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DeVuono MV, Venkatesan T, Hillard CJ. Endocannabinoid signaling in stress, nausea, and vomiting. Neurogastroenterol Motil 2024:e14911. [PMID: 39223918 DOI: 10.1111/nmo.14911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 08/06/2024] [Accepted: 08/20/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Classical antiemetics that target the serotonin system may not be effective in treating certain nausea and vomiting conditions like cyclic vomiting syndrome (CVS) and cannabinoid hyperemesis syndrome (CHS). As a result, there is a need for better therapies to manage the symptoms of these disorders, including nausea, vomiting, and anxiety. Cannabis is often used for its purported antiemetic and anxiolytic effects, given regulation of these processes by the endocannabinoid system (ECS). However, there is considerable evidence that cannabinoids can also produce nausea and vomiting and increase anxiety in certain instances, especially at higher doses. This paradoxical effect of cannabinoids on nausea, vomiting, and anxiety may be due to the dysregulation of the ECS, altering how it maintains these processes and contributing to the pathophysiology of CVS or CHS. PURPOSE The purpose of this review is to highlight the involvement of the ECS in the regulation of stress, nausea, and vomiting. We discuss how prolonged cannabis use, such as in the case of CHS or heightened stress, can dysregulate the ECS and affect its modulation of these functions. The review also examines the evidence for the roles of ECS and stress systems' dysfunction in CVS and CHS to better understand the underlying mechanisms of these conditions.
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Affiliation(s)
- Marieka V DeVuono
- Department of Anatomy and Cell Biology, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Thangam Venkatesan
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Cecilia J Hillard
- Department of Pharmacology and Toxicology and Neuroscience Research Center, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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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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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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DeVuono MV, La Caprara O, Sullivan MT, Bath A, Petrie GN, Limebeer CL, Rock EM, Hill MN, Parker LA. Role of the stress response and the endocannabinoid system in Δ 9-tetrahydrocannabinol (THC)-induced nausea. Psychopharmacology (Berl) 2020; 237:2187-2199. [PMID: 32399633 DOI: 10.1007/s00213-020-05529-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 04/16/2020] [Indexed: 12/20/2022]
Abstract
RATIONALE Dysregulation of the endocannabinoid (eCB) system by high doses of Δ9-tetrahydrocannabinol (THC) is hypothesized to generate a dysfunctional hypothalamic-pituitary-adrenal (HPA) axis contributing to cannabinoid hyperemesis syndrome (CHS). OBJECTIVES AND METHODS Using the conditioned gaping model of nausea, we aimed to determine if pre-treatments that interfere with stress, or an anti-emetic drug, interfere with THC-induced nausea in male rats. The corticotropin-releasing hormone (CRH) antagonist, antalarmin, was given to inhibit the HPA axis during conditioning. Since eCBs inhibit stress, MJN110 (which elevates 2-arachidonylglycerol (2-AG)) and URB597 (which elevates anandamide (AEA)) were also tested. Propranolol (β-adrenergic antagonist) and WAY-100635 (5-HT1A antagonist) attenuate HPA activation by cannabinoids and, therefore, were assessed. In humans, CHS symptoms are not alleviated by anti-emetic drugs, such as ondansetron (5-HT3 antagonist); however, benzodiazepines are effective. Therefore, ondansetron and chlordiazepoxide were tested. To determine if HPA activation by THC is dose-dependent, corticosterone (CORT) was analyzed from serum of rats treated with 0.0, 0.5, or 10 mg/kg THC. RESULTS Antalarmin (10 and 20 mg/kg), MJN110 (10 mg/kg), URB597 (0.3 mg/kg), propranolol (2.5 and 5 mg/kg), WAY-100635 (0.5 mg/kg), and chlordiazepoxide (5 mg/kg) interfered with THC-induced conditioned gaping, but the anti-emetic ondansetron (0.1 and 0.01 mg/kg) did not. THC produced significantly higher CORT levels at 10 mg/kg than at 0.0 and 0.5 mg/kg THC. CONCLUSIONS Treatments that interfere with the stress response also inhibit THC-induced conditioned gaping, but a typical anti-emetic drug does not, supporting the hypothesis that THC-induced nausea, and CHS, is a result of a dysregulated stress response.
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Affiliation(s)
- Marieka V DeVuono
- Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, ON, N1G 2W1, Canada
| | - Olivia La Caprara
- Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, ON, N1G 2W1, Canada
| | - Megan T Sullivan
- Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, ON, N1G 2W1, Canada
| | - Alexandra Bath
- Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, ON, N1G 2W1, Canada
| | - Gavin N Petrie
- Departments of Cell Biology and, Anatomy and Psychiatry, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, T2N 4N1, Canada
| | - Cheryl L Limebeer
- Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, ON, N1G 2W1, Canada
| | - Erin M Rock
- Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, ON, N1G 2W1, Canada
| | - Matthew N Hill
- Departments of Cell Biology and, Anatomy and Psychiatry, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, T2N 4N1, Canada
| | - Linda A Parker
- Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, ON, N1G 2W1, Canada.
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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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Venkatesan T, Levinthal DJ, Li BUK, Tarbell SE, Adams KA, Issenman RM, Sarosiek I, Jaradeh SS, Sharaf RN, Sultan S, Stave CD, Monte AA, Hasler WL. Role of chronic cannabis use: Cyclic vomiting syndrome vs cannabinoid hyperemesis syndrome. Neurogastroenterol Motil 2019; 31 Suppl 2:e13606. [PMID: 31241817 PMCID: PMC6788295 DOI: 10.1111/nmo.13606] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 03/17/2019] [Accepted: 03/25/2019] [Indexed: 12/13/2022]
Abstract
Cannabis is commonly used in cyclic vomiting syndrome (CVS) due to its antiemetic and anxiolytic properties. Paradoxically, chronic cannabis use in the context of cyclic vomiting has led to the recognition of a putative new disorder called cannabinoid hyperemesis syndrome (CHS). Since its first description in 2004, numerous case series and case reports have emerged describing this phenomenon. Although not pathognomonic, a patient behavior called "compulsive hot water bathing" has been associated with CHS. There is considerable controversy about how CHS is defined. Most of the data remain heterogenous with limited follow-up, making it difficult to ascertain whether chronic cannabis use is causal, merely a clinical association with CVS, or unmasks or triggers symptoms in patients inherently predisposed to develop CVS. This article will discuss the role of cannabis in the regulation of nausea and vomiting, specifically focusing on both CVS and CHS, in order to address controversies in this context. To this objective, we have collated and analyzed published case series and case reports on CHS in order to determine the number of reported cases that meet current Rome IV criteria for CHS. We have also identified limitations in the existing diagnostic framework and propose revised criteria to diagnose CHS. Future research in this area should improve our understanding of the role of cannabis use in cyclic vomiting and help us better understand and manage this disorder.
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Affiliation(s)
- Thangam Venkatesan
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsin
| | - David J. Levinthal
- Division of Gastroenterology, Hepatology, and NutritionUniversity of Pittsburgh Medical CenterPittsburghPennsylvania
| | - B U. K. Li
- Department of PediatricsMedical College of WisconsinMilwaukeeWisconsin
| | - Sally E. Tarbell
- Department of Psychiatry and Behavioral SciencesNorthwestern Feinberg School of MedicineChicagoIllinois
| | | | - Robert M. Issenman
- Division of Pediatric GastroenterologyMcMaster UniversityHamiltonOntarioCanada
| | - Irene Sarosiek
- Division of GastroenterologyTexas Tech University Health Sciences CenterEl PasoTexas
| | | | - Ravi N. Sharaf
- Division of GastroenterologyDepartment of Medicine and Department of Healthcare Policy and ResearchWeill Cornell Medical CenterNew YorkNew York
| | | | | | - Andrew A. Monte
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColorado
| | - William L. Hasler
- Division of GastroenterologyUniversity of Michigan Health SystemAnn ArborMichigan
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Lee C, Greene SL, Wong A. The utility of droperidol in the treatment of cannabinoid hyperemesis syndrome. Clin Toxicol (Phila) 2019; 57:773-777. [DOI: 10.1080/15563650.2018.1564324] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Carl Lee
- Austin Clinical School, University of Melbourne, Melbourne, Australia
| | - Shaun L. Greene
- Austin Clinical School, University of Melbourne, Melbourne, Australia
- Austin Health, Austin Toxicology Unit and Victorian Poisons Information Centre, Heidelberg, Australia
| | - Anselm Wong
- Austin Clinical School, University of Melbourne, Melbourne, Australia
- Austin Health, Austin Toxicology Unit and Victorian Poisons Information Centre, Heidelberg, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Australia
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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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Abstract
BACKGROUND Cannabinoid hyperemesis syndrome (CHS) is a syndrome of cyclic vomiting associated with chronic cannabis use. As cannabis consumption steadily increases each year, CHS is becoming a commonplace and costly occurrence in hospitals nationwide. Currently, there are no best treatment strategies agreed upon universally. AREAS OF UNCERTAINTY Thus far, most data about CHS have come from case reports and case series. Consequently, the pathophysiology of the syndrome is unclear, and its occurrence in some cannabis users, but not others, is not understood. DATA SOURCES A literature search was conducted through PubMed, Embase, and Google Scholar from inception until 2017. Publications only in English describing the epidemiology, pathophysiology, diagnostic criteria, and treatments of CHS were incorporated after thorough evaluation. National government surveys were also referred to for current information about the CHS patient population. RESULTS CHS should be considered in the differential diagnosis of any patient presenting with persistent nausea and vomiting. In particular, the diagnosis is suggested if the patient demonstrates regular and chronic cannabis use, intractable nausea and vomiting, cyclical vomiting, relief of symptoms with hot baths, and resolution of symptoms after cannabis cessation. There are currently many possible explanations regarding the mechanisms behind CHS. A variety of treatment options have also been examined, including hot water baths, haloperidol, capsaicin, and benzodiazepines. CONCLUSIONS CHS is becoming an increasingly prevalent and complicated problem for health care providers and patients. Further research must be done to address the diagnostic and therapeutic challenges of this syndrome.
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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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