Greater intolerance to uncertainty predicts poorer quality of life in adults with cyclic vomiting syndrome

Endocannabinoid signaling in stress, nausea, and vomiting

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.

A call to action [plans] for cyclic vomiting syndrome

Cyclic vomiting syndrome (CVS) is a disorder of gut-brain interaction which has a wide clinical spectrum. Clinical action plans have been developed to address and to facilitate treatment in the setting of complex, chronic medical conditions. The CVS Action Plan was developed to meet the chronic and acute care needs of children and adults with CVS. While this tool has not been tested for clinical efficacy as was shown with action plans for functional constipation, anecdotal and indirect evidence supports its use. The CVS Action Plan has the potential to enhance outcomes by simplifying home management and streamlining disease recognition and acute care in the emergency department.

Acute care of cyclic vomiting syndrome and cannabinoid hyperemesis syndrome in the home and emergency department for: Special supplement/proceedings of 3rd international symposium

BACKGROUND

Cyclic vomiting syndrome (CVS) and cannabinoid hyperemesis syndrome (CHS) are both characterized by episodic, acute transitions from asymptomatic states to highly symptomatic states of nausea, repetitive vomiting, and often severe abdominal pain. Patients with CVS and CHS face significant challenges to abort or mitigate episodes at home and often require emergency department (ED)-based care.

PURPOSE

This paper reviews the current treatment approach to abort acute CVS and CHS episodes at home and in ED settings. Multiple pharmacologic and nonpharmacologic interventions have been demonstrated to potentially abort CVS or CHS episodes. Systemic pharmacologic agents often used as abortive therapy include triptans, antiemetics, anxiolytics, NK-1 receptor antagonists, antipsychotics, sedatives in general, and various analgesic / anti-inflammatory medications. Nonsystemic, nonpharmacologic approaches include reducing external stimuli (quiet room, dim lights, etc.), and hot water bathing or the application of topical capsaicin cream. More research is needed to develop evidence-based, individualized abortive treatment plans, as well as to determine whether the abortive treatment for CVS requires a fundamentally different approach than for CHS. When home-based approaches fail, all patients with CVS or CHS should receive nonjudgmental, informed, and compassionate care in the ED to abort their episode. Patients with more severe forms of CVS/CHS who require more frequent ED utilization should develop care plans with their ED to assure predictable and effective treatment.

Acute and Long-Term Effects of App-Delivered Heartfulness Meditation on Psychological Outcomes and the Endocannabinoid Signaling System in Cyclic Vomiting Syndrome

INTRODUCTION

Cyclic vomiting syndrome (CVS) is a disorder of gut-brain interaction often triggered by stress. Interventions such as meditation may improve psychological outcomes and health-related quality of life (HRQoL), but their efficacy and the underlying mechanism are unknown.

METHODS

We conducted a 6-week single-arm pilot study to assess the effects of heartfulness meditation (HFM) in CVS using a custom-designed meditation app. Primary outcomes included state and trait anxiety and mood state changes pre vs post-meditation, and secondary outcomes were psychological distress, coping, sleep quality, and HRQoL at baseline and at weeks 3 and 6. Serum concentrations of endocannabinoids N -arachidonylethanolamine and 2-arachidonoylglycerol and related lipids were measured pre- and post-HFM at baseline and week 6.

RESULTS

In 30 treatment completers, there was a significant improvement in state anxiety ( P < 0.001), total mood disturbance ( P < 0.001), and other mood states (all P values < 0.05) across the 3 time points. Trait anxiety was also improved at week 6. There was a significant improvement in psychological distress (Global Severity Index), sleep quality (daytime dysfunction), coping (using religion/spirituality), and HRQoL (mental and physical) across the 3 time points (all P < 0.05). Significant increases in N -arachidonylethanolamine and related lipids N -oleoylethanolamine and palmitoylethanolamide post vs pre-HFM were observed at week 6 ( P < 0.001, 0.002, 0.003, respectively). No adverse effects were noted.

DISCUSSION

App-delivered HFM is feasible, safe, and effective and improves psychological outcomes and augments endocannabinoids. This provides insight into the mechanism underlying HFM and has potential for widespread use as a digital therapeutic in CVS and other disorder of gut-brain interaction.

Cyclic vomiting syndrome: From pathophysiology to treatment

Cyclic vomiting syndrome (CVS) is a disorder characterized by recurrent and unpredictable episodes of intense vomiting, interspersed with periods of apparent wellbeing. This disorder, which primarily affects children and adolescents but can persist into adulthood, has recently been the subject of extensive study and analysis in the medical literature. The aim of the present review is to examine the most important aspects of the epidemiology, pathophysiology, subtypes, diagnostic criteria, and current management of CVS. Even though the exact etiology remains unknown, genetic factors (polymorphisms), nervous system alterations and autonomic dysregulation, and environmental factors (use and abuse of cannabinoids) are postulated as possible triggers. CVS has significant diagnostic challenges, given that there is no specific test for confirming its presence. Thorough evaluation of symptoms and the ruling out of other possible causes of recurrent vomiting are required. Management of CVS typically involves a multidisciplinary approach. Pharmacologic options are explored, such as antiemetics and preventive medications, as well as behavioral and psychologic support therapies. Treatment personalization is essential, adapting it to the individual needs of each patient. Despite advances in the understanding of CVS, it remains a significant clinical challenge. This disorder impacts the quality of life of those affected and their families, underscoring the ongoing need for research and the development of more effective treatment strategies.

Association of Anxiety and Gastrointestinal Comorbidities in Repeat Hospital Admissions in Pediatric Cyclic Vomiting Syndrome

INTRODUCTION

Cyclic vomiting syndrome (CVS) is a functional gastrointestinal disorder with recurrent episodes of intense nausea and vomiting and thus may require frequent hospitalizations. There is paucity of data exploring the association of psychiatric and gastrointestinal comorbidities in repeat hospitalizations among pediatric patients with CVS.

METHODS

We analyzed the Pediatric Health Information System database and included all patients up to 18 years of age with a diagnosis of CVS between 2016 and 2020. We excluded patients with chronic conditions, which mimic CVS. The primary outcome variable was 90-day admission rate, which was defined as a visit to emergency department or admission to observation/inpatient unit with a primary diagnosis of CVS within 90 days after an index CVS hospitalization.

RESULTS

We evaluated a total of 2,604 hospitalizations represented by 1,370 unique individuals. The overall 90-day admission rate was 28.5%, which steadily decreased from 35.7% in 2016 to 23% in 2019 ( P < 0.001). Patients in the repeat hospitalization cohort were slightly older and more often men. Patients with repeat admissions had an increased proportion of anxiety and other gastrointestinal disorders. Multivariable logistic regression showed that anxiety, gastroesophageal reflux disease, functional dyspepsia, and abdominal migraine were associated with increased odds of repeat admissions.

DISCUSSION

Ninety-day admission rates in pediatric CVS are decreasing overall, although still contributing to significant healthcare expenditure. Anxiety and gastrointestinal comorbidities were associated with increased risk of repeat admissions. Further prospective studies are needed to better understand the complex interactions of these comorbidities and their management affecting the natural course of CVS.

Negative Impact of Disorders of Gut-Brain Interaction on Health-Related Quality of Life: Results From the Rome Foundation Global Epidemiology Survey

BACKGROUND & AIMS

This study used the database from the Rome Foundation Global Epidemiology Survey to assess the differences in quality of life overall, and by age and sex, across individual disorders of gut-brain interaction (DGBI), gastrointestinal anatomical region(s), and number of overlapping DGBI.

METHODS

Data were collected via the Internet in 26 countries, using the Rome IV diagnostic questionnaire and a supplemental questionnaire including the Patient-Reported Outcomes Measurement Information Systems Global-10 quality of life measure. Factorial analyses of variance were used to explore physical and mental quality of life, adjusting for multiple comparisons.

RESULTS

Among the 54,127 respondents, quality of life deteriorated significantly with increasing number of overlapping DGBI, with respondents reporting ≥2 DGBI having significantly poorer quality of life than those with only 1 DGBI or those without any DGBI. Men with DGBI reported better quality of life than women, and those aged ≥65 years reported better quality of life than those <65 years. Age, sex, number of overlapping DGBI, somatization, anxiety, depression, and functional experiences (concern, embarrassment, or stress associated with bowel functioning) relating to DGBI, were significant predictors of poorer physical and mental quality of life.

CONCLUSIONS

This study is the most comprehensive assessment of quality of life to date in adults living with a DGBI. It provides a representative picture of DGBI impact on adults in the global adult population and highlights the significant detrimental impact of living with a DGBI on quality of life.

Diagnosis and Management of Cyclic Vomiting Syndrome: A Critical Review

Cyclic vomiting syndrome (CVS) is a chronic disorder of gut-brain interaction characterized by recurrent disabling episodes of nausea, vomiting, and abdominal pain. CVS affects both children and adults with a prevalence of approximately 2% in the United States. CVS is more common in female individuals and affects all races. The pathophysiology of CVS is unknown and a combination of genetic, environmental, autonomic, and neurohormonal factors is believed to play a role. CVS is also closely associated with migraine headaches and likely have a shared pathophysiology. The diagnosis of CVS is based on the Rome criteria, and minimal recommended testing includes an upper endoscopy and imaging studies of the abdomen. CVS is frequently associated with anxiety, depression, and autonomic dysfunction. Patients with CVS commonly use cannabis therapeutically for symptom relief. By contrast, cannabinoid hyperemesis syndrome is believed to be a subset of CVS with chronic heavy cannabis use leading to hyperemesis. Due to the recalcitrant nature of the illness, patients often visit the emergency department and are hospitalized for acute CVS flares. Guidelines on the management of CVS recommend a biopsychosocial approach. Prophylactic therapy consists of tricyclic antidepressants (amitriptyline), antiepileptics (topiramate), and aprepitant in refractory patients. Abortive therapy consists of triptans, antiemetics (ondansetron), and sedation. Treatment of comorbid conditions is extremely important to improve overall patient outcomes. CVS has a significant negative impact on patients, families, and the healthcare system, and future research to understand its pathophysiology and develop targeted therapies is needed.

Productivity Loss and Indirect Burden of Cyclic Vomiting Syndrome in the United States

Background and Aims

To quantify the indirect burden of cyclic vomiting syndrome (CVS), we assessed work-related productivity loss in patients with CVS and caregivers using large-sized databases in the United States.

Methods

Patients aged 18-64 years with full-time employment in MarketScan Commercial and Health and Productivity Management Databases were selected if they had ≥1 inpatient or ≥2 outpatient claims for CVS between 2008 and 2018 and continuous enrollment of ≥6 months before and ≥3 months after the initial CVS diagnosis. CVS caregivers were adults with full-time employment and also having dependent(s) with CVS. Propensity scores via multivariable regressions were used to match patients with CVS and their caregivers to non-CVS controls. Productivity loss was assessed by short-term disability (STD) and absenteeism (ABS) days, and the associated costs were also calculated. Differences between the matched cohorts were regarded as the burden attributable to CVS.

Results

Patients with CVS had longer annualized STD (21.1 vs 7.0, P < .001) and ABS days (26.4 vs 22.8, P < .05) than their matched controls. CVS caregivers had more annualized STD (3.9 vs 2.6, P < .001) and ABS days (20.9 vs 19.5, P < .05) than controls. Productivity loss costs for STD or ABS days were greater for patients with CVS and caregivers. Annualized health-care resource utilization (inpatient, emergency room, outpatient) was 5.2-6.0 times higher in patients with CVS (P < .001).

Conclusion

CVS is associated with higher productivity loss due to STD/ABS and, therefore, greater indirect costs for patients and caregivers. Further research is needed to assess the full societal burden of CVS. More effective interventions may reduce the disease burden.