side effects. Adverse events were more likely to be associated with faster infusion rates (2-5 min) and higher doses (>2.1 mg/70 kg). Of 149 subjects on whom long-term follow-up data were gathered, 94% reported either no change or a reduction in their desire to use cannabis in the post-study period, 18% stated that their cannabis use decreased, and 3% stated that it increased in the post-study period.

CONCLUSIONS

With careful subject selection and screening, risk to subjects is relatively low. Safeguards are generally sufficient and effective, reducing both the duration and severity of adverse events.

Cannabinoid hyperemesis: a case series of 98 patients

OBJECTIVE

To promote wider recognition and further understanding of cannabinoid hyperemesis (CH).

PATIENTS AND METHODS

We constructed a case series, the largest to date, of patients diagnosed with CH at our institution. Inclusion criteria were determined by reviewing all PubMed indexed journals with case reports and case series on CH. The institution's electronic medical record was searched from January 1, 2005, through June 15, 2010. Patients were included if there was a history of recurrent vomiting with no other explanation for symptoms and if cannabis use preceded symptom onset. Of 1571 patients identified, 98 patients (6%) met inclusion criteria.

RESULTS

All 98 patients were younger than 50 years of age. Among the 37 patients in whom duration of cannabis use was available, most (25 [68%]) reported using cannabis for more than 2 years before symptom onset, and 71 of 75 patients (95%) in whom frequency of use was available used cannabis more than once weekly. Eighty-four patients (86%) reported abdominal pain. The effect of hot water bathing was documented in 57 patients (58%), and 52 (91%) of these patients reported relief of symptoms with hot showers or baths. Follow-up was available in only 10 patients (10%). Of those 10, 7 (70%) stopped using cannabis and 6 of these 7 (86%) noted complete resolution of their symptoms.

CONCLUSION

Cannabinoid hyperemesis should be considered in younger patients with long-term cannabis use and recurrent nausea, vomiting, and abdominal pain. On the basis of our findings in this large series of patients, we propose major and supportive criteria for the diagnosis of CH.

Cannabinoid hyperemesis syndrome

Coinciding with the increasing rates of cannabis abuse has been the recognition of a new clinical condition known as Cannabinoid Hyperemesis Syndrome. Cannabinoid Hyperemesis Syndrome is characterized by chronic cannabis use, cyclic episodes of nausea and vomiting, and frequent hot bathing. Cannabinoid Hyperemesis Syndrome occurs by an unknown mechanism. Despite the well-established anti-emetic properties of marijuana, there is increasing evidence of its paradoxical effects on the gastrointestinal tract and CNS. Tetrahydrocannabinol, cannabidiol, and cannabigerol are three cannabinoids found in the cannabis plant with opposing effects on the emesis response. The clinical course of Cannabinoid Hyperemesis Syndrome may be divided into three phases: prodromal, hyperemetic, and recovery phase. The hyperemetic phase usually ceases within 48 hours, and treatment involves supportive therapy with fluid resuscitation and anti-emetic medications. Patients often demonstrate the learned behavior of frequent hot bathing, which produces temporary cessation of nausea, vomiting, and abdominal pain. The broad differential diagnosis of nausea and vomiting often leads to delay in the diagnosis of Cannabinoid Hyperemesis Syndrome. Cyclic Vomiting Syndrome shares several similarities with CHS and the two conditions are often confused. Knowledge of the epidemiology, pathophysiology, and natural course of Cannabinoid Hyperemesis Syndrome is limited and requires further investigation.

Cannabinoid hyperemesis syndrome: literature review and proposed diagnosis and treatment algorithm

Cannabinoid hyperemesis syndrome (CHS) is characterized by cyclic vomiting and compulsive bathing behaviors in chronic cannabis users. Patients are typically diagnosed with CHS only after multiple and extensive medical evaluations, consequently without a clear etiology of their symptoms or treatment plan leading to symptomatic improvement. Increased healthcare provider awareness of CHS as a cause of nausea, vomiting, and abdominal pain coupled with an attentiveness to focused history taking-especially noting symptomatic improvement with prolonged exposure to hot showers or baths-can lead to effective treatment through cannabis cessation. We propose a diagnosis and treatment algorithm for physicians to follow when evaluating patients presenting with nausea, vomiting, and abdominal pain who are suspected to suffer from CHS.

Cannabinoid hyperemesis syndrome: an underreported entity causing nausea and vomiting of pregnancy

INTRODUCTION

In the western world, cannabis is the most widely used drug of abuse. Cannabinoid hyperemesis syndrome, which seems to be a rare paradoxical reaction in individuals with a particular predisposition, is characterized by cyclic severe nausea and vomiting in long-term cannabis users. While the symptoms are unresponsive to antiemetic drugs, compulsive hot baths result in a considerable symptom relief.

METHODS

We report the first case of cannabinoid hyperemesis syndrome in pregnancy. A 26-year-old patient was admitted to our clinic in the 10th week of gestation.

CONCLUSION

Before undertaking time-consuming and expensive medical examinations to rule out other medical reasons for therapy-resistant hyperemesis in pregnancy, obstetricians should determine whether compulsive bathing or showering provides symptomatic relief and ask specific questions regarding possible/suspected cannabis consumption.

Pediatric cannabinoid hyperemesis: two cases

Cannabinoid hyperemesis has recently been described in the literature. It is a syndrome characterized by severe nausea and hyperemesis in the setting of chronic marijuana abuse and, to date, has been described only in adults. We describe the syndrome in 2 pediatric patients, for whom extensive gastrointestinal workups failed to identify a clear cause and cessation of marijuana use resulted in the alleviation of their symptoms. As in most published adult cases, compulsive bathing was present in both of these cases.

The cannabis hyperemesis syndrome characterized by persistent nausea and vomiting, abdominal pain, and compulsive bathing associated with chronic marijuana use: a report of eight cases in the United States

GOALS/BACKGROUND

The cannabis hyperemesis syndrome, which is associated with chronic cannabis use, was recently reported in seven case reports and one clinical series of ten patients from Australia. We further characterize this syndrome with eight well-documented cases in the United States and report results of cannabis discontinuation and cannabis rechallenge.

STUDY METHODS

Patients were identified by the three investigators in gastroenterology clinic or inpatient wards at William Beaumont Hospital from January to August 2009 based on chronic cannabis use; otherwise unexplained refractory, recurrent vomiting; and compulsive bathing. Charts were retrospectively analyzed with follow-up data obtained from subsequent physician visits and patient interviews.

RESULTS

The eight patients on average were 32.4 ± 4.1 years old. Five were male. The mean interval between the onset of cannabis use and development of recurrent vomiting was 19.0 ± 3.7 years. Patients had a mean of 7.1 ± 4.3 emergency room visits, 5.0 ± 2.7 clinic visits, and 3.1 ± 1.9 admissions for this syndrome. All patients had visited at least one other hospital in addition to Beaumont Hospital. All patients had vomiting (mean vomiting episodes every 3.0 ± 1.7 h), compulsive bathing (mean = 5.0 ± 2.0 baths or showers/day; mean total bathing time = 5.0 ± 5.1 h/day), and abdominal pain. Seven patients took hot baths or showers, and seven patients experienced polydipsia. Four out of five patients who discontinued cannabis use recovered from the syndrome, while the other three patients who continued cannabis use, despite recommendations for cessation, continued to have this syndrome. Among those four who recovered, one patient had recurrence of vomiting and compulsive bathing with cannabis resumption.

CONCLUSIONS

Cannabis hyperemesis is characterized by otherwise unexplained recurrent nausea and vomiting, compulsive bathing, abdominal pain, and polydipsia associated with chronic cannabis use. This syndrome can occur in the United States as well as in Australia. Cannabis cessation may result in complete symptomatic recovery.

Cannabinoid-Induced Hyperemesis: A Conundrum-From Clinical Recognition to Basic Science Mechanisms

Cannabinoids are used clinically on a subacute basis as prophylactic agonist antiemetics for the prevention of nausea and vomiting caused by chemotherapeutics. Cannabinoids prevent vomiting by inhibition of release of emetic neurotransmitters via stimulation of presynaptic cannabinoid CB₁ receptors. Cannabis-induced hyperemesis is a recently recognized syndrome associated with chronic cannabis use. It is characterized by repeated cyclical vomiting and learned compulsive hot water bathing behavior. Although considered rare, recent international publications of numerous case reports suggest the contrary. The syndrome appears to be a paradox and the pathophysiological mechanism(s) underlying the induced vomiting remains unknown. Although some traditional hypotheses have already been proposed, the present review critically explores the basic science of these explanations in the clinical setting and provides more current mechanisms for the induced hyperemesis. These encompass: (1) pharmacokinetic factors such as long half-life, chronic exposure, lipid solubility, individual variation in metabolism/excretion leading to accumulation of emetogenic cannabinoid metabolites, and/or cannabinoid withdrawal; and (2) pharmacodynamic factors including switching of the efficacy of Δ⁸-THC from partial agonist to antagonist, differential interaction of Δ⁸-THC with Gs and Gi signal transduction proteins, CB₁ receptor desensitization or downregulation, alterations in tissue concentrations of endocannabinoid agonists/inverse agonists, Δ⁸-THC-induced mobilization of emetogenic metabolites of the arachidonic acid cascade, brainstem versus enteric actions of Δ⁸-THC, and/or hypothermic versus hyperthermic actions of Δ⁸-THC. In addition, human and animal findings suggest that chronic exposure to cannabis may not be a prerequisite for the induction of vomiting but is required for the intensity of emesis.

Cannabinoids and the gut: new developments and emerging concepts

Cannabis has been used to treat gastrointestinal (GI) conditions that range from enteric infections and inflammatory conditions to disorders of motility, emesis and abdominal pain. The mechanistic basis of these treatments emerged after the discovery of Delta(9)-tetrahydrocannabinol as the major constituent of Cannabis. Further progress was made when the receptors for Delta(9)-tetrahydrocannabinol were identified as part of an endocannabinoid system, that consists of specific cannabinoid receptors, endogenous ligands and their biosynthetic and degradative enzymes. Anatomical, physiological and pharmacological studies have shown that the endocannabinoid system is widely distributed throughout the gut, with regional variation and organ-specific actions. It is involved in the regulation of food intake, nausea and emesis, gastric secretion and gastroprotection, GI motility, ion transport, visceral sensation, intestinal inflammation and cell proliferation in the gut. Cellular targets have been defined that include the enteric nervous system, epithelial and immune cells. Molecular targets of the endocannabinoid system include, in addition to the cannabinoid receptors, transient receptor potential vanilloid 1 receptors, peroxisome proliferator-activated receptor alpha receptors and the orphan G-protein coupled receptors, GPR55 and GPR119. Pharmacological agents that act on these targets have been shown in preclinical models to have therapeutic potential. Here, we discuss cannabinoid receptors and their localization in the gut, the proteins involved in endocannabinoid synthesis and degradation and the presence of endocannabinoids in the gut in health and disease. We focus on the pharmacological actions of cannabinoids in relation to GI disorders, highlighting recent data on genetic mutations in the endocannabinoid system in GI disease.

Cannabinoid hyperemesis syndrome: Clinical diagnosis of an underrecognised manifestation of chronic cannabis abuse

Cannabis is a common drug of abuse that is associated with various long-term and short-term adverse effects. The nature of its association with vomiting after chronic abuse is obscure and is underrecognised by clinicians. In some patients this vomiting can take on a pattern similar to cyclic vomiting syndrome with a peculiar compulsive hot bathing pattern, which relieves intense feelings of nausea and accompanying symptoms. In this case report, we describe a twenty-two year-old-male with a history of chronic cannabis abuse presenting with recurrent vomiting, intense nausea and abdominal pain. In addition, the patient reported that the hot baths improved his symptoms during these episodes. Abstinence from cannabis led to resolution of the vomiting symptoms and abdominal pain. We conclude that in the setting of chronic cannabis abuse, patients presenting with chronic severe nausea and vomiting that can sometimes be accompanied by abdominal pain and compulsive hot bathing behaviour, in the absence of other obvious causes, a diagnosis of cannabinoid hyperemesis syndrome should be considered.