Intravenous Haloperidol Versus Ondansetron for Cannabis Hyperemesis Syndrome (HaVOC): A Randomized, Controlled Trial

The Incidence of Torsades de Pointes With Perioperative Triple Antiemetic Administration

BACKGROUND

The safety of triple antiemetic therapy consisting of ondansetron, haloperidol, and a steroid, to surgical patients is unknown.

OBJECTIVE

To determine the incidence of torsade de pointes (TdP) or death following perioperative administration of triple antiemetic therapy.

METHODS

A retrospective cohort study identified 19,874 patients who received 22,202 doses of triple antiemetics during the 2.5-year time frame from March 4, 2020 to September 7, 2022 for surgical nausea prophylaxis or treatment of nausea. These patients above were cross-matched with an electrocardiogram and adverse outcome database; this identified 226 patients with documentation of a QTc > 450 ms, all ventricular tachycardias including TdP within 48 hours of receiving triple antiemetic therapy, or death within 7 days of receiving ondansetron.

RESULTS

There were 3 patients who had documented VT (n = 3), but there were no documented incidents of TdP (n = 0). There were 9 codes called on patients within 48 hours of medication administration, and none of them were due to ventricular arrythmias (n = 0). A total of 11 patients died within 7 days of triple antiemetic therapy. Ten of the 11 deaths were determined to not be from the triple antiemetic. One patient died at home within 24 hours of the procedure of an unknown cause (n = 1).

CONCLUSIONS AND RELEVANCE

No episodes of TdP were identified in patients receiving triple antiemetic therapy perioperatively, though the cause of death in 1 patient could not be determined. This suggest that low-dose triple antiemetic therapy is low risk for the development of TdP.

Cannabis use patterns and association with hyperemesis: A comprehensive review

BACKGROUND

Cannabis use in the general population is prevalent and is rising because of increased acceptance of its use, legalization in most US states, and perceived health benefits. Cannabis product potency has dramatically increased with higher delta-9-tetrahydrocannabinol content. Cannabis has documented antiemetic properties and cannabinoid pharmaceuticals are used in disorders like chemotherapy-induced nausea and vomiting.

PURPOSE

Forty to eighty percent of cyclic vomiting syndrome (CVS) patients use cannabis products, which reportedly reduce stress as well as nausea and vomiting. Cannabinoid hyperemesis syndrome (CHS) has a presentation similar to CVS, but is associated with longstanding, high dose cannabis use, and is thought to be relieved by sustained cannabis abstinence. Most CHS patients have used cannabis on a daily or near-daily basis for more than 2 years. Compulsive hot-water bathing behaviors are reported by most CHS patients, but are not specific for this disorder as they are also noted by about half of CVS patients. Episodic vomiting associated with cannabis use contributes to extensive health resource use, including emergency department visits and inpatient hospitalizations, and impacts patients and their families negatively. Treatment for CHS overlaps with CVS although cannabis abstinence remains the cornerstone of its management. Challenges associated with cannabis use cessation in CHS include patient skepticism of the role of cannabis as a cause of symptoms, perceived benefits of cannabis, and a lack of other effective therapies. In this review, we highlight cannabis use patterns in the US and discuss diagnosis and management of CHS and gaps in knowledge about this disorder.

Distinguishing Clinical Features of Cannabinoid Hyperemesis Syndrome and Cyclic Vomiting Syndrome: A Retrospective Cohort Study

OBJECTIVE

To identify clinical characteristics that distinguish cannabinoid hyperemesis syndrome (CHS) from cyclic vomiting syndrome (CVS), 2 conditions marked by episodes of nausea, vomiting, and abdominal pain.

STUDY DESIGN

We performed a retrospective chart review of patients admitted to a large children's health care system from 2015 through 2022. Patients with CHS and CVS were identified by the electronic medical record using International Classification of Diseases, Ninth and Tenth Revision codes.

RESULTS

Of 201 patients screened, 125 were included. Patients with CHS were older than those with CVS (mean [SD] 18.06 [1.41] vs 14.50 [2.91] years, P < .001). There were no significant differences in sex, race, ethnicity, or hospital length of stay between groups. Patients with CHS were more likely to have a positive urine drug screen (86% vs 2.9%, P < .001), lower mean (SD) serum potassium (3.62 [0.77] vs 3.88 [0.49], P < .001), and greater mean (SD) serum creatinine (0.83 (0.41) vs 0.63 (0.17), P < .001). The average (SD) systolic blood pressure was significantly greater in patients with CHS (systolic blood pressure 124.46 [10.66] vs 118.55 [10.99], P = .032) compared with children of comparable age range with CVS. Imaging was obtained in 36% of all patients, and only 2.4% had abnormalities.

CONCLUSIONS

Clinical features including older age, greater systolic blood pressure, positive urine drug screen, and select electrolyte findings might distinguish CHS from CVS. Abdominal imaging in both conditions is of low yield. These findings may allow for early recognition and appropriate therapy in CHS patients.

SAEM GRACE: Dopamine antagonists and topical capsaicin for cannabis hyperemesis syndrome in the emergency department: A systematic review of direct evidence

BACKGROUND

Adults with cannabis hyperemesis syndrome (CHS) are increasingly presenting to the emergency department (ED), and this systematic review will evaluate the direct evidence on the effectiveness of capsaicin and dopamine antagonists in its clinical management.

METHODS

A bibliographic search was conducted to address the following population-intervention-control-outcome (PICO) question: (P) adults >18 years old with a diagnosis of acute CHS presenting to the ED; (I) dopamine antagonists (e.g., haloperidol, droperidol) and topical capsaicin; (C) usual care or no active comparator; and (O) symptoms improvement/resolution in ED, ED length of stay, admission rate, ED recidivism, need for rescue medication, and adverse events. This systematic review was conducted in accordance with PRISMA reporting recommendations.

RESULTS

From 53 potentially relevant articles, seven articles were included: five observational studies and two randomized controlled trials, including a total of 492 patients. Five of these studies evaluated the efficacy of capsaicin cream (n = 386), and two examined dopamine antagonists (haloperidol, droperidol; n = 106). There was mixed evidence for the efficacy of capsaicin for reducing nausea and emesis. Both studies evaluating dopamine antagonists detected clinical benefit to usual care or no active comparator.

CONCLUSIONS

There is limited direct evidence on the efficacy of dopamine antagonists or capsaicin for treating CHS in the ED. Current evidence is mixed for capsaicin and potentially beneficial for dopamine antagonists. Because of the small number of studies, small number of participants, lack of standardization of treatment administration, and risk of bias of the included studies, methodologically rigorous trials on both types of intervention are needed to directly inform ED management of CHS.

AGA Clinical Practice Update on Diagnosis and Management of Cannabinoid Hyperemesis Syndrome: Commentary

DESCRIPTION

The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update (CPU) is to review the available evidence and provide expert advice regarding diagnosis and management of cannabinoid hyperemesis syndrome.

METHODS

This CPU was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPUC and external peer review through standard procedures of Gastroenterology. This expert commentary incorporates important as well as recently published studies in this field, and it reflects the experiences of the authors.

RCEM best practice guideline: suspected cannabinoid hyperemesis syndrome in emergency departments

Cannabinoid hyperemesis syndrome (CHS) is an episodic syndrome of cyclic vomiting in the context of the prolonged use of cannabis. The Royal College of Emergency Medicine Toxicology Special Interest Group has produced guidance to support emergency medicine clinicians with the recognition and treatment of people experiencing CHS.Considerations regarding recognition, investigation and communication are discussed, and recommendations regarding treatment options (which include haloperidol and capsaicin) are made. There is a focus on making recommendations on the best available evidence.

Cannabinoid hyperemesis syndrome in pregnancy: Challenges and opportunities

Antenatal cannabis consumption is common and associated with adverse perinatal outcomes, including low birthweight, pre-term birth and increased rates of admission to neonatal intensive care. Cannabinoid hyperemesis syndrome (CHS) comprises severe, cyclical episodes of vomiting, intractable nausea and abdominal pain observed in chronic cannabis users. CHS, particularly during pregnancy, poses a diagnostic dilemma with a tendency to be ineffectively managed secondary to reduced clinician awareness and a scarcity of available therapies. This clinical perspective explores the current literature on CHS in pregnancy, available pharmacotherapeutics, and recognises the current barriers to improving clinical care.

Acute Treatment of Adolescent Cannabinoid Hyperemesis Syndrome With Haloperidol, Lorazepam, and/or Capsaicin: A Single Institution Case Series

Cannabinoid hyperemesis syndrome (CHS), an under-recognized and seemingly paradoxical condition, arises in some adolescents and adults who chronically use cannabis. It presents acutely with intractable nausea, vomiting, and abdominal pain but standard antiemetic therapy leads to improvement for only a minority of patients. Randomized controlled trial evidence in adults indicates the superiority of haloperidol over ondansetron in alleviating the acute symptoms of CHS, but safe and effective treatment for adolescents with the disorder is currently unknown. The successful use of topical capsaicin has also been reported. We report a case series of 6 adolescent patients with CHS who presented to Johns Hopkins All Children's Hospital and were treated with haloperidol, lorazepam, and/or capsaicin. Four patients given 5 mg intravenous (IV) haloperidol and 2 mg IV lorazepam and 1 patient treated with 5 mg IV haloperidol and peri-umbilical topical capsaicin (0.025%) experienced full acute symptomatic relief. One patient, treated only with topical capsaicin, reported improvement of symptoms with some persistent nausea. Haloperidol/lorazepam, haloperidol/capsaicin, and topical capsaicin alone appear safe and effective in adolescents, but larger studies are required to confirm our findings.

Cannabis Hyperemesis Syndrome in a Young Patient: A Case Report and Literature Review

Cannabis hyperemesis syndrome (CHS) is a condition characterized by recurrent episodes of severe vomiting, abdominal pain, and intractable nausea in chronic cannabis users. With the legalization of recreational marijuana in many states, awareness of CHS is crucial to prevent delayed diagnosis or misdiagnosis. This case report presents a 25-year-old male with a history of type 1 diabetes mellitus and chronic cannabis use who presented to the emergency department with vomiting and epigastric pain. Our literature review sheds light on existing treatment options for this syndrome and gives future direction for research.

Should gastroenterologists prescribe cannabis? The highs, the lows and the unknowns

Cannabis, commonly known as marijuana, is a drug extracted from the Cannabis plant known for its psychotropic and medicinal properties. It has been used for healing purposes during ancient times, although its psychoactive components led to its restricted use in medicine. Nonetheless, cannabis is found to have modulatory effects on the endocannabinoid system exhibiting its medicinal role in the gastrointestinal (GI) system. Emerging animal and human studies demonstrate the influential effects of cannabis on a variety of GI diseases including inflammatory bowel disease, motility disorders and GI malignancies. It also has a regulatory role in GI symptoms including nausea and vomiting, anorexia, weight gain, abdominal pain, among others. However, both its acute and chronic use can lead to undesirable side effects such as dependency and addiction, cognitive impairment and cannabinoid hyperemesis syndrome. We will discuss the role of cannabis in the GI system as well as dosing strategies to help guide gastroenterologists to assess its efficacy and provide patient counseling before prescription of medical marijuana.

Cyclic Vomiting Syndrome and Cannabis Hyperemesis Syndrome: The State of the Science

This article provides a narrative review of the state of the science for both cyclic vomiting syndrome and cannabis hyperemesis syndrome along with a discussion of the relationship between these 2 conditions. The scope of this review includes the historical context of these conditions as well as the prevalence, diagnostic criteria, pathogenesis, and treatment strategies for both conditions. A synopsis of the endocannabinoid system provides a basis for the hypothesis that a lack of cannabidiol in modern high-potency Δ 9 -tetrahydrocannabinol cannabis may be contributory to cannabis hyperemesis syndrome and possibly other cannabis use disorders. In concluding assessment, though the publications addressing both adult cyclic vomiting syndrome and cannabis hyperemesis syndrome are steadily increasing overall, the state of the science supporting the treatments, prognosis, etiology, and confounding factors (including cannabis use) is of moderate quality. Much of the literature portrays these conditions separately and as such sometimes fails to account for the confounding of adult cyclic vomiting syndrome with cannabis hyperemesis syndrome. The diagnostic and therapeutic approaches are, at present, based generally on case series publications and expert opinion, with a very limited number of randomized controlled trials and a complete absence of Level 1 evidence within the cyclic vomiting literature overall as well as for cannabis hyperemesis syndrome specifically.

Paediatric cannabinoid hyperemesis

PURPOSE OF REVIEW

The prevalence of adolescent cannabinoid hyperemesis syndrome (CHS) continues to grow, as clinicians increasingly recognize the presenting features of cyclical nausea, emesis, abdominal pain and relief of symptoms with hot showers, in the setting of chronic cannabinoid use.

RECENT FINDINGS

Our understanding of the contributory mechanisms continues to grow, but high-quality evidence of effective treatment in adolescents remains lacking. Current best evidence in the treatment of acute paediatric CHS suggests intravenous rehydration and electrolyte correction, followed by 0.05 mg/kg haloperidol with or without a benzodiazepine. The only long-term treatment remains complete cessation of cannabinoid use.

SUMMARY

This article reviews our growing knowledge of adolescent CHS and provides practical guidance for diagnosis, treatment and understanding the underlying mechanisms of the condition.

Cannabinoid hyperemesis syndrome and cannabis withdrawal syndrome: a review of the management of cannabis-related syndrome in the emergency department

Background

Cannabis-related medical consultations are increasing worldwide, a non-negligible public health issue; patients presenting to acute care traditionally complain of abdominal pain and vomiting. Often recurrent, these frequent consultations add to the congestion of already chronically saturated emergency department(s) (ED). In order to curb this phenomenon, a specific approach for these patients is key, to enable appropriate treatment and long-term follow-up.

Objectives

This study reviews cannabinoid hyperemesis syndrome (CHS) and cannabis withdrawal syndrome (CWS), in a bid to help promote better understanding and handling of pathologies associated with chronic cannabis use. Following a literature review, we present a novel therapeutic algorithm aimed at guiding clinicians, in a bid to improve long-term outcomes and prevent recurrences.

Methods

Using the keywords “Cannabis,” “Hyperemesis,” “Syndrome,” “Withdrawal,” and “Emergency Medicine,” we completed a literature review of three different electronic databases (PubMed®, Google scholar®, and Cochrane®), up to November 2021.

Results

Although often presenting with similar symptoms such as abdominal pain and vomiting, cannabinoid hyperemesis syndrome (CHS) and cannabis withdrawal syndrome (CWS) are the result of two differing pathophysiological processes. Distinguishing between these two syndromes is essential to provide appropriate symptomatic options.

Conclusion

The correct identification of the underlying cannabis-related syndrome, and subsequent therapeutic choice, may help decrease ED presentations. Our study emphasizes the importance of both acute care and long-term outpatient follow-up, as key processes in cannabis-related disorder treatment.

A case report on cannabinoid hyperemesis syndrome in palliative care: how good intentions can go wrong

INTRODUCTION

Synthetic cannabinoids are commonly used to manage pain, nausea, and vomiting in oncology and palliative care. Despite the current acceptance of cannabinoids as a treatment option for nausea and vomiting, there is a lack of data regarding the side effects of its prolonged use leading to possible toxicity due to accumulation, and as a result, exacerbation of nausea and vomiting rather than alleviation. Case report presentation: The patient, a 70-year-old female who was residing in the palliative care unit with the diagnosis of small-cell lung cancer. She underwent a course of chemotherapy consisting of paclitaxel, docetaxel, and cisplatin. She presented with hair loss, sore mouth, and loss of appetite, diarrhea, neuralgia, nausea and vomiting which developed approximately five hours after chemotherapy. Nabilone was used for the last five years to manage the patient's neuralgia. As her cancer progressed, dosage of nabilone was incrementally increased from 0.5 mg to 2 mg to control her pain; however, it exacerbated refractory nausea and vomiting. Nabilone was discontinued seven weeks after administration due to suspicion of cannabinoid hyperemesis syndrome. Hot baths were attempted with temporary relief. Her pain became well controlled with opioids and adjuvants and there has been no recurrence of nausea and vomiting since the cessation of nabilone.

DISCUSSION/CONCLUSION

Successful recognition and management of cannabinoid hyperemesis syndrome is especially important in individuals with co-morbid disorders in order to avoid cannabis toxicity.

Cannabinoid hyperemesis syndrome: A 6-year audit of adult presentations to an urban district hospital

OBJECTIVE

To describe the local experience of adult patients presenting with cannabinoid hyperemesis syndrome (CHS) to an urban ED in the outer northern suburbs of Melbourne.

METHODS

Retrospective chart review of adult patients presenting to the ED with a documented history of CHS or equivalent terminology from January 2015 to January 2021. Age, sex, cannabis use, clinical features, pathology results, imaging and symptomatic management were examined as well as outcomes regarding disposition, representation, morbidity and mortality.

RESULTS

One hundred and forty-two adult presentations were included. Sixty-seven were unique presentations and 29 were patients who represented during the study period. Most represented within 3 months (37.8%) and most represented at least twice. Males were overrepresented (68.7%). Patients were young (median age 31 years, interquartile range 23-35 years) and all had a history of regular cannabis use (usually daily). Cyclical nausea and/or vomiting was the most common clinical feature compared to others in previously reported diagnostic criteria. Patients typically had elevated white cell counts with associated neutrophilia (75.8%) and mild hypokalaemia (57.9%). Lipase was not elevated, and C-reactive protein was typically less than 50 mmol/L (98.2%). Imaging was not commonly performed but largely normal. Treatment was supportive with anti-emetic use, intravenous fluids and analgesia. There were no deaths or admissions to intensive care.

CONCLUSIONS

Cyclical nausea and vomiting was the most common feature observed in this cohort compared to other clinical features reported in prior studies. Serum lipase was normal and C-reactive protein only mildly elevated. Prospective studies are required to further assess these findings.

A Systematic Review on Cannabis Hyperemesis Syndrome and Its Management Options

INTRODUCTION

Several forms of cannabinoids are currently being used to manage nausea and vomiting (N/V). Emerging cases of refractory N/V associated with chronic cannabis use among adults and older patients have been reported named cannabis hyperemesis syndrome (CHS). CHS is a condition that leads to repeated and severe N/V in long-term users of cannabinoids.

OBJECTIVE

The aim of this study was to outline current treatments for the management of CHS.

METHODS

A systematic review was conducted using PubMed, Ovid MEDLINE, Cochrane Central, EMBASE, and Google Scholar. Databases were used to search for articles on CHS published from January 2009 to June 2021, yielding 225 results of which 17 were deemed relevant and underwent review by 2 separate reviewers.

RESULTS

The duration of cannabis administration ranged between 6 months to 11 years may precipitate symptoms of CHS. The Rome IV diagnostic criteria of CHS require cannabinoid use and persistence of N/V symptoms for at least the past 6 months. Cannabis cessation is noted to be the most successful management, but other treatments also demonstrated symptom relief; these include hot water hydrotherapy, topical capsaicin cream, haloperidol, droperidol, benzodiazepines, propranolol, and aprepitant administration.

CONCLUSION

More research on CHS is needed to enhance knowledge translation, education, and create awareness in the medical community on the side effects of cannabinoids and to propose the best treatment options.

Cannabinoid Hyperemesis Syndrome Survey and Genomic Investigation

Background:

Cannabinoid hyperemesis syndrome (CHS) is a diagnosis of exclusion with intractable nausea, cyclic vomiting, abdominal pain, and hot bathing behavior associated with ongoing tetrahydrocannabinol (THC) exposure. Increasing cannabis use may elevate CHS prevalence, exacerbating a public health issue with attendant costs and morbidity.

Objective, Design, and Data Source:

This study, the largest contemporaneous database, investigated genetic mutations underlying CHS. Patients with CHS diagnosis and ongoing symptoms were compared with current cannabis users lacking symptoms.

Target Population:

A screening questionnaire was posted online. Of 585 respondents, 205 qualified as the CHS pool and 54 as controls; a reduced pool of 28 patients and 12 controls ultimately completed genomic testing.

Results:

Patients and controls were high-frequency users of cannabis flower or concentrates (93%), using multiple grams/day of THC-predominant material. Among patients, 15.6% carried diagnoses of cannabis dependency or addiction, and 56.6% experienced withdrawal symptoms. About 87.7% of patients improved after cannabis cessation, most suffering recurrence rapidly after resumption. Findings in patients included mutations in genes COMT {odds ratio, 12 (95% confidence limit [CL], 1.3–88.1) p=0.012}, transient receptor potential vanilloid receptor 1 (TRPV1) (odds ratio, 5.8 [95% CL, 1.2–28.4] p=0.015), CYP2C9 (odds ratio, 7.8 [95% CL, 1.1–70.1] p=0.043), gene coding dopamine-2 receptor (DRD2) (odds ratio, 6.2 [95% CL, 1.1–34.7] p=0.031), and ATP-binding cassette transporter gene (ABCA1) (odds ratio, 8.4 [95% CL, 1.5–48.1] p=0.012).

Limitations:

Some participants were reluctant to undergo genetic testing; only 28 of 99 CHS patients who agreed to testing ultimately returned a kit.

Conclusion:

This is the largest patient cohort of CHS examined to date, and first to note associated mutations in genes affecting neurotransmitters, the endocannabinoid system, and the cytochrome P450 complex associated with cannabinoid metabolism. Although the sample size was smaller than desired, these preliminary findings may contribute to the growing body of knowledge, stimulate additional investigation, help elucidate the pathophysiology of CHS, and, ultimately, direct future treatment.