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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Addressing cannabis consumption among patients with hyperemesis gravidarum

Severe nausea and vomiting of pregnancy and hyperemesis gravidarum affect up to 3% of all pregnant people, causing substantial maternal and neonatal morbidity, suffering, and financial cost. Evidence supports the association of cannabis consumption with symptoms of severe nausea and vomiting of pregnancy or hyperemesis gravidarum as the general public has come to believe that cannabis is a natural, safe antiemetic. Cannabis consumption in pregnancy is discouraged strongly by the Surgeon General of the United States and the American College of Obstetricians and Gynecologists because of evidence of potential harms. Symptoms of intractable, severe nausea and vomiting of pregnancy or hyperemesis gravidarum associated with cannabis consumption may be unrecognized cannabinoid hyperemesis syndrome, and this syndrome may be more common than previously thought. Cannabis consumption is especially detrimental when causing or exacerbating debilitating symptoms such as the intense, persistent, recurrent, or cyclic vomiting and associated dehydration and other sequelae of cannabinoid hyperemesis syndrome. Open discussion of cannabis consumption during pregnancy is very challenging for patients and maternity care providers in our current environment of variable legal status across states and variable degrees of personal and societal acceptance. Evidence-based medical knowledge, guidance, tools, and skills are needed to differentially diagnose and treat cannabinoid hyperemesis syndrome in pregnancy. Researchers, clinicians, and medical specialty organizations must work together to strengthen the evidence base and develop or refine the necessary guidelines and tools for maternity care provider skill development, and to increase public and patient awareness of cannabinoid hyperemesis syndrome, specifically during pregnancy.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Marijuana use in children: An update focusing on pediatric tetrahydrocannabinol and cannabidiol use

Cannabis is the most used recreational drug in the United States, and its use is increasing among children and adolescents.  With the increase in legalized use, there have been increases in intentional and accidental cannabis exposure in the pediatric population. There is also minimized perceived risk.  We review the current use of cannabis and its derivatives, the drug effects and clinical presentation, common misconceptions, pharmacology, and epidemiology. Finally, we review some long-term consequences of cannabis use.

Surfactant-mediated extraction of capsaicin from Capsicum annuum L. fruit in various solvents

Capsaicin is a valuable compound found in Capsicum annuum. The present study aimed to explore the efficiency of different solvents and surfactants on its extraction by maceration. Ethyl acetate was found to be the best solvent followed by dichloromethane and acetone, respectively. Overall order of efficiency of the solvents used was this: ethyl acetate > dichloromethane > acetone > glycerol > acetonitrile > methanol > acetic acid > toluene. Extractability of ethyl acetate for capsaicin remained unaffected by the surfactants. Tween-80 had very positive effect on the extraction efficiency of dichloromethane (DCM) and acetone. Kinetics of the extraction with the most efficient solvent ethyl acetate showed extraction of capsaicin to follow a pseudo-second order kinetic model. In conclusion, for extraction of capsaicin from green chili, ethyl acetate was the most powerful amongst the solvents used in the present work and tween-80 had a notable positive effect on the efficiency of DCM and acetone.

A Systematic Review on Cannabis Hyperemesis Syndrome and Its Management Options

INTRODUCTION

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Use of Capsaicin Cream in Cannabinoid Hyperemesis Syndrome in Patients Presenting to the Emergency Department

BACKGROUND

Cannabinoid hyperemesis syndrome (CHS) is characterized by cyclical nausea, vomiting, and abdominal pain often relieved with hot showers. Patients with CHS are usually long-term cannabis smokers whose symptoms are not relieved by antiemetics. The use of topical capsaicin has been recently reported as an adjunctive therapy in the emergency department (ED).

OBJECTIVE

To describe the use of capsaicin cream in patients presenting to the ED with suspected CHS.

METHODS

We performed a retrospective review of patients with suspected CHS receiving capsaicin in an ED from July 2014 to October 2018. We report data on demographics, cannabis consumption, hot showers use, length of stay, concurrent treatments, pain scores, and adverse events.

RESULTS

There were 57 patients who received capsaicin cream for suspected CHS. Nearly all patients received antiemetics (98%), whereas 47% of patients received an opioid. Antiemetics were typically administered first (median, 1.6 hours; interquartile range [IQR], 0.9-2.4]), followed by an opioid (median, 1.8 hours [IQR, 1-3.75]), followed by capsaicin cream (median 4 hours [IQR, 2.7-5.2]). The overall precapsaicin pain score was 8 (IQR, 2-9), decreasing to 5.5 (IQR, 0-8). Around 42% of patients received no further symptomatic therapy after capsaicin. No adverse drug events to capsaicin were reported.

CONCLUSION AND RELEVANCE

This is the largest retrospective study describing capsaicin cream use in suspected CHS patients with a focus on abdominal pain relief. Capsaicin treatment was associated with a modest pain score reduction. Application of these findings may help providers in identifying more effective therapies to provide symptomatic relief for CHS patients.

Efficacy of topical capsaicin for the treatment of cannabinoid hyperemesis syndrome: A retrospective cohort study

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.

Diagnosis and Acute Management of Adolescent Cannabinoid Hyperemesis Syndrome: A Systematic Review

PURPOSE

This study aimed to synthesize qualitative and quantitative data on the diagnosis and effective management of cannabinoid hyperemesis syndrome (CHS) in the adolescent population.

METHODS

Using keywords, 1,334 studies published between December 1954 and December 2019 were extracted from MEDLINE via PubMed, Embase via OVID, CINAHL via EBSCO, Web of Science, and the Cochrane Library. Studies were evaluated by two independent reviewers using predetermined inclusion and exclusion criteria.

RESULTS

The search yielded 148 studies for full-text review, of which 21 were included in this systematic review. A total of 10 articles were related to the diagnosis of CHS, while 11 articles discussed the treatment and management of adolescent cases of CHS.

CONCLUSIONS

CHS in the adolescent population fulfills the major and minor diagnostic criteria of CHS in the adult population; however, in adolescent patients, CHS may present more frequently in females, with the earliest reported case presenting at age 15 years. There appears to be a substantial proportion (21%) of adolescent patients diagnosed with CHS that have a history of anxiety and depression; however, higher quality studies to assess the prevalence are warranted. Although haloperidol and topical capsaicin cream may provide symptom relief in isolated cases, complete cessation of cannabis use is currently the only known effective treatment.

Topical capsaicin for the treatment of cannabinoid hyperemesis syndrome, a systematic review and meta-analysis

INTRODUCTION

Cannabinoid hyperemesis syndrome (CHS) is a condition that is being recognized and treated more frequently in emergency departments (EDs) across the United States. Currently, ED providers rely on antiemetics, antipsychotics and benzodiazepines to alleviate the symptoms. Topical capsaicin, a transient receptor potential vanilloid 1 (TRPV1) agonist, has been proposed in recent years as a low-cost and effective alternative to the traditional antiemetic regimen when treating CHS. The aim of this systematic review and meta-analysis is to demonstrate the reliability and the gaps of what is known about this treatment modality.

METHODS

Articles were extracted from PubMed, SCOPUS, and Google Scholar databases. Publication dates ranged from the inception of the databases to October 2020. Initial searches found 328 studies. After careful review and screening by two investigators, 7 studies met the inclusion criteria and were included for our meta-analysis. Variables that were evaluated included the prevalence of hospital admissions for patients treated with capsaicin, time to relief of symptoms after capsaicin administration, and ED length of stay (LOS). I-square and Q-statistic values were used to assess heterogeneity.

RESULTS

Among the 7 studies, there was a total of 106 patients. Two studies reported time to resolution of symptoms following capsaicin administration and ED LOS. Means for these outcomes were 325 (95% CI 234-787) and 379 (95% CI 10-747) minutes respectively. I-square was 44%, and Q-statistic was 11 with 6 degrees of freedom, with a p-value of 0.1.

DISCUSSION

With acceptable time to resolution of symptoms after topical administration and ED LOS, capsaicin appears to be an effective treatment option for symptomatic relief of CHS. Further randomized controlled trials should be conducted to examine if it is the more efficacious and efficient treatment for CHS across various care settings.

Cannabis in Gastroenterology: Watch Your Head! A Review of Use in Inflammatory Bowel Disease, Functional Gut Disorders, and Gut-Related Adverse Effects

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.

A Pilot Trial of Topical Capsaicin Cream for Treatment of Cannabinoid Hyperemesis Syndrome

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.

Role of Cannabis and Its Derivatives in Gastrointestinal and Hepatic Disease

Medical and recreational cannabis use has increased dramatically over the last decade, resulting from mainstream cultural acceptance and legalization in several countries worldwide. Cannabis and its derivatives affect many gastrointestinal processes via the endocannabinoid system (ECS). The ECS influences gastrointestinal homeostasis through anti-inflammatory, anti-nociceptive, and anti-secretory effects. Some gastrointestinal disorders might therefore be treated with cannabinoids. Despite numerous studies in cell lines and animals, few human studies have evaluated the therapeutic effects of cannabinoids. Cannabis' schedule 1 drug status has limited its availability in research; cannabis has been legalized only recently, in some states, for medicinal and/or recreational use. Cannabinoids can alleviate chemotherapy-induced nausea and emesis and chronic pain. Studies have demonstrated the important roles of the ECS in metabolism, obesity, and nonalcoholic fatty liver disease and the anti-inflammatory effects of cannabis have been investigated in patients with inflammatory bowel diseases. Despite its potential benefits, undesired or even detrimental effects of cannabis can limit its use. Side effects such as cannabinoid hyperemesis syndrome affect some users. We review the ECS and the effects of cannabis and its derivatives on gastrointestinal and hepatic function in health and disease.

Identification of the dietary supplement capsaicin as an inhibitor of Lassa virus entry

The limited treatment options for the increasing occurrence of Lassa hemorrhagic fever in West Africa poses an urgent need for the discovery and development of novel therapeutics. Dietary supplements, especially natural products that are edible and safe for human use, are a good source of drug discovery with potential for uncovering novel applications. In this study, we tested 40 natural products of dietary supplements and identified capsaicin, a common dietary supplement abundant in chili peppers, as an inhibitor of Lassa virus (LASV) entry with EC50 of 6.9-10.0 μmol/L using an HIV based pseudovirus platform. Capsaicin inhibits the entry of five LASV strains but not against the Old World arenavirus lymphocytic choriomeningitis virus (LCMV), showing a preferential activity against LASV. Capsaicin inhibits LASV entry by blocking the pH dependent viral fusion through affecting the stable signal peptide (SSP)-GP2 transmembrane (GP2TM) region of the LASV surface glycoprotein. Mutational study revealed the key residues Ala25, Val431, Phe434 and Val435 in SSP-GP2TM region in capsaicin's antiviral effect. This study for the first time reveals a direct acting antiviral effect of capsaicin against the hemorrhagic fever causing LASV, providing detailed interaction hot spots in the unique SSP-GP2TM interface of LASV glycoprotein that is crucial in fusion inhibition, and offering a new strategy in discovering and developing antivirals from natural products that are safe for human use.