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Acharya P, Mishra A, Kuikel S, Mishra A, Rauniyar R, Khanal K, Nepal AS, Thapaliya S. Severe and rapidly changing hypophosphatemia in cannabinoid hyperemesis syndrome: a case report. Oxf Med Case Reports 2024; 2024:omae055. [PMID: 38860017 PMCID: PMC11162588 DOI: 10.1093/omcr/omae055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 03/18/2024] [Accepted: 04/13/2024] [Indexed: 06/12/2024] Open
Abstract
The increasing prevalence of cannabis worldwide requires awareness of a potential, less recognized, paradoxical entity, the cannabinoid hyperemesis syndrome (CHS). This includes cyclic episodes of nausea, vomiting, and compulsive hot water bathing for alleviation in individuals with chronic cannabis use. An 18-year-old male with daily and prolonged cannabis use has excessive nausea and vomiting, is diagnosed with CHS, and is further complicated by severe and rapidly fluctuating hypophosphatemia. He was successfully managed with intravenous (IV) antiemetic (metoclopramide) and IV normal saline in the emergency department. Hypophosphatemia was treated with IV phosphorous. Although hypophosphatemia in CHS is a rare encounter, the authors share their experience to promote broader recognition and insight into successful management.
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Affiliation(s)
- Prakash Acharya
- Department of Internal Medicine, Greater Baltimore Medical Center, Baltimore, MD, USA
| | - Aakash Mishra
- Kathmandu Medical College Teaching Hospital, Kathmandu, Bagmati Province, Nepal
| | - Sandip Kuikel
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Bagmati Province, Nepal
| | - Aman Mishra
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Bagmati Province, Nepal
| | - Robin Rauniyar
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Bagmati Province, Nepal
| | - Kunjan Khanal
- Green City Hospital Private Limited, Kathmandu, Bagmati Province, Nepal
| | - Amit Sharma Nepal
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Bagmati Province, Nepal
| | - Sahil Thapaliya
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Bagmati Province, Nepal
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Bright HR, Singh A, Joel A, Georgy JT, John AO, Rajkumar P, Jiji H, Stehno-Bittel L, Samuel P, Chandy SJ. Randomized Placebo-Controlled Trial of Topical Capsaicin for Delayed Chemotherapy-Induced Nausea and Vomiting. JCO Glob Oncol 2024; 10:e2400130. [PMID: 38905580 DOI: 10.1200/go.24.00130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 04/15/2024] [Accepted: 05/03/2024] [Indexed: 06/23/2024] Open
Abstract
PURPOSE We examined the efficacy of topical capsaicin in reducing delayed chemotherapy-induced nausea and vomiting (CINV). METHODS Adults on highly emetogenic chemotherapy regimens applied 2 g of capsaicin ointment (0.075%) or matching placebo four times a day to the abdomen for 5 days in addition to standard antiemetic regimen in this blinded randomized controlled trial. Patients were monitored for nausea and vomiting in the immediate (day 1), delayed (days 2-5), and extended phases (days 2-15). Self-reported incidence and daily episodes of CINV were compared between the groups. Onset, severity, need for rescue antiemetics, cumulative vomiting episodes, and safety were also compared. RESULTS In total, 160 patients were enrolled. The final modified intention-to-treat population included 75 patients each in the capsaicin and placebo groups. Fewer patients experienced nausea (36.0% [n = 27] v 53.3% [n = 40]; P = .033) and vomiting (28.0% [n = 21] v 42.7% [n = 32]; P = .060) in the capsaicin arm during the delayed phase. During the extended phase, there was a significantly lower incidence of nausea (44% v 64.0%; P = .014) in the capsaicin arm. No difference in nausea (26.7% v 25.3%) or vomiting (22.7% v 18.7%) was evident in the immediate phase. The average daily episodes of nausea and vomiting were significantly fewer in the capsaicin arm during the delayed and extended phases. With capsaicin, no grade 3 nausea (9.3% v 0.0%; P = .007) was observed, and the time to first nausea and vomiting was significantly prolonged. There were no differences between the groups with respect to rescue antiemetics, unscheduled hospital visits, and adverse events. CONCLUSION Topical capsaicin reduced the incidence of nausea and the average number of vomiting episodes during delayed and extended phases without increasing adverse effects.
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Affiliation(s)
- Heber Rew Bright
- Department of Pharmacy, Christian Medical College, Vellore, India
| | - Ashish Singh
- Department of Medical Oncology, Christian Medical College, Vellore, India
| | - Anjana Joel
- Department of Medical Oncology, Christian Medical College, Vellore, India
| | - Josh Thomas Georgy
- Department of Medical Oncology, Christian Medical College, Vellore, India
| | - Ajoy Oommen John
- Department of Medical Oncology, Christian Medical College, Vellore, India
| | - Pradeep Rajkumar
- Department of Pharmacy, Christian Medical College, Vellore, India
| | - Hema Jiji
- Department of Pharmacy, Christian Medical College, Vellore, India
| | - Lisa Stehno-Bittel
- Likarda, Inc, Kansas City, MO
- University of Kansas Medical Center, Rehabilitation Science, Kansas City, KS
| | - Prasanna Samuel
- Department of Biostatistics, Christian Medical College, Vellore, India
| | - Sujith J Chandy
- Department of Pharmacology and Clinical Pharmacology, Christian Medical College, Vellore, India
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Elnagar A, Kgomo M, Mokone M, Yousif B. Cannabinoid hyperemesis syndrome. BMJ Case Rep 2024; 17:e256921. [PMID: 38688569 PMCID: PMC11085687 DOI: 10.1136/bcr-2023-256921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2024] [Indexed: 05/02/2024] Open
Abstract
SummaryCannabis use is legalised in many countries. We present a patient in their 40s who complained of recurrent abdominal pain and associated nausea and vomiting. The patient was previously seen in various hospitals, treated symptomatically, and discharged with a diagnosis of non-specific abdominal pain. The patient had a chronic history of smoking cannabis and nicotine and drinking alcohol. Abdominal examination revealed no masses, and abdominal X-ray was normal. Blood tests and gastroduodenoscopy revealed no obvious aetiology. Intravenous fluids, together with antiemetics and proton pump inhibitors, were administered. The patient also received counselling and was advised to stop cannabis use. At discharge, the patient was well and asked to come back for review in 2 weeks, and, thereafter monthly for a period of 6 months after stopping cannabis use. The patient reported no recurrent symptoms despite continued cigarette and alcohol use. A suspected cannabinoid hyperemesis syndrome (CHS) became a consideration. Awareness of cannabis-related disorders such as CHS may assist in avoiding costly hospital workups.
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Affiliation(s)
- Ali Elnagar
- University of Pretoria Faculty of Health Sciences, Pretoria, South Africa
| | - Mpho Kgomo
- Internal Medicine, University of Pretoria Faculty of Health Sciences, Pretoria, South Africa
| | - Modise Mokone
- University of Pretoria Faculty of Health Sciences, Pretoria, South Africa
| | - Badreldin Yousif
- University of Pretoria Faculty of Health Sciences, Pretoria, South Africa
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Stubbs JJ, McCallum R. Cannabinoid hyperemesis syndrome: prevalence and management in an era of cannabis legalization. J Investig Med 2024; 72:171-177. [PMID: 37997432 DOI: 10.1177/10815589231217495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
As more states legalize cannabinoid products for recreational use and medicinal purposes, the prevalence of cannabinoid hyperemesis syndrome has become increasingly common. Yet, it remains unrecognized to many healthcare providers along with the most efficacious treatments. Cannabinoid hyperemesis syndrome most often presents with episodic vomiting secondary to chronic daily cannabis use over several months to years. Patients often complain of nausea and abdominal pain that is improved by taking hot showers or baths. Symptoms are alleviated with the cessation of cannabis use over a period of 6-12 months. Treatment for acute attacks often consists of parenteral benzodiazepines in the inpatient setting. Long-term management and prevention of further attacks are aided by tricyclic antidepressants such as amitriptyline with a dose range of 50-200 mg/d. Once a patient is in remission, amitriptyline can be tapered slowly. As cannabis becomes more widely available and accepted in the continental United States, so must education on the diagnosis of cannabinoid hyperemesis syndrome and treatment strategies.
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Affiliation(s)
- Justin Joe Stubbs
- Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Richard McCallum
- Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
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Khalid N, Abdullah M, Khalil M, Afzal MA, Hindawi M. Cannabis Hyperemesis Syndrome in a Young Patient: A Case Report and Literature Review. Cureus 2023; 15:e43868. [PMID: 37736461 PMCID: PMC10511210 DOI: 10.7759/cureus.43868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2023] [Indexed: 09/23/2023] Open
Abstract
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.
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Affiliation(s)
- Noman Khalid
- Internal Medicine, St. Joseph's University Medical Center, Paterson, USA
| | - Muhammad Abdullah
- Department of Medicine/Department of Public Health and Community Medicine, Shaikh Khalifa Bin Zayed Al-Nahyan Medical and Dental College, Shaikh Zayed Federal Postgraduate Medical Institute at Shaikh Zayed Medical Complex, Lahore, PAK
| | - Musa Khalil
- Medicine, Shaikh Zayed Hospital, Lahore, PAK
| | | | - Mulham Hindawi
- Internal Medicine, St. Joseph's University Medical Center, Paterson, USA
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Wightman RS, Metrik J, Lin TR, Li Y, Badea A, Almeida R, Collins AB, Beaudoin FL. Cannabis Use Patterns and Whole-Blood Cannabinoid Profiles of Emergency Department Patients With Suspected Cannabinoid Hyperemesis Syndrome. Ann Emerg Med 2023; 82:121-130. [PMID: 37479395 PMCID: PMC10363750 DOI: 10.1016/j.annemergmed.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/17/2023] [Accepted: 03/03/2023] [Indexed: 07/23/2023]
Abstract
STUDY OBJECTIVES The objectives of this study were to characterize the detailed cannabis use patterns (eg, frequency, mode, and product) and determine the differences in the whole-blood cannabinoid profiles during symptomatic versus asymptomatic periods of participants with suspected cannabinoid hyperemesis syndrome recruited from the emergency department (ED) during a symptomatic episode. METHODS This is a prospective observational cohort study of participants with symptomatic cyclic vomiting onset after chronic cannabis use. Standardized assessments were conducted to evaluate for lifetime and recent cannabis use, cannabis use disorder, and cannabis withdrawal symptoms. Quantitative whole-blood cannabinoid testing was performed at 2 times, first when symptomatic (ie, baseline) and at least 2 weeks after the ED visit when asymptomatic. The differences in cannabinoid concentrations were compared between symptomatic and asymptomatic testing. The study was conducted from September 2021 to August 2022. RESULTS There was a difference observed between delta-9-tetrahydrocannabinol metabolites, but not the parent compound during symptomatic episodes and asymptomatic periods. Most participants (84%) reported using cannabis > once per day (median 3 times per day on weekdays, 4 times per day on weekends). Hazardous cannabis use was universal among participants; the mean cannabis withdrawal discomfort score was 13, indicating clinically significant rates of cannabis withdrawal symptoms with cessation of use. Most participants (79%) previously tried to stop cannabis use, but a few (13%) of them had sought treatment. CONCLUSION Patients presenting to the ED with cannabinoid hyperemesis syndrome have high cannabis use disorder scores. Further studies are needed to better understand the influence of THC metabolism and concentrations on symptomatic cyclic vomiting.
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Affiliation(s)
- Rachel S Wightman
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI; Department of Epidemiology, School of Public Health at Brown University, Providence, RI.
| | - Jane Metrik
- Center for Alcohol and Addiction Studies, Brown University, School of Public Health, Providence, RI; Providence VA Medical Center, Providence, RI
| | | | - Yu Li
- Department of Epidemiology, School of Public Health at Brown University, Providence, RI
| | - Adina Badea
- Department of Pathology and Laboratory Medicine, Lifespan Academic Medical Center, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI
| | - Robert Almeida
- Forensic Toxicology Laboratory, Department of Health, Rhode Island, Providence, RI
| | - Alexandra B Collins
- Department of Epidemiology, School of Public Health at Brown University, Providence, RI
| | - Francesca L Beaudoin
- Department of Epidemiology, School of Public Health at Brown University, Providence, RI
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Murphy LM, Whelan AR, Griffin LB, Hamel MS. A pilot randomized control trial of topical capsaicin as adjunctive therapy for nausea and vomiting of pregnancy. Am J Obstet Gynecol MFM 2023; 5:100997. [PMID: 37271593 DOI: 10.1016/j.ajogmf.2023.100997] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/18/2023] [Accepted: 04/26/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Nausea and vomiting is one of the most common complications of pregnancy, affecting 50% to 80% of pregnant persons. Moreover, despite its prevalence, it remains a challenging condition to treat. Treatment often involves oral and intravenous medications with potential side effects, particularly when taken in combination. Capsaicin cream is proven to decrease nausea and vomiting in cyclic vomiting syndrome; however, its use has not been well studied among pregnant patients. OBJECTIVE This study aimed to test the feasibility of the off-label use of capsaicin for the treatment of nausea and vomiting in pregnancy. STUDY DESIGN This was a double-blinded randomized controlled trial of pregnant individuals in their first trimester of pregnancy seeking care at a tertiary care hospital for nausea and vomiting. Consenting participants were randomized to abdominal application of topical capsaicin vs placebo. All participants received intravenous hydration and metoclopramide. The primary outcome, total treatment time, was recorded for all participants. In addition, symptom severity was assessed every 30 minutes using a visual analog scale. Data were analyzed using the Wilcoxon rank-sum test for continuous variables and the Fisher exact test for binary variables. RESULTS Of the 38 eligible individuals approached, 30 were randomized. There was a trend toward decreased mean treatment time in the capsaicin group compared with the placebo group (79.9 vs 97.3 minutes; P=.1). There was no significant difference in visual analog scale scores at any time point between groups. Furthermore, capsaicin was well tolerated, with only 1 individual requesting the medication be removed. CONCLUSION This study demonstrated that capsaicin is an acceptable treatment of nausea and vomiting in pregnancy and additional explorations of its use as treatment are feasible. A larger randomized controlled trial is needed to determine the efficacy of capsaicin in this population.
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Affiliation(s)
- Lauren M Murphy
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, RI.
| | - Anna R Whelan
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, RI
| | - Laurie B Griffin
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, RI
| | - Maureen S Hamel
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, RI
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Lathrop JR, Rosen SN, Heitkemper MM, Buchanan DT. Cyclic Vomiting Syndrome and Cannabis Hyperemesis Syndrome: The State of the Science. Gastroenterol Nurs 2023; 46:208-224. [PMID: 37074964 DOI: 10.1097/sga.0000000000000730] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/10/2022] [Indexed: 04/20/2023] Open
Abstract
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.
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Affiliation(s)
- James R Lathrop
- James R. Lathrop, DNP, FNP, ARNP, is a PhD student under the Department of Biobehavioral Nursing & Health Informatics, School of Nursing, University of Washington, Seattle
- Sheldon N. Rosen, MD, is Clinical Associate Professor, Division of Gastroenterology, School of Medicine, University of Washington, Seattle
- Margaret M. Heitkemper, PhD, RN, FAAN, is Professor and Elizabeth Sterling Soule Endowed Chair in Nursing, Department of Biobehavioral Nursing & Health Informatics, School of Nursing, University of Washington, Seattle
- Diana Taibi Buchanan, PhD, RN, is Associate Professor and Mary S. Tschudin Endowed Professor of Nursing Education, Department of Biobehavioral Nursing & Health Informatics, School of Nursing, University of Washington, Seattle
| | - Sheldon N Rosen
- James R. Lathrop, DNP, FNP, ARNP, is a PhD student under the Department of Biobehavioral Nursing & Health Informatics, School of Nursing, University of Washington, Seattle
- Sheldon N. Rosen, MD, is Clinical Associate Professor, Division of Gastroenterology, School of Medicine, University of Washington, Seattle
- Margaret M. Heitkemper, PhD, RN, FAAN, is Professor and Elizabeth Sterling Soule Endowed Chair in Nursing, Department of Biobehavioral Nursing & Health Informatics, School of Nursing, University of Washington, Seattle
- Diana Taibi Buchanan, PhD, RN, is Associate Professor and Mary S. Tschudin Endowed Professor of Nursing Education, Department of Biobehavioral Nursing & Health Informatics, School of Nursing, University of Washington, Seattle
| | - Margaret M Heitkemper
- James R. Lathrop, DNP, FNP, ARNP, is a PhD student under the Department of Biobehavioral Nursing & Health Informatics, School of Nursing, University of Washington, Seattle
- Sheldon N. Rosen, MD, is Clinical Associate Professor, Division of Gastroenterology, School of Medicine, University of Washington, Seattle
- Margaret M. Heitkemper, PhD, RN, FAAN, is Professor and Elizabeth Sterling Soule Endowed Chair in Nursing, Department of Biobehavioral Nursing & Health Informatics, School of Nursing, University of Washington, Seattle
- Diana Taibi Buchanan, PhD, RN, is Associate Professor and Mary S. Tschudin Endowed Professor of Nursing Education, Department of Biobehavioral Nursing & Health Informatics, School of Nursing, University of Washington, Seattle
| | - Diana Taibi Buchanan
- James R. Lathrop, DNP, FNP, ARNP, is a PhD student under the Department of Biobehavioral Nursing & Health Informatics, School of Nursing, University of Washington, Seattle
- Sheldon N. Rosen, MD, is Clinical Associate Professor, Division of Gastroenterology, School of Medicine, University of Washington, Seattle
- Margaret M. Heitkemper, PhD, RN, FAAN, is Professor and Elizabeth Sterling Soule Endowed Chair in Nursing, Department of Biobehavioral Nursing & Health Informatics, School of Nursing, University of Washington, Seattle
- Diana Taibi Buchanan, PhD, RN, is Associate Professor and Mary S. Tschudin Endowed Professor of Nursing Education, Department of Biobehavioral Nursing & Health Informatics, School of Nursing, University of Washington, Seattle
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Mandal SK, Rath SK, Logesh R, Mishra SK, Devkota HP, Das N. Capsicum annuum L. and its bioactive constituents: A critical review of a traditional culinary spice in terms of its modern pharmacological potentials with toxicological issues. Phytother Res 2023; 37:965-1002. [PMID: 36255140 DOI: 10.1002/ptr.7660] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 09/07/2022] [Accepted: 09/27/2022] [Indexed: 11/12/2022]
Abstract
Capsicum annuum L., commonly known as chili pepper, is used as an important spice globally and as a crude drug in many traditional medicine systems. The fruits of C. annuum have been used as a tonic, antiseptic, and stimulating agent, to treat dyspepsia, appetites, and flatulence, and to improve digestion and circulation. The article aims to critically review the phytochemical and pharmacological properties of C. annuum and its major compounds. Capsaicin, dihydrocapsaicin, and some carotenoids are reported as the major active compounds with several pharmacological potentials especially as anticancer and cardioprotectant. The anticancer effect of capsaicinoids is mainly mediated through mechanisms involving the interaction of Ca2+ -dependent activation of the MAPK pathway, suppression of NOX-dependent reactive oxygen species generation, and p53-mediated activation of mitochondrial apoptosis in cancer cells. Similarly, the cardioprotective effects of capsaicinoids are mediated through their interaction with cellular transient receptor potential vanilloid 1 channel, and restoration of calcitonin gene-related peptide via Ca2+ -dependent release of neuropeptides and suppression of bradykinin. In conclusion, this comprehensive review presents detailed information about the traditional uses, phytochemistry, and pharmacology of major bioactive principles of C. annuum with special emphasis on anticancer, cardioprotective effects, and plausible toxic adversities along with food safety.
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Affiliation(s)
- Sudip Kumar Mandal
- Department of Pharmaceutical Chemistry, Dr. B. C. Roy College of Pharmacy and AHS, Durgapur, India
| | - Santosh Kumar Rath
- School of Pharmaceuticals and Population Health Informatics, Faculty of Pharmacy, DIT University, Dehradun, India
| | - Rajan Logesh
- TIFAC CORE in Herbal Drugs, Department of Pharmacognosy, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Rockland's, Ooty, India
| | | | - Hari Prasad Devkota
- Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Niranjan Das
- Department of Chemistry, Ramthakur College, Agartala, India
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TRPV1: A Common Denominator Mediating Antinociceptive and Antiemetic Effects of Cannabinoids. Int J Mol Sci 2022; 23:ijms231710016. [PMID: 36077412 PMCID: PMC9456209 DOI: 10.3390/ijms231710016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/26/2022] [Accepted: 08/29/2022] [Indexed: 12/19/2022] Open
Abstract
The most common medicinal claims for cannabis are relief from chronic pain, stimulation of appetite, and as an antiemetic. However, the mechanisms by which cannabis reduces pain and prevents nausea and vomiting are not fully understood. Among more than 450 constituents in cannabis, the most abundant cannabinoids are Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD). Cannabinoids either directly or indirectly modulate ion channel function. Transient receptor potential vanilloid 1 (TRPV1) is an ion channel responsible for mediating several modalities of pain, and it is expressed in both the peripheral and the central pain pathways. Activation of TRPV1 in sensory neurons mediates nociception in the ascending pain pathway, while activation of TRPV1 in the central descending pain pathway, which involves the rostral ventral medulla (RVM) and the periaqueductal gray (PAG), mediates antinociception. TRPV1 channels are thought to be implicated in neuropathic/spontaneous pain perception in the setting of impaired descending antinociceptive control. Activation of TRPV1 also can cause the release of calcitonin gene-related peptide (CGRP) and other neuropeptides/neurotransmitters from the peripheral and central nerve terminals, including the vagal nerve terminal innervating the gut that forms central synapses at the nucleus tractus solitarius (NTS). One of the adverse effects of chronic cannabis use is the paradoxical cannabis-induced hyperemesis syndrome (HES), which is becoming more common, perhaps due to the wider availability of cannabis-containing products and the chronic use of products containing higher levels of cannabinoids. Although, the mechanism of HES is unknown, the effective treatment options include hot-water hydrotherapy and the topical application of capsaicin, both activate TRPV1 channels and may involve the vagal-NTS and area postrema (AP) nausea and vomiting pathway. In this review, we will delineate the activation of TRPV1 by cannabinoids and their role in the antinociceptive/nociceptive and antiemetic/emetic effects involving the peripheral, spinal, and supraspinal structures.
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Senderovich H, Waicus S. A case report on cannabinoid hyperemesis syndrome in palliative care: how good intentions can go wrong. Oncol Res Treat 2022; 45:438-443. [PMID: 35504245 PMCID: PMC9533451 DOI: 10.1159/000524746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/12/2022] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Helen Senderovich
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Baycrest Hospital, Toronto, Ontario, Canada
- *Helen Senderovich,
| | - Sarah Waicus
- Department of Medicine, Trinity College Dublin, Dublin, Ireland
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Niriella MA, Jayasena H, Withanage M, Devanarayana NM, De Silva AP. Chronic nausea and vomiting: a diagnostic approach. Expert Rev Gastroenterol Hepatol 2022; 16:311-320. [PMID: 35303783 DOI: 10.1080/17474124.2022.2056016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Chronic nausea and vomiting (CNV) are commonly encountered symptoms in medical practice. CNV is the presenting symptom in a variety of gastrointestinal and non-gastrointestinal disorders. However, in a significant percentage of patients without an obvious underlying cause, CNV poses a significant diagnostic challenge to the evaluating physician. AREAS COVERED A comprehensive clinical history and physical examination form the foundation for further diagnostic work-up. In the present review, we discuss the diagnostic approach to CNV, highlighting the epidemiology, pathophysiology, causes, and modes of evaluation of this condition. Specific investigations, carefully guided by clinical assessment and tailored for each patient, would be more beneficial in diagnosing CNV than empirically performing a blanket of investigations. EXPERT OPINION Whilst CNV remains a historically challenging diagnostic and therapeutic dilemma, research into this topic is limited. Hence, there is a growing call for more research into diagnostic modalities for CNV. With scientific advancement and further research, it is hoped that easy-to-use, cheap, noninvasive novel diagnostic modalities for CNV will be available soon.
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Affiliation(s)
- Madunil A Niriella
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka.,University Medical Unit, Colombo North Teaching Hospital, Ragama, Sri Lanka
| | - Hiruni Jayasena
- Department of Clinical Medicine, Faculty of Medicine, General Sir John Kotelawala Defence University, Rathmalana, Sri Lanka
| | - Maduri Withanage
- Gastroenterology Unit, Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Niranga M Devanarayana
- Department of Physiology, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Arjuna P De Silva
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka.,University Medical Unit, Colombo North Teaching Hospital, Ragama, Sri Lanka
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13
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Burillo-Putze G, Richards JR, Rodríguez-Jiménez C, Sanchez-Agüera A. Pharmacological management of cannabinoid hyperemesis syndrome: an update of the clinical literature. Expert Opin Pharmacother 2022; 23:693-702. [DOI: 10.1080/14656566.2022.2049237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
| | - John R. Richards
- Department of Emergency Medicine, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Consuelo Rodríguez-Jiménez
- Facultad de Ciencias de la Salud, Universidad Europea de Canarias, Tenerife, Spain
- Clinical Pharmacology Department, Hospital Universitario de Canarias, Tenerife, Spain
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14
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Senderovich H, Patel P, Jimenez Lopez B, Waicus S. A Systematic Review on Cannabis Hyperemesis Syndrome and Its Management Options. Med Princ Pract 2022; 31:29-38. [PMID: 34724666 PMCID: PMC8995641 DOI: 10.1159/000520417] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 10/18/2021] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Helen Senderovich
- Department of Family and Community Medicine, Geriatrics and Palliative Care, Baycrest Health Sciences, University of Toronto, Toronto, Ontario, Canada
- *Helen Senderovich,
| | - Preet Patel
- University of Waterloo, Waterloo, Ontario, Canada
| | | | - Sarah Waicus
- School of Medicine, Trinity College Dublin, Dublin, Ireland
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15
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Kum V, Bell A, Fang W, VanWert E. Efficacy of topical capsaicin for cannabinoid hyperemesis syndrome in a pediatric and adult emergency department. Am J Emerg Med 2021; 49:343-351. [PMID: 34242945 PMCID: PMC8595616 DOI: 10.1016/j.ajem.2021.06.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/18/2021] [Accepted: 06/24/2021] [Indexed: 10/21/2022] Open
Abstract
INTRODUCTION Cannabinoid hyperemesis syndrome (CHS) is a clinical diagnosis characterized by symptoms of recurrent nausea, vomiting, and severe abdominal pain in the setting of chronic cannabis use. Symptoms of CHS are frequently unresponsive to standard antiemetic therapy. Topical capsaicin applied to the abdomen has been cited as a potential effective agent for CHS however robust evidence is lacking. METHODS This was a single-center retrospective cohort study to evaluate the efficacy of topical capsaicin in pediatric and adult patients presenting to the emergency department (ED) with suspected or confirmed CHS. The primary outcome assessed was if utilization of capsaicin for CHS resulted in more patients achieving an "efficacious" result, defined as only requiring ≤1 rescue medication for symptom relief after receiving capsaicin or after administration of the first agent in patients who did not receive capsaicin during their ED course. Secondary outcomes included total ED length of stay, time to discharge after administration of the reference agent (RA), proportion of patients requiring admission, total number of medication doses given for symptom relief, change in pain score and episodes of emesis, and proportion of patients returning to the ED within 24 h for the same complaint. Additional analyses were also performed to explore patient characteristics that may be predictive of capsaicin efficacy. RESULTS 201 patients were included in the final analysis of which 25 were <21 years old and seen in the pediatric ED. A greater proportion of patients in the capsaicin group achieved the primary outcome of efficacy as compared to patients who did not receive capsaicin (55% vs 21%, p < 0.001, unadjusted OR 1.44 [95% CI 0.586-0.820]). There were no differences in secondary outcomes except for time to discharge after administration of the RA which was shorter in the capsaicin group (3.72 vs 6.11 h, p = 0.001). CONCLUSION Significantly more patients in the capsaicin group experienced efficacy compared to patients who did not. Time to discharge after administration of the reference agent was shorter for those who received capsaicin compared to patients who did not. Administration of capsaicin did not influence patients' total number of medications received or total ED length of stay. Future research is needed to determine capsaicin's efficacy when utilized earlier in therapy, ideally upon initial diagnosis of CHS, and before additional adjunct medications are administered.
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Affiliation(s)
- Vivian Kum
- University of Michigan Health System, 1500 E Medical Center Drive, Ann Arbor, MI 48109, USA.
| | - Adrienne Bell
- University of Michigan Health System, 1500 E Medical Center Drive, Ann Arbor, MI 48109, USA.
| | - Wei Fang
- West Virginia Clinical and Translational Science Institute, WVU Health Sciences Center Erma Byrd Biomedical Research Center, Morgantown, WV 26506-9102, USA.
| | - Elizabeth VanWert
- University of Michigan Health System, 1500 E Medical Center Drive, Ann Arbor, MI 48109, USA.
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16
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Burillo-Putze G, Trujillo-Burillo D, García-Hernandez JC, López-Hernández MA, Hernández-Ramos I, Ramos-Suárez I, Richards JR. Cannabis hyperemesis syndrome: Incidence and treatment with topical capsaicin. Med Clin (Barc) 2021; 159:183-186. [PMID: 34756408 DOI: 10.1016/j.medcli.2021.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/11/2021] [Accepted: 07/12/2021] [Indexed: 12/01/2022]
Abstract
There are few studies in Spain on cannabinoid hyperemesis syndrome (CHS), as well as on the use of topical capsaicin as a treatment. METHODS Retrospective study of patients over 14 years of age seen in a hospital emergency department during 2018 and 2019 with a diagnosis of CHS based on the following criteria: compatible clinical picture, cannabis use less than 48h and positive urine cannabis test. Epidemiological and clinical variables, attendance times and treatment (including use of topical capsaicin 0.075%) were collected. RESULTS Fifty-nine attendances were studied, from 29 patients (4.4 cases/10,000 visits, 95% CI 2.8-4.7). Fifty per cent returned for CHS, differing only in more tobacco (P=.01) and cocaine (P=.031) use. Capsaicin was used in 74.6% of visits. The mean time to resolution of vomiting after application was 17.87min. CONCLUSIONS Although probably underdiagnosed, CHS has a low incidence in the emergency department in Spain, with high patient recurrence. The use of capsaicin ointment is efficient and safe.
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Affiliation(s)
- Guillermo Burillo-Putze
- Departamento de Medicina Física y Farmacología, Universidad de La Laguna, San Cristóbal de La Laguna, Santa Cruz de Tenerife, España; Grupo de investigación Urgencias y toxicología clínica: patologías agudas y procesos asistenciales (GRUCATOX), Universidad de La Laguna, San Cristóbal de La Laguna, Santa Cruz de Tenerife, España.
| | - David Trujillo-Burillo
- Departamento de Medicina Física y Farmacología, Universidad de La Laguna, San Cristóbal de La Laguna, Santa Cruz de Tenerife, España
| | - Jose Carlos García-Hernandez
- Departamento de Medicina Física y Farmacología, Universidad de La Laguna, San Cristóbal de La Laguna, Santa Cruz de Tenerife, España
| | - M Angeles López-Hernández
- Grupo de investigación Urgencias y toxicología clínica: patologías agudas y procesos asistenciales (GRUCATOX), Universidad de La Laguna, San Cristóbal de La Laguna, Santa Cruz de Tenerife, España; Servicio de Urgencias, Hospital Universitario de Canarias, San Cristóbal de La Laguna , Santa Cruz de Tenerife, España
| | - Iván Hernández-Ramos
- Grupo de investigación Urgencias y toxicología clínica: patologías agudas y procesos asistenciales (GRUCATOX), Universidad de La Laguna, San Cristóbal de La Laguna, Santa Cruz de Tenerife, España; Servicio de Urgencias, Hospital Universitario de Canarias, San Cristóbal de La Laguna , Santa Cruz de Tenerife, España
| | - Isabel Ramos-Suárez
- Grupo de investigación Urgencias y toxicología clínica: patologías agudas y procesos asistenciales (GRUCATOX), Universidad de La Laguna, San Cristóbal de La Laguna, Santa Cruz de Tenerife, España; Department of Emergency Medicine, University of California, Davis Medical Center, Davis, California, Estados Unidos
| | - John R Richards
- Department of Emergency Medicine, University of California, Davis Medical Center, Davis, California, Estados Unidos
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Nacca N, McGraw MD, Croft DP, Kalininskiy A. Weight loss in adolescents presenting with EVALI. Pediatr Pulmonol 2021; 56:2785-2786. [PMID: 34102043 DOI: 10.1002/ppul.25523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/30/2021] [Accepted: 05/25/2021] [Indexed: 11/06/2022]
Affiliation(s)
- Nicholas Nacca
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Matthew D McGraw
- Department of Pediatrics Pulmonology, University of Rochester Medical Center, Rochester, New York, USA
| | - Daniel P Croft
- Department of Medicine, Pulmonary Diseases and Critical Care, Rochester, New York, USA
| | - Aleksandr Kalininskiy
- Department of Medicine, Pulmonary Diseases and Critical Care, Rochester, New York, USA
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18
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Russo EB, Spooner C, May L, Leslie R, Whiteley VL. Cannabinoid Hyperemesis Syndrome Survey and Genomic Investigation. Cannabis Cannabinoid Res 2021; 7:336-344. [PMID: 34227878 PMCID: PMC9225400 DOI: 10.1089/can.2021.0046] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
| | | | - Len May
- Endocanna Health, Los Angeles, California, USA
| | - Ryan Leslie
- Endocanna Health, Los Angeles, California, USA
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19
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Zhong W, Shahbaz O, Teskey G, Beever A, Kachour N, Venketaraman V, Darmani NA. Mechanisms of Nausea and Vomiting: Current Knowledge and Recent Advances in Intracellular Emetic Signaling Systems. Int J Mol Sci 2021; 22:5797. [PMID: 34071460 PMCID: PMC8198651 DOI: 10.3390/ijms22115797] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/20/2021] [Accepted: 05/21/2021] [Indexed: 02/07/2023] Open
Abstract
Nausea and vomiting are common gastrointestinal complaints that can be triggered by diverse emetic stimuli through central and/or peripheral nervous systems. Both nausea and vomiting are considered as defense mechanisms when threatening toxins/drugs/bacteria/viruses/fungi enter the body either via the enteral (e.g., the gastrointestinal tract) or parenteral routes, including the blood, skin, and respiratory systems. While vomiting is the act of forceful removal of gastrointestinal contents, nausea is believed to be a subjective sensation that is more difficult to study in nonhuman species. In this review, the authors discuss the anatomical structures, neurotransmitters/mediators, and corresponding receptors, as well as intracellular emetic signaling pathways involved in the processes of nausea and vomiting in diverse animal models as well as humans. While blockade of emetic receptors in the prevention of vomiting is fairly well understood, the potential of new classes of antiemetics altering postreceptor signal transduction mechanisms is currently evolving, which is also reviewed. Finally, future directions within the field will be discussed in terms of important questions that remain to be resolved and advances in technology that may help provide potential answers.
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Affiliation(s)
- Weixia Zhong
- Department of Basic Medical Sciences, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, 309 East Second Street, Pomona, CA 91766, USA; (W.Z.); (G.T.); (V.V.)
| | - Omar Shahbaz
- School of Medicine, Universidad Iberoamericana, Av. Francia 129, Santo Domingo 10203, Dominican Republic;
| | - Garrett Teskey
- Department of Basic Medical Sciences, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, 309 East Second Street, Pomona, CA 91766, USA; (W.Z.); (G.T.); (V.V.)
| | - Abrianna Beever
- Graduate College of Biomedical Sciences, Western University of Health Sciences, Pomona, CA 91766, USA; (A.B.); (N.K.)
| | - Nala Kachour
- Graduate College of Biomedical Sciences, Western University of Health Sciences, Pomona, CA 91766, USA; (A.B.); (N.K.)
| | - Vishwanath Venketaraman
- Department of Basic Medical Sciences, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, 309 East Second Street, Pomona, CA 91766, USA; (W.Z.); (G.T.); (V.V.)
- Graduate College of Biomedical Sciences, Western University of Health Sciences, Pomona, CA 91766, USA; (A.B.); (N.K.)
| | - Nissar A. Darmani
- Department of Basic Medical Sciences, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, 309 East Second Street, Pomona, CA 91766, USA; (W.Z.); (G.T.); (V.V.)
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20
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Kichloo A, Albosta M, Aljadah M, El-Amir Z, Goldar G, Khan MZ, Dahiya DS, Vallabhaneni S, Wani F, Singh J. Marijuana: A systems-based primer of adverse effects associated with use and an overview of its therapeutic utility. SAGE Open Med 2021; 9:20503121211000909. [PMID: 33786179 PMCID: PMC7958160 DOI: 10.1177/20503121211000909] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 02/12/2021] [Indexed: 12/18/2022] Open
Abstract
Marijuana use is on the rise in the United States. By the end of 2019, 33 states have legalized marijuana use and marijuana byproduct use for medical purposes. However, marijuana use does not come without side effects. This manuscript reviews the increasing usage of marijuana and the different forms (natural and synthetic) that patients may use when presenting to clinicians. It also addresses the biochemical and behavioral changes observed with marijuana use, including the location and changes associated with cannabinoid receptors (abbreviated CB1 and CB2). These two topics lead into an extensive review of the side effects of marijuana use. This manuscript discusses gastrointestinal side-effects, such as Cannabinoid Hyperemesis Syndrome, pancreatitis, and hepatotoxicity. It also briefly reviews cardiovascular, neurologic, and pulmonary side effects. This article provides an overview of therapeutic effects of marijuana including the antiemetic effect, its medical utility as an appetite stimulant, and usefulness in cancer patients post-chemotherapy. A thorough social history pertaining to marijuana use is an important consideration for clinicians in patients presenting with a variety of symptoms, including those effecting the gastrointestinal, cardiovascular, pulmonary, or neurologic systems.
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Affiliation(s)
- Asim Kichloo
- Department of Internal Medicine,
Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Michael Albosta
- Department of Internal Medicine,
Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Michael Aljadah
- Department of Internal Medicine,
Medical College of Wisconsin, Milwaukee, WI, USA
| | - Zain El-Amir
- Department of Internal Medicine,
Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Ghazaleh Goldar
- Department of Internal Medicine,
Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Muhammed Zatmar Khan
- Department of Internal Medicine,
Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Dushyant Singh Dahiya
- Department of Internal Medicine,
Central Michigan University College of Medicine, Saginaw, MI, USA
| | | | - Farah Wani
- Department of Family Medicine,
Samaritan Medical Center, Watertown, NY, USA
| | - Jagmeet Singh
- Department of Nephrology, Guthrie
Robert Packer Hospital, Sayre, PA, USA
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21
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Yusuf HM, Geier C, Staidle A, Montoy JCC. Efficacy of topical capsaicin for the treatment of cannabinoid hyperemesis syndrome: A retrospective cohort study. Am J Emerg Med 2021; 43:142-148. [PMID: 33561623 DOI: 10.1016/j.ajem.2021.01.073] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/23/2021] [Accepted: 01/25/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Cannabis Hyperemesis Syndrome (CHS) is a clinical disorder characterized by abdominal pain and intractable vomiting among patients with chronic marijuana use. We sought to assess the efficacy of capsaicin to determine whether it could reduce ED length of stay in patients with CHS. METHODS his retrospective observational study was conducted among patients with CHS. Patients were classified based on whether they received capsaicin, which was pseudorandomized and dependent on the pharmacist available. Outcomes included time to discharge, number of medications given, bounceback rate, and admission rate. Statistical analyses included t-tests, survival analyses, and cox regressions. RESULTS 55 patients (35 capsaicin, 20 no capsaicin) met inclusion criteria. There was no difference in time to discharge between the experimental and control groups (4.46 h vs 3.52 h, p = 0.10), rounds of medications given (2.60 vs 3.54, p = 0.09), bounceback rate within 24 h (0.11 vs 0.10, p = 0.43), or admission rate to the hospital (0.19 vs 0.05, p = 0.07). A survival analysis and cox regression showed no difference in time to discharge. A subgroup analysis between patients who received capsaicin within their first two rounds of treatment had statistically significantly shorter length of stays than patients who received capsaicin afterwards, (4.83 h vs 7.09 h, p = 0.01). CONCLUSION Topical capsaicin was not associated with shorter length of stays than no capsaicin. When given earlier during an ED visit, it is associated with a shorter length of stay than when given later.
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Affiliation(s)
- Hamzah M Yusuf
- University of California, San Francisco, 1001 Potrero Ave, San Francisco, CA 94110, USA.
| | - Curtis Geier
- Department of Emergency Medicine, University of California, San Francisco, 1001 Potrero Ave, San Francisco, CA 94110, USA.
| | - Alex Staidle
- San Francisco Department of Public Health, 1001 Potrero Ave, San Francisco, CA 94110, USA.
| | - Juan Carlos C Montoy
- Department of Emergency Medicine, University of California, San Francisco, 1001 Potrero Ave, San Francisco, CA 94110, USA.
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22
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Topical Capsaicin for Treating Cannabinoid Hyperemesis Syndrome. Case Rep Gastrointest Med 2020; 2020:8868385. [PMID: 33294233 PMCID: PMC7718060 DOI: 10.1155/2020/8868385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 10/17/2020] [Accepted: 10/28/2020] [Indexed: 12/18/2022] Open
Abstract
Introduction Cannabinoid hyperemesis syndrome (CHS), associated with chronic cannabis use, presents with cyclic abdominal pain, nausea, and vomiting. With increasing use of marijuana, the incidence of CHS is expected to increase. Most patients with CHS make frequent visits to the emergency room and are usually refractory to conventional treatment. We, therefore, present a case of CHS successfully treated with topical capsaicin application. Case Presentation. A 41-year-old female with a recent excess use of cannabis presented to the emergency department for evaluation of recurrent excruciating epigastric pain accompanied by severe nausea and vomiting. She had similar, milder symptoms a year ago and underwent endoscopic evaluation which was negative except for mild reflux esophagitis for which she was started on a proton pump inhibitor. On this presentation, basic laboratory workup, EKG, and CT scan of abdomen and pelvis were unremarkable. A detailed abdominal exam was only positive for mild epigastric tenderness. She was instructed to continue pantoprazole and pain medication and outpatient repeat esophagogastroduodenoscopy. The patient returned the next day with extreme retching, nausea, and vomiting and was admitted for further evaluation. Intravenous fluids, antiemetics, and morphine were started for pain control with no symptomatic improvement. A diagnosis of cannabis hyperemesis syndrome was made based on history of chronic marijuana use and otherwise negative workup. A trial of topical capsaicin, over the epigastric region, was tried that provided dramatic relief within 24 hours. Repeat endoscopic evaluation had no evidence of ulcers, celiac disease, or esophagitis. She was discharged on topical capsaicin and counselled on marijuana abstinence, with no return of symptoms. Conclusion Based on the dramatic resolution of symptoms with topical capsaicin, our case supports this promising intervention and provides an alternate approach to antiemetics and narcotics routinely used in patients with cannabis hyperemesis syndrome.
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Nasser Y, Woo M, Andrews CN. Cannabis in Gastroenterology: Watch Your Head! A Review of Use in Inflammatory Bowel Disease, Functional Gut Disorders, and Gut-Related Adverse Effects. ACTA ACUST UNITED AC 2020; 18:519-530. [PMID: 33250629 PMCID: PMC7680210 DOI: 10.1007/s11938-020-00323-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2020] [Indexed: 12/22/2022]
Abstract
Purpose of review To review recent clinical evidence surrounding the use of cannabinoids and cannabis in gastrointestinal diseases, particularly inflammatory bowel disease (IBD) and functional gut disorders. A second aim is to evaluate the current status of gastrointestinal related adverse effects which have been linked to cannabis use, specifically cannabis hyperemesis syndrome (CHS) and acute pancreatitis. Recent findings Observational and prospective studies suggest that cannabinoids improve IBD symptoms. Small prospective clinical trials have not shown any effects on objective inflammatory findings, other than one recent paper in ulcerative colitis, in abstract form only, which suggests endoscopic improvement. Short duration mechanistic studies in functional gut disorders suggest cannabinoids may attenuate gastric emptying and slow colonic motility but appear to have less effect on sensory thresholds in the gut. Summary In general, while mostly uncontrolled data suggests cannabis may improve symptoms in IBD (and to a lesser degree functional gut disorders), this is not likely due to any substantial anti-inflammatory effect. Much remains unknown about CHS etiology and complete abstinence from cannabinoids remains the generally accepted treatment strategy. Population-based studies do not suggest that cannabis use is related to acute pancreatitis. Further research is certainly warranted.
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Affiliation(s)
- Yasmin Nasser
- Department of Medicine, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada
| | - Matthew Woo
- Department of Medicine, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada
| | - Christopher N. Andrews
- Department of Medicine, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada
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24
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Dean DJ, Sabagha N, Rose K, Weiss A, France J, Asmar T, Rammal J, Beyer M, Bussa R, Ross J, Chaudhry K, Smoot T, Wilson K, Miller J. A Pilot Trial of Topical Capsaicin Cream for Treatment of Cannabinoid Hyperemesis Syndrome. Acad Emerg Med 2020; 27:1166-1172. [PMID: 32569429 DOI: 10.1111/acem.14062] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 06/10/2020] [Accepted: 06/17/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Patients with cannabinoid hyperemesis syndrome (CHS) present frequently to the emergency department. Previous case studies suggest dramatic symptomatic improvement with topical capsaicin treatment. This exploratory study examined the potential effectiveness of topical capsaicin in patients with nausea and vomiting due to a suspected CHS exacerbation. METHODS This was a double-blind, randomized placebo-controlled pilot trial. Adults who presented with vomiting suspected to be from CHS were eligible for enrollment. We excluded pregnant women and those with resolution of symptoms. Following randomization, topical 0.1% capsaicin or placebo cream was applied to the anterior abdomen in a uniform manner. The primary outcome was the severity of nausea on a visual analog scale (VAS) of 0 to 10 cm assessed at 30 minutes. Secondary outcomes were adverse events, occurrence of posttreatment vomiting, nausea by VAS at 60 minutes, and hospital admission. RESULTS This pilot trial enrolled 30 patients, 17 in the capsaicin arm and 13 in the placebo arm. One patient in the capsaicin arm did not tolerate treatment due to skin irritation. Mean ± SD nausea severity at 30 minutes was 4.1 ± 2.3 cm in the capsaicin arm and 6.1 ± 3.3 cm in the placebo arm (difference = -2.0 cm, 95% confidence interval [CI] = 0.2 to -4.2 cm). At 60 minutes, mean ± SD nausea severity was 3.2 ± 3.2 cm versus 6.4 ± 2.8 cm (difference = -3.2 cm, 95% CI = -0.9 to -5.4 cm). The percent reduction in nausea at 60 minutes from baseline was 46.0% in the capsaicin arm and 24.9% in the placebo arm (difference = 21.1%, 95% CI = -5.6% to 47.9%). A higher proportion of capsaicin group patients (29.4% vs. 0%) had complete resolution of nausea (relative risk = 3.4, 95% CI = 1.6 to 7.1). CONCLUSION In this pilot trial, the application of topical capsaicin cream was associated with a significant reduction in nausea at 60 minutes but not at 30 minutes and provided more complete relief of nausea.
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Affiliation(s)
- Diana J. Dean
- From the Department of Emergency Medicine Henry Ford Hospital Detroit MI USA
- the Michigan Poison Center Detroit MI USA
| | - Noor Sabagha
- From the Department of Emergency Medicine Henry Ford Hospital Detroit MI USA
| | - Kaitlin Rose
- From the Department of Emergency Medicine Henry Ford Hospital Detroit MI USA
- the Central Michigan University College of Medicine Mount Pleasant MI USA
| | - Alexander Weiss
- From the Department of Emergency Medicine Henry Ford Hospital Detroit MI USA
| | | | - Timothy Asmar
- From the Department of Emergency Medicine Henry Ford Hospital Detroit MI USA
| | - Jo‐Ann Rammal
- From the Department of Emergency Medicine Henry Ford Hospital Detroit MI USA
| | - Margaret Beyer
- From the Department of Emergency Medicine Henry Ford Hospital Detroit MI USA
| | - Rebecca Bussa
- From the Department of Emergency Medicine Henry Ford Hospital Detroit MI USA
| | - Jacob Ross
- From the Department of Emergency Medicine Henry Ford Hospital Detroit MI USA
| | - Kaleem Chaudhry
- From the Department of Emergency Medicine Henry Ford Hospital Detroit MI USA
| | - Thomas Smoot
- and the Frederick Memorial Hospital Frederick MD USA
| | - Kathleen Wilson
- From the Department of Emergency Medicine Henry Ford Hospital Detroit MI USA
| | - Joseph Miller
- From the Department of Emergency Medicine Henry Ford Hospital Detroit MI USA
- the Wayne State University Detroit MI USA
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Stuart R, Richards JR. Cannabinoid Hyperemesis Syndrome: An Unexpected Problem in an Unusual Setting—A Case Report. Mil Med 2020; 185:e1894-e1896. [DOI: 10.1093/milmed/usaa113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 04/04/2020] [Accepted: 04/21/2020] [Indexed: 11/14/2022] Open
Abstract
Abstract
Cannabinoid hyperemesis syndrome presents with abdominal pain, nausea, and intractable vomiting caused by phytogenic and synthetic cannabinoid use. Complications associated with this disorder range from severe dehydration to acute kidney injury and rhabdomyolysis. This syndrome mimics many acute surgical and emergency medical conditions and can present several diagnostic and treatment challenges. While this syndrome is increasingly recognized as a common clinical entity in civilian emergency departments, there is little data concerning experience at military hospitals. We present a case of cannabinoid hyperemesis syndrome that was diagnosed and treated in a combat-zone US military emergency department in Southwest Asia.
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Affiliation(s)
- Rory Stuart
- Department of Emergency Medicine, University of California Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA 95817
| | - John Ray Richards
- Department of Emergency Medicine, University of California Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA 95817
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26
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Stumpf JL, Williams LD. Management of Cannabinoid Hyperemesis Syndrome: Focus on Capsaicin. J Pharm Pract 2020; 34:786-793. [PMID: 32613883 DOI: 10.1177/0897190020934289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cannabinoid hyperemesis syndrome is a condition characterized by cyclic severe nausea, vomiting, and abdominal pain associated with frequent, long-term marijuana use. The condition resolves with cessation of cannabis but may be temporarily relieved by bathing in hot water. Topical capsaicin cream may also alleviate symptoms, perhaps through antiemetic effects produced by activation of TRPV1 receptors, similar to that of hot water bathing. This review summarizes the epidemiology, clinical presentation, diagnosis, pathophysiology, and management of cannabinoid hyperemesis syndrome, focusing on treatment with topical capsaicin.
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Affiliation(s)
- Janice L Stumpf
- University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Lauren D Williams
- University of Michigan College of Pharmacy, Ann Arbor, MI, USA.,VA Ann Arbor Healthcare System, MI, USA
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27
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DeVuono MV, Parker LA. Cannabinoid Hyperemesis Syndrome: A Review of Potential Mechanisms. Cannabis Cannabinoid Res 2020; 5:132-144. [PMID: 32656345 PMCID: PMC7347072 DOI: 10.1089/can.2019.0059] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Introduction: Cannabinoids have long been known for their ability to treat nausea and vomiting. Recent reports, however, have highlighted the paradoxical proemetic effects of cannabinoids. Cannabinoid hyperemesis syndrome (CHS) is characterized by cyclical episodes of nausea and vomiting, accompanied by abdominal pain following prolonged, high-dose cannabis use, which is alleviated by hot baths and showers. Little is known about the cause of this syndrome. Discussion: Cannabinoids produce a biphasic effect on nausea and vomiting, with low doses having an antiemetic effect and high doses producing emesis. Presentation and treatment of CHS are similar to cyclical vomiting syndrome as well as chemotherapy-related anticipatory nausea and vomiting, suggesting that these phenomena may share mechanisms. The prevalence of CHS is not known because of the symptomatic overlap with other disorders and the lack of knowledge of the syndrome by the public and physicians. Treatment with typical antiemetic drugs is ineffective for CHS, but anxiolytic and sedative drugs, along with hot showers, seem to be consistently effective at reducing symptoms. The only known way to permanently end CHS, however, is abstinence from cannabinoids. Case studies and limited pre-clinical data on CHS indicate that prolonged high doses of the main psychotropic compound in cannabis, Δ9-tetrahydrocannabinol (THC), result in changes to the endocannabinoid system by acting on the cannabinoid 1 (CB1) receptor. These endocannabinoid system changes can dysregulate stress and anxiety responses, thermoregulation, the transient receptor potential vanilloid system, and several neurotransmitters systems, and are thus potential candidates for mediating the pathophysiology of CHS. Conclusions: Excessive cannabinoid administration disrupts the normal functioning of the endocannabinoid system, which may cause CHS. More clinical and pre-clinical research is needed to fully understand the underlying pathophysiology of this disorder and the negative consequences of prolonged high-dose cannabis use.
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Affiliation(s)
- Marieka V. DeVuono
- Department of Psychology and Collabortive Neuroscience Program, University of Guelph, Guelph, Canada
| | - Linda A. Parker
- Department of Psychology and Collabortive Neuroscience Program, University of Guelph, Guelph, Canada
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28
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Laborde-Casterot H, Larabi IA, Dufayet L, Etting I, Alvarez JC, Vodovar D. Does cannabidiol induce cannabinoid hyperemesis syndrome? Clin Toxicol (Phila) 2020; 58:1351-1352. [PMID: 32163300 DOI: 10.1080/15563650.2020.1736298] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Hervé Laborde-Casterot
- Centre AntiPoison et de Toxicovigilance de Paris - Fédération de toxicologie de l'APHP (FeTox), Hôpital Fernand-Widal - APHP, Paris, France
| | - Islam Amine Larabi
- Laboratoire de Pharmacologie-Toxicologie, Centre Hospitalier Universitaire Raymond Poincaré - APHP, Garches, France.,Plateforme de Spectrométrie de Masse MassSpecLab, INSERM UMR 1173, UFR des Sciences de la Santé Simone Veil, Université Versailles Saint-Quentin, Montigny le Bretonneux, France
| | - Laurène Dufayet
- Centre AntiPoison et de Toxicovigilance de Paris - Fédération de toxicologie de l'APHP (FeTox), Hôpital Fernand-Widal - APHP, Paris, France.,Optimisation Thérapeutique en Neuropsychopharmacologie, INSERM UMR-S 1144, Faculté de Pharmacie, Paris, France.,UFR de médecine, Université de Paris, Paris, France
| | - Isabelle Etting
- Laboratoire de Pharmacologie-Toxicologie, Centre Hospitalier Universitaire Raymond Poincaré - APHP, Garches, France
| | - Jean-Claude Alvarez
- Laboratoire de Pharmacologie-Toxicologie, Centre Hospitalier Universitaire Raymond Poincaré - APHP, Garches, France.,Plateforme de Spectrométrie de Masse MassSpecLab, INSERM UMR 1173, UFR des Sciences de la Santé Simone Veil, Université Versailles Saint-Quentin, Montigny le Bretonneux, France
| | - Dominique Vodovar
- Centre AntiPoison et de Toxicovigilance de Paris - Fédération de toxicologie de l'APHP (FeTox), Hôpital Fernand-Widal - APHP, Paris, France.,Optimisation Thérapeutique en Neuropsychopharmacologie, INSERM UMR-S 1144, Faculté de Pharmacie, Paris, France.,Urgences Médico-Judiciaires, Hôpital Hôtel Dieu - APHP, Paris, France
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29
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Abreu Jáuregui E, López Hernández Á, Mendoza Romero CL, Armas Pérez MDP. [Cannabinoid hyperemesis syndrome during pregnancy: A case report]. Aten Primaria 2019; 52:513-514. [PMID: 31864754 PMCID: PMC7393562 DOI: 10.1016/j.aprim.2019.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 10/15/2019] [Indexed: 11/19/2022] Open
Affiliation(s)
- Emmanuel Abreu Jáuregui
- Unidad Docente de Medicina Familiar y Comunitaria «La Laguna-Tenerife Norte», Tenerife, España.
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30
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Chronic Nausea and Vomiting: Sifting Through the Smoke and Weed. Am J Gastroenterol 2019; 114:1704-1706. [PMID: 31592784 DOI: 10.14309/ajg.0000000000000409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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31
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Howard I. Cannabis Hyperemesis Syndrome in Palliative Care: A Case Study and Narrative Review. J Palliat Med 2019; 22:1227-1231. [DOI: 10.1089/jpm.2018.0531] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Ileana Howard
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
- Rehabilitation Care Services, VA Puget Sound, Seattle, Washington
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32
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Wagner S, Hoppe J, Zuckerman M, Schwarz K, McLaughlin J. Efficacy and safety of topical capsaicin for cannabinoid hyperemesis syndrome in the emergency department. Clin Toxicol (Phila) 2019; 58:471-475. [PMID: 31482758 DOI: 10.1080/15563650.2019.1660783] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Introduction: Cannabinoid hyperemesis syndrome (CHS) is a disorder of cyclic and recurrent nausea, vomiting, and abdominal pain associated with high-frequency and extended-duration marijuana use. Standard antiemetic therapy is often ineffective; however, capsaicin, an agonist of transient receptor potential vanilloid 1 (TRPV1), has shown promise in treating CHS.Methods: This retrospective cohort analysis evaluated the safety and efficacy of topical capsaicin for patients presenting with CHS. The primary outcome was to assess if utilization of capsaicin for ED management of CHS decreased ED length of stay (LOS) as compared to a visit without capsaicin. Secondary outcomes included a cost analysis, use of rescue therapies, and adverse events.Results: Forty-three patients met the inclusion criteria within the study period. ED LOS was reduced with capsaicin by a median of 22 minutes (201 vs. 179 min, p = 0.33). Patients received fewer additional medications if capsaicin was utilized (4 vs. 3 doses, p = 0.015), and 67% of visits where capsaicin was utilized required no further treatment prior to discharge. Additionally, opioid usage was less when utilizing capsaicin (166.5 vs. 69 mg OME). Forty-two percent of patients did not have a repeat CHS presentation to the ED after receiving capsaicin for an additional three months after the study period ended. Total medication cost was minimally more expensive (median difference of $3.26) in the capsaicin group. There were no significant adverse events reported with capsaicin.Conclusion: There was no significant difference in ED LOS when capsaicin was utilized for CHS. However, there was a decrease in total medications administered and a reduction in opioid requirements. While medication costs for capsaicin visits were minimally more expensive, the utility of capsaicin as an over-the-counter (OTC) product may empower at home therapy with OTC products, decreasing potentially unnecessary healthcare encounters and costs.
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Affiliation(s)
- Samantha Wagner
- Department of Pharmacy, University of Colorado Hospital, Aurora, CO, USA.,University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Jason Hoppe
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA.,Rocky Mountain Poison and Drug Center, Denver Health, Denver, CO, USA
| | - Matthew Zuckerman
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA.,Rocky Mountain Poison and Drug Center, Denver Health, Denver, CO, USA
| | - Kerry Schwarz
- Department of Pharmacy, University of Colorado Hospital, Aurora, CO, USA.,University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Julie McLaughlin
- Department of Pharmacy, University of Colorado Hospital, Aurora, CO, USA.,University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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33
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Affiliation(s)
- Yaniv Chocron
- Internal medicine, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Julien Vaucher
- Internal medicine, Lausanne University Hospital, Lausanne, Switzerland
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34
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Burillo Putze G, Darias-Acosta AT, López-Hernández Á. Improving the diagnosis of cannabinoid hyperemesis syndrome. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 111:574-575. [PMID: 31190547 DOI: 10.17235/reed.2019.6003/2018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Two recent publications in this journal regarding cannabinoid hyperemesis syndrome (CHS) reflect a common fact in the clinical practice. Although the syndrome is increasingly well-known, patients still receive a late diagnosis, sometimes after years of delay. This entails multiple visits to the ER, as well multiple outpatient visits and diagnostic tests in gastroenterology departments. Furthermore, there are many unnecessary hospital admissions that are often accompanied by an uncertain discharge diagnosis (psychogenic vomiting, etc.).
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35
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Lua J, Olney L, Isles C. Cannabis hyperemesis syndrome: still under recognised after all these years. J R Coll Physicians Edinb 2019; 49:132-134. [PMID: 31188343 DOI: 10.4997/jrcpe.2019.210] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Cannabis hyperemesis syndrome (CHS) is characterised by cyclical vomiting, relieved by hot water bathing, in the context of chronic cannabis consumption. Many cannabis users find this hard to accept given that cannabis is often promoted as a treatment for vomiting. Stopping cannabis is the best and only effective way to manage the condition. We report a case showing that CHS remains under recognised 15 years after it was first described.
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Affiliation(s)
- Joanne Lua
- Medical Unit, Dumfries Royal Infirmary, Dumfries, UK
| | - Lauren Olney
- Medical Unit, Dumfries Royal Infirmary, Dumfries, UK
| | - Chris Isles
- Medical Unit, Dumfries Royal Infirmary, Dumfries DG2 8RX, UK,
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36
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Abstract
OBJECTIVES Gastroparesis (Gp) can be a challenging disorder to manage due to the paucity of treatment options. We do not know how frequently patients with Gp symptoms resort to cannabinoids to address their symptoms. This study (i) determines the prevalence of cannabinoid use in patients with Gp symptoms, (ii) describes the patients with Gp symptoms using cannabinoids, and (iii) assesses the patients' perceived benefit of cannabinoids for Gp symptoms. METHODS Consecutive outpatients with symptoms suggestive of Gp seen on follow-up at our academic center from June 2018 to September 2018 filled out questionnaires on their symptoms and the current treatments. RESULTS Of 197 patients, nearly half (n = 92, 46.7%) reported current (35.5%) or past (11.2%) use of cannabinoids, including tetrahydrocannabinol (n = 63), dronabinol (n = 36), and/or cannabidiol (n = 16). Of these, most perceived improvement in Gp symptoms from cannabinoids (93.5% with tetrahydrocannabinol, 81.3% with cannabidiol, and 47.2% with dronabinol). Cannabinoids were used most commonly via smoking (n = 46). Patients taking cannabinoids were younger (41.0 ± 15.4 vs 48.0 ± 15.9 years; P < 0.01) and had a higher Gastroparesis Cardinal Symptom Index total score (3.4 ± 1.0 vs 2.8 ± 1.3; P < 0.01) compared with patients with no history of cannabinoid use. CONCLUSIONS A third of patients with Gp symptoms actively use cannabinoids for their chronic symptoms. Most of these patients perceive improvement in their symptoms with cannabinoids. Patients taking cannabinoids were younger and more symptomatic than those not taking cannabinoids. Further studies on the efficacy and safety of cannabinoids in Gp will be useful.
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37
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McConachie SM, Caputo RA, Wilhelm SM, Kale-Pradhan PB. Efficacy of Capsaicin for the Treatment of Cannabinoid Hyperemesis Syndrome: A Systematic Review. Ann Pharmacother 2019; 53:1145-1152. [DOI: 10.1177/1060028019852601] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Objective: Cannabinoid hyperemesis syndrome (CHS) is characterized by cyclic vomiting, abdominal pain, and alleviation of symptoms via hot showers in chronic cannabinoid users. Capsaicin is recommended as a reasonable first-line treatment approach for CHS despite limited clinical evidence regarding its use. The objective of this study is to systematically review the efficacy data for capsaicin in CHS. Data Sources: A literature search using keywords related to cannabinoids, emesis, and capsaicin was performed in MEDLINE, CINAHL, and EMBASE from inception through March 31, 2019. Study Selection and Data Extraction: Studies and published abstracts in which capsaicin was used for CHS and clinical outcomes were reported were eligible for inclusion. Data Synthesis: A total of 241 articles were screened, of which 5 full-text articles and 6 conference abstracts were included. Full-text case reports (n = 3) and case series (n = 2) found capsaicin to be effective in a total of 18 patients. Published abstracts were in the form of case reports (n = 1), case series (n = 3), and retrospective cohort studies (n = 2). Relevance to Patient Care and Clinical Practice: Capsaicin use was described as beneficial in all case series and case reports; however, both retrospective cohort studies were unable to find a significant benefit for capsaicin on primary outcomes (emergency department length of stay). Conclusion: Current data for capsaicin efficacy in CHS is of low methodological quality. However, the limited data on alternative antiemetic therapies and capsaicin’s favorable risk-benefit profile make it a reasonable adjunctive treatment option.
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Affiliation(s)
- Sean M. McConachie
- Wayne State University, Detroit, MI, USA
- Beaumont Hospital, Dearborn, MI, USA
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38
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Banister SD, Arnold JC, Connor M, Glass M, McGregor IS. Dark Classics in Chemical Neuroscience: Δ 9-Tetrahydrocannabinol. ACS Chem Neurosci 2019; 10:2160-2175. [PMID: 30689342 DOI: 10.1021/acschemneuro.8b00651] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Cannabis ( Cannabis sativa) is the most widely used illicit drug in the world, with an estimated 192 million users globally. The main psychoactive component of cannabis is (-)- trans-Δ9-tetrahydrocannabinol (Δ9-THC), a compound with a diverse range of pharmacological actions. The unique and distinctive intoxication caused by Δ9-THC primarily reflects partial agonist action at central cannabinoid type 1 (CB1) receptors. Δ9-THC is an approved therapeutic treatment for a range of conditions, including chronic pain, chemotherapy-induced nausea and vomiting, and multiple sclerosis, and is being investigated in indications such as anorexia nervosa, agitation in dementia, and Tourette's syndrome. It is available as a regulated pharmaceutical in products such as Marinol, Sativex, and Namisol as well as in an ever-increasing range of unregistered medicinal and recreational cannabis products. While cannabis is an ancient medicament, contemporary use is embroiled in legal, scientific, and social controversy, much of which relates to the potential hazards and benefits of Δ9-THC itself. Robust contemporary debate surrounds the therapeutic value of Δ9-THC in different diseases, its capacity to produce psychosis and cognitive impairment, and the addictive and "gateway" potential of the drug. This review will provide a profile of the chemistry, pharmacology, and therapeutic uses of Δ9-THC as well as the historical and societal import of this unique, distinctive, and ubiquitous psychoactive substance.
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Affiliation(s)
- Samuel D. Banister
- Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW 2050, Australia
- Faculty of Science and School of Chemistry, The University of Sydney, Sydney, NSW 2006, Australia
| | - Jonathon C. Arnold
- Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW 2050, Australia
- School of Medical Science and Discipline of Pharmacology, The University of Sydney, Sydney, NSW 2006, Australia
| | - Mark Connor
- Faculty of Medicine and Health Sciences, Macquarie University, Macquarie Park, NSW 2109, Australia
| | - Michelle Glass
- Department of Pharmacology and Toxicology, University of Otago, Dunedin 9016, New Zealand
| | - Iain S. McGregor
- Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW 2050, Australia
- Faculty of Science and School of Psychology, The University of Sydney, Sydney, NSW 2006, Australia
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39
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Pergolizzi Jr. JV, LeQuang JA, Bisney JF. Cannabinoid Hyperemesis. Med Cannabis Cannabinoids 2019; 1:73-95. [PMID: 34676325 PMCID: PMC8489348 DOI: 10.1159/000494992] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 10/30/2018] [Indexed: 11/08/2023] Open
Abstract
Cannabinoid hyperemesis syndrome (CHS) is a paradoxical condition in which a long-term cannabis user suffers an episode of intractable vomiting that may last days separated by longer asymptomatic periods of weeks or months. Cannabinoids are often utilized for their antiemetic properties, so CHS can be a puzzling condition, and the diagnosis of CHS may be disputed by patients. Unlike other cyclic vomiting syndromes, CHS can be relieved by hot showers or topical capsaicin. Abstinence from cannabinoids causes CHS to resolve, sometimes in a matter of days or hours. Marijuana users as well as many clinicians are not aware of CHS, and patients may undergo unnecessary tests, scans, and other procedures to get an accurate diagnosis. Symptoms may be severe enough to require hospitalization. With liberalization of marijuana laws and favorable public opinion about the healing properties of cannabis, CHS may be more frequently observed in clinical practice.
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41
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Abstract
A young woman with chronic cannabis use presents with 2-day history of cyclical nausea, vomiting and abdominal pain. Clinical and laboratory examination excluded other causes. Patient's symptoms improved with topical capsaicin, hot showers, antiemetics and she was subsequently discharged home 4 days later. The patient was educated on side effects of cannabis use and chose to stop cannabis use completely.
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Affiliation(s)
- Umesh Sharma
- Community Division of Hospital Medicine, Mayo Clinic Health System, Rochester, Minnesota, USA
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42
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Abstract
Adolescent substance abuse remains common, with almost a third of adolescents admitting to ethanol use, and a quarter admitting to illicit drug use. It is essential for pediatricians to regularly screen adolescent patients for substance use, because early initiation of drug use has been associated with physical, behavioral, and social health risks. Adolescents abuse what is common and readily available; this includes ethanol, over-the-counter products, marijuana, and inhalants. The most common and effective clinical treatments for significant toxicity from substances of abuse is symptomatic and supportive care including hemodynamic support, respiratory support, and sedation to control psychomotor agitation.
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Affiliation(s)
- George Sam Wang
- Section of Emergency Medicine and Medical Toxicology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO.,Rocky Mountain Poison and Drug Center, Denver Health Hospital, Denver, CO
| | - Christopher Hoyte
- Rocky Mountain Poison and Drug Center, Denver Health Hospital, Denver, CO.,Department of Emergency Medicine and Medical Toxicology, University of Colorado Anschutz Medical Campus, University Hospital, Aurora, CO
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43
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Richards JR. Cannabinoid Hyperemesis Syndrome: Pathophysiology and Treatment in the Emergency Department. J Emerg Med 2018; 54:354-363. [DOI: 10.1016/j.jemermed.2017.12.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 09/14/2017] [Accepted: 12/01/2017] [Indexed: 12/19/2022]
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44
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Moon AM, Buckley SA, Mark NM. Successful Treatment of Cannabinoid Hyperemesis Syndrome with Topical Capsaicin. ACG Case Rep J 2018; 5:e3. [PMID: 29379817 PMCID: PMC5758720 DOI: 10.14309/crj.2018.3] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 11/08/2017] [Indexed: 12/11/2022] Open
Abstract
Cannabinoid hyperemesis syndrome (CHS) is a clinical entity in which marijuana users develop nausea, vomiting, and abdominal pain that improves with hot water bathing or cannabis cessation. Previous models suggest that CHS arises solely from the derangement of cannabinoid receptor type 1 signaling. However, involvement of transient receptor potential vanilloid subtype 1 (TRPV1) receptor, which is activated by marijuana, capsaicin, and heat, could fill gaps in existing models, including the enigmatic role of hot water bathing. We propose that chronic cannabis use decreases TRPV1 signaling and alters gastric motility, and we report the case of a CHS patient whose symptoms improved after topical capsaicin.
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Affiliation(s)
- Andrew M Moon
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Sarah A Buckley
- Hematology/Oncology Fellowship Program, University of Washington, Seattle, WA
| | - Nicholas M Mark
- Division of Pulmonary and Critical Care, University of Washington, Seattle, WA
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