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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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2
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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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3
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Shah J, Fermo O. Review of systemic and syndromic complications of cannabis use: A review. Medicine (Baltimore) 2022; 101:e32111. [PMID: 36626471 PMCID: PMC9750691 DOI: 10.1097/md.0000000000032111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
PURPOSE OF REVIEW Prescribed and non-prescribed cannabis use is common. Providers in specialties treating chronic pain - primary care, pain management, and neurology-will be coming across medical cannabis as a treatment for chronic pain, regardless of whether they are prescribers. It is important to be aware of the systemic and syndromic complications of acute and chronic cannabis use in the differential diagnosis of cardiac, cardiovascular, cerebrovascular, gastrointestinal, and psychiatric disorders. RECENT FINDINGS Medical cannabis is legal in 36 states. Studies have shown several potentially serious adverse effects associated with cannabis use. SUMMARY Cannabis use has the potential to cause several complications that can be easily overlooked without a preexisting high index of suspicion.
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Affiliation(s)
- Jay Shah
- University of Queensland/Ochsner Clinical School, Brisbane, QLD, Australia
| | - Olga Fermo
- Department of Neurology, Mayo Clinic Florida, Jacksonville, FL, USA
- * Correspondence: Olga Fermo, Department of Neurology, Mayo Clinic Florida, 4500 San Pablo Rd., Jacksonville, FL, USA (e-mail: )
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4
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Andrews CN, Rehak R, Woo M, Walker I, Ma C, Forbes N, Rittenbach K, Hathaway J, Wilsack L, Liu A, Nasser Y, Sharkey KA. Cannabinoid hyperemesis syndrome in North America: evaluation of health burden and treatment prevalence. Aliment Pharmacol Ther 2022; 56:1532-1542. [PMID: 36307209 DOI: 10.1111/apt.17265] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 06/16/2022] [Accepted: 10/11/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Cannabinoid hyperemesis syndrome (CHS) is a poorly understood vomiting disorder associated with chronic cannabis use. AIMS To characterise patients experiencing CHS in North America and to obtain a population-based estimate of CHS treatment prevalence in Canada before and during the Covid-19 pandemic METHODS: Internet survey of 157 CHS sufferers in Canada and the United States. Administrative health databases for the province of Alberta (population 5 million) were accessed to measure emergency department (ED) visits for vomiting, with a concurrent diagnostic code for cannabis use. Three time periods of 1 year were assessed: prior to recreational cannabis legalisation (2017-2018), after recreational legalisation (2018-2019) and during the first year of the Covid-19 pandemic (2020-2021). RESULTS Problematic cannabis use (defined as a CUDIT-R score ≥8) was universal among the survey cohort, and 59% and 68% screening for moderate or worse anxiety or depression, respectively. The overall treatment prevalence of CHS across all ages increased from 15 ED visits per 100,000 population (95% CI, 14-17) prior to legalisation, to 21 (95% CI, 20-23) after legalisation, to 32 (95% CI, 31-35) during the beginning of the Covid-19 pandemic (p < 0.001). Treatment prevalence among chronic cannabis users was as high as 6 per 1000 in the 16-24 age group. CONCLUSION Survey data suggest patients with CHS almost universally suffer from a cannabis use disorder, which has significant treatment implications. Treatment prevalence in the ED has increased substantially over a very short time period, with the highest rates seen during the Covid-19 pandemic.
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Affiliation(s)
- Christopher N Andrews
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Renata Rehak
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew Woo
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ian Walker
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Ma
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nauzer Forbes
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Katherine Rittenbach
- Provincial Addiction and Mental Health Portfolio™, Alberta Health Services, Calgary, Alberta, Canada.,Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Joshua Hathaway
- Alberta Health Services/CRISM Prairies, CRISM-AHS Advancement of Analytics in Substance Use, Edmonton, Alberta, Canada
| | - Lynn Wilsack
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andy Liu
- Division of Digestive and Liver Diseases, Columbia University Medical Centre, New York, New York City, USA
| | - Yasmin Nasser
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Keith A Sharkey
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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5
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Razban M, Exadaktylos AK, Santa VD, Heymann EP. Cannabinoid hyperemesis syndrome and cannabis withdrawal syndrome: a review of the management of cannabis-related syndrome in the emergency department. Int J Emerg Med 2022; 15:45. [PMID: 36076180 PMCID: PMC9454163 DOI: 10.1186/s12245-022-00446-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 08/19/2022] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Mohammad Razban
- Department of Internal Medicine, University Hospital of Geneva, Geneva, Switzerland. .,University of Bern, Bern, Switzerland.
| | | | - Vincent Della Santa
- Department of Emergency Medicine, Cantonal Hospital of Neuchatel, Neuchatel, Switzerland
| | - Eric P Heymann
- Department of Emergency Medicine, Cantonal Hospital of Neuchatel, Neuchatel, Switzerland
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6
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La Sala MS, Constantino E, Koola MM, Yel I, Chacko M. Treatment of Cannabis Hyperemesis Syndrome Using Haloperidol in a Pregnant Patient: Case Report. J Clin Psychopharmacol 2022; 42:506-508. [PMID: 35943399 DOI: 10.1097/jcp.0000000000001579] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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7
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Chronic Cannabis Intoxication and Propofol-Induced Salivation: Causes and Considerations. PATHOPHYSIOLOGY 2022; 29:223-232. [PMID: 35736646 PMCID: PMC9229402 DOI: 10.3390/pathophysiology29020018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/16/2022] [Accepted: 05/19/2022] [Indexed: 11/16/2022] Open
Abstract
Legalization/decriminalization of cannabis will increase the numbers of patients who have had recent exposure to recreational or medical cannabis. Currently, little has been reported about potential interactions between cannabis use and Propofol anesthesia e.g., for oropharyngeal procedures. We describe three cases of ‘cannabis-induced hypersalivation after propofol’ (CHAP) and present our institutions’ experience with this unique pharmacological combination. Increased hypersalivation may complicate procedures and represent a procedural risk of suffocation. We evaluate possible pharmacological interactions that might underlie this phenomenon and consider management options going forward.
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8
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DeVuono MV, La Caprara O, Petrie GN, Limebeer CL, Rock EM, Hill MN, Parker LA. Cannabidiol Interferes with Establishment of Δ 9-Tetrahydrocannabinol-Induced Nausea Through a 5-HT 1A Mechanism. Cannabis Cannabinoid Res 2022; 7:58-64. [PMID: 33998876 PMCID: PMC8864431 DOI: 10.1089/can.2020.0083] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Introduction: Cannabinoid hyperemesis syndrome (CHS) is characterized by intense nausea and vomiting brought on by the use of high-dose Δ9-tetrahydrocannabinol (THC), the main psychotropic compound in cannabis. Cannabidiol (CBD), a nonpsychotropic compound found in cannabis, has been shown to interfere with some acute aversive effects of THC. In this study, we evaluated if CBD would interfere with THC-induced nausea through a 5-HT1A receptor mechanism as it has been shown to interfere with nausea produced by lithium chloride (LiCl). Since CHS has been attributed to a dysregulated stress response, we also evaluated if CBD would interfere with THC-induced increase in corticosterone (CORT). Materials and Methods: The potential of CBD (5 mg/kg, ip) to suppress THC-induced conditioned gaping (a measure of nausea) was evaluated in rats, as well as the potential of the 5-HT1A receptor antagonist, WAY-100635 (WAY; 0.1 mg/kg, ip), to reverse the suppression of THC-induced conditioned gaping by CBD. Last, the effect of CBD (5 mg/kg, ip) on THC-induced increase in serum CORT concentration was evaluated. Results: Pretreatment with CBD (5 mg/kg, ip) interfered with the establishment of THC-induced conditioned gaping (p=0.007, relative to vehicle [VEH] pretreatment), and this was reversed by pretreatment with 0.1 mg/kg WAY. This dose of WAY had no effect on gaping on its own. THC (10 mg/kg, ip) significantly increased serum CORT compared with VEH-treated rats (p=0.04). CBD (5 mg/kg, ip) pretreatment reversed the THC-induced increase in CORT. Conclusions: CBD attenuated THC-induced nausea as well as THC-induced elevation in CORT. The attenuation of THC-induced conditioned gaping by CBD was mediated by its action on 5-HT1A receptors, similar to that of LiCl-induced nausea.
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Affiliation(s)
- Marieka V. DeVuono
- Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, Canada
| | - Olivia La Caprara
- Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, Canada
| | - Gavin N. Petrie
- Department of Cell Biology and Anatomy, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada.,Department of Psychiatry, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Cheryl L. Limebeer
- Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, Canada
| | - Erin M. Rock
- Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, Canada
| | - Matthew N. Hill
- Department of Cell Biology and Anatomy, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada.,Department of Psychiatry, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Linda A. Parker
- Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, Canada.,*Address correspondence to: Linda A. Parker, PhD, Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, ON N1G 2W1, Canada,
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9
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Abstract
Cannabis use has been increasing in the United States and throughout the world. It is derived from one of the earliest plants cultivated by humans - Cannabis sativa. Cannabis (also called marijuana) is the most commonly used psychoactive substance worldwide. The cannabis plant has more than 400 chemicals, of which more than 100 cannabinoids (such as cannabigerol, cannabidiol, and cannabinol) have been identified. The endocannabinoid system (ECS) plays an essential role in the effects of cannabis on end organs. Although cannabis use has been reported for many decades, some of its unique adverse effects of nausea, vomiting, and abdominal pain, termed as cannabis hyperemesis syndrome (CHS), were noted recently. The legal status of cannabis in the United States has been rapidly changing from state to state. The incidence of CHS is expected to rise with rising access to cannabis in the United States. Furthermore, CHS is frequently underdiagnosed due to a lack of uniform criteria, subjective nature of symptoms, and overlap with cyclical vomiting syndrome (CVS). Understanding the ECS and its role in biphasic response (proemetic and antiemetic) of CHS is critical to explain its pathophysiology. As the use of cannabis increases globally, awareness of CHS is warranted for early recognition and prompt treatment to avoid complications. We describe the putative mechanism of CHS with an overview of the clinical features in these patients. Furthermore, we highlight the differences between CHS and CVS with important differentials to consider. We provide a narrative update on the current evidence on CHS pathophysiology, diagnosis, treatment, and identifying research gaps.
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Affiliation(s)
- Abhilash Perisetti
- Department of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Hemant Goyal
- The Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
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10
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Rosenthal J, Howell M, Earl V, Malik M. Cannabinoid Hyperemesis Syndrome Secondary to Delta-8 THC Use. Am J Med 2021; 134:e582-e583. [PMID: 34343506 DOI: 10.1016/j.amjmed.2021.06.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 06/28/2021] [Indexed: 11/17/2022]
Affiliation(s)
| | - Marshall Howell
- Emory University School of Medicine; Emory University School of Medicine, Division of Emergency Medicine
| | - Victoria Earl
- Emory University School of Medicine; Emory University School of Medicine, Division of Internal Medicine
| | - Manpreet Malik
- Emory University School of Medicine; Emory University School of Medicine, Division of Hospital Medicine, Atlanta, Ga
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11
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von Both I, Santos B. Death of a young woman with cyclic vomiting: a case report. Forensic Sci Med Pathol 2021; 17:715-722. [PMID: 34735682 DOI: 10.1007/s12024-021-00410-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2021] [Indexed: 01/19/2023]
Abstract
We report the death of a 22-year-old woman, with a 3½ year history of cyclic vomiting and cannabis use since age 14, who developed torsades de pointes cardiac arrythmia while being treated in the emergency room for nausea and vomiting. Resuscitation restored spontaneous cardiac circulation, however, due to post-cardiac arrest anoxic brain injury, she never regained consciousness and was declared brain dead 4 days later. Postmortem examination confirmed hypoxic-ischemic encephalopathy, in keeping with the in-hospital diagnosis of brain death. The heart was anatomically normal but showed signs of acute post-cardiopulmonary arrest reperfusion injury. As a consequence of limited survival in hospital in a neuro-vegetative state, early bronchopneumonia and isolated pulmonary thromboemboli were seen. Toxicological studies confirmed cannabis use, in addition to the presence of haloperidol and ondansetron. Genetic studies were performed to rule out a possible channelopathy and revealed a mutation in the MYBPC3 and RYR2 genes. Death in this woman with cannabinoid hyperemesis syndrome was attributed to a fatal cardiac arrhythmia complicating vomiting-induced hypokalemia and treatment with QT interval prolonging and potentially arrhythmogenic medications, with the identified cardiac genetic mutations listed as contributing factors. The emphasis of this report is a) to raise awareness that death can occur due to cyclic vomiting, b) provide a brief but practical overview of cannabinoid hyperemesis syndrome, c) describe the findings from our postmortem examination and come to the most reasonable cause and mechanism of death, d) comment on the risk factors associated with torsades de pointes cardiac arrythmia, and e) conclude that a complete postmortem examination is needed to exclude an anatomical or toxicological cause of death in cannabinoid hyperemesis syndrome, a disabling but preventable disorder.
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Affiliation(s)
- Ingo von Both
- Provincial Forensic Pathology Unit, Department of Laboratory Medicine & Pathobiology, Ontario Forensic Pathology Service, University of Toronto, 25 Morton Shulman Avenue, Toronto, ON, M3M 0B1, Canada. .,Office of the Chief Medical Examiner, Department of Laboratory Medicine & Pathology, University of Alberta, 7007 - 116 Street NW, Edmonton, AB T6H 5R8, Canada.
| | - Brittini Santos
- Provincial Forensic Pathology Unit, Department of Laboratory Medicine & Pathobiology, Ontario Forensic Pathology Service, University of Toronto, 25 Morton Shulman Avenue, Toronto, ON, M3M 0B1, Canada
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12
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Bukke VN, Archana M, Villani R, Serviddio G, Cassano T. Pharmacological and Toxicological Effects of Phytocannabinoids and Recreational Synthetic Cannabinoids: Increasing Risk of Public Health. Pharmaceuticals (Basel) 2021; 14:ph14100965. [PMID: 34681189 PMCID: PMC8541640 DOI: 10.3390/ph14100965] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/19/2021] [Accepted: 09/20/2021] [Indexed: 01/01/2023] Open
Abstract
Synthetic Cannabinoids (CBs) are a novel class of psychoactive substances that have rapidly evolved around the world with the addition of diverse structural modifications to existing molecules which produce new structural analogues that can be associated with serious adverse health effects. Synthetic CBs represent the largest class of drugs detected by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) with a total of 207 substances identified from 2008 to October 2020, and 9 compounds being reported for the first time. Synthetic CBs are sprayed on natural harmless herbs with an aim to mimic the euphoric effect of Cannabis. They are sold under different brand names including Black mamba, spice, K2, Bombay Blue, etc. As these synthetic CBs act as full agonists at the CB receptors, they are much more potent than natural Cannabis and have been increasingly associated with acute to chronic intoxications and death. Due to their potential toxicity and abuse, the US government has listed some synthetic CBs under schedule 1 classification. The present review aims to provide a focused overview of the literature concerning the development of synthetic CBs, their abuse, and potential toxicological effects including renal toxicity, respiratory depression, hyperemesis syndrome, cardiovascular effects, and a range of effects on brain function.
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13
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Dosani K, Koletic C, Alhosh R. Cannabinoid Hyperemesis Syndrome in Pediatrics: An Emerging Problem. Pediatr Rev 2021; 42:500-506. [PMID: 34470869 DOI: 10.1542/pir.2019-0097] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Cannabis use has been evolving in both recreational drug use and medicinal uses, in part due to the recent introduction of various strains and components. With increasing use, we have seen emergence of a hyperemesis syndrome called cannabinoid hyperemesis syndrome characterized as intractable vomiting, nausea, and abdominal pain in the context of prolonged cannabinoid use. Although the antiemetic properties of cannabis have been known for years, the paradoxical effect of hyperemesis has yet to be elucidated. Herein we discuss the current research, epidemiology, and diagnosis and treatment of cannabinoid hyperemesis syndrome. Without timely diagnosis and treatment, patients may experience significant physical and emotional distress, as well as place unnecessary financial burden on the medical system.
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Affiliation(s)
- Kaushal Dosani
- University of Nevada Las Vegas School of Medicine, Las Vegas, NV
| | - Carolina Koletic
- University of Nevada Las Vegas School of Medicine, Las Vegas, NV
| | - Rabea Alhosh
- University of Nevada Las Vegas School of Medicine, Las Vegas, NV
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14
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Hsu J, Herrmann Z, Kashyap S, Claassen C. Treatment of Cannabinoid Hyperemesis With Olanzapine: A Case Series. J Psychiatr Pract 2021; 27:316-321. [PMID: 34398582 DOI: 10.1097/pra.0000000000000564] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The use and availability of cannabis for recreational and medical purposes has become more widespread with increased legalization. Adverse health outcomes of this increased use include cannabinoid hyperemesis syndrome (CHS), which is underrecognized in medical settings. Cessation of substance use is the recommendation of choice for the complete resolution of CHS. However, interventions that provide rapid relief may be necessary in treatment-refractory cases. Little evidence is available to guide care in these cases. Here we report 4 cases of treatment-refractory CHS, all of which remitted after treatment with olanzapine. Olanzapine is known to block multiple neurotransmitter receptors involved in nausea and vomiting in chemotherapy-induced nausea and vomiting. Outcomes of the cases reported here suggest that off-label use of olanzapine may be effective in the symptomatic treatment of refractory CHS and may be the preferred treatment in cases in which comorbid psychotic symptoms or agitation are present.
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Affiliation(s)
- Jennifer Hsu
- HSU, HERRMANN, KASHYAP, CLAASSEN: Department of Psychiatry, John Peter Smith Hospital, Fort Worth, TX
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15
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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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16
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Boursier A, Caron C, Dekemp J, Fague V, Fulcrand J, Boccara E, Caous AS, Lemaire A. [Dronabinol and hyperemesis syndrom: A potential risk?]. Therapie 2021; 77:495-496. [PMID: 34045079 DOI: 10.1016/j.therap.2021.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/30/2021] [Accepted: 05/04/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Amélie Boursier
- Pôle 8 cancérologie et spécialités médicales, centre d'évaluation et de traitement de la douleur, centre hospitalier de Valenciennes, 59300 Valenciennes, France.
| | - Clément Caron
- Centre régional de pharmacovigilance du Nord-Pas de Calais, CHRU de Lille, 59045 Lille, France
| | - Joelle Dekemp
- Centre régional de pharmacovigilance du Nord-Pas de Calais, CHRU de Lille, 59045 Lille, France
| | - Vassili Fague
- Pôle 8 cancérologie et spécialités médicales, service de chirurgie gynécologique, centre hospitalier de Valenciennes, 59300 Valenciennes, France
| | - Julie Fulcrand
- Pôle 8 cancérologie et spécialités médicales, centre d'évaluation et de traitement de la douleur, centre hospitalier de Valenciennes, 59300 Valenciennes, France
| | - Eugénie Boccara
- Pôle 7 psychiatrie, unité de traitement de la dépendance, centre hospitalier de Valenciennes, 59300 Valenciennes, France
| | - Anne-Sylvie Caous
- CEIP-addictovigilance, service de pharmacologie médicale, CHU de Lille, 59035 Lille cedex, France
| | - Antoine Lemaire
- Pôle 8 cancérologie et spécialités médicales, centre d'évaluation et de traitement de la douleur, centre hospitalier de Valenciennes, 59300 Valenciennes, France
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17
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Aung ET, Balafshan T, Wace P, Weston PJ. Cannabinoid hyperemesis syndrome as a cause of recurrent vomiting in type 1 diabetes. PRACTICAL DIABETES 2021. [DOI: 10.1002/pdi.2316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Ei Thuzar Aung
- Diabetes and Endocrinology, Royal Liverpool University Hospital Liverpool UK
| | - Tala Balafshan
- Diabetes and Endocrinology, Whiston Hospital Prescot, Knowsley UK
| | | | - Philip J Weston
- Diabetes and Endocrinology, Royal Liverpool University Hospital Liverpool UK
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18
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DeVuono MV, Hrelja KM, Petrie GN, Limebeer CL, Rock EM, Hill MN, Parker LA. Nausea-Induced Conditioned Gaping Reactions in Rats Produced by High-Dose Synthetic Cannabinoid, JWH-018. Cannabis Cannabinoid Res 2020; 5:298-304. [PMID: 33381644 DOI: 10.1089/can.2019.0103] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Introduction: Cannabinoid hyperemesis syndrome is becoming a more prominently reported side effect of cannabis containing high-dose Δ9-tetrahydrocannabinol (THC) and designer cannabinoid drugs such as "Spice." One active ingredient that has been found in "Spice" is 1-pentyl-3-(1-naphthoyl)indole (JWH-018), a synthetic full agonist of the cannabinoid 1 (CB1) receptor. In this study, we evaluated the potential of different doses of JWH-018 to produce conditioned gaping in rats, an index of nausea. Materials and Methods: Rats received 3 daily conditioning trials in which saccharin was paired with JWH-018 (0.0, 0.1, 1, and 3 mg/kg, intraperitoneal [i.p.]). Then the potential of pretreatment with the CB1 antagonist, rimonabant (SR), to prevent JWH-018-induced conditioned gaping was determined. To begin to understand the potential mechanism underlying JWH-018-induced nausea, serum collected from trunk blood was subjected to a corticosterone (CORT) analysis in rats receiving three daily injections with vehicle (VEH) or JWH-018 (3 mg/kg). Results: At doses of 1 and 3 mg/kg (i.p.), JWH-018 produced nausea-like conditioned gaping reactions. The conditioned gaping produced by 3 mg/kg JWH-018 was reversed by pretreatment with rimonabant, which did not modify gaping on its own. Treatment with JWH-018 elevated serum CORT levels compared to vehicle-treated rats. Conclusions: As we have previously reported with high-dose THC, JWH-018 produced conditioned gaping in rats, reflective of a nausea effect mediated by its action on CB1 receptors and accompanied by elevated CORT, reflective of hypothalamic-pituitary-adrenal (HPA) activation.
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Affiliation(s)
- Marieka V DeVuono
- Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, Canada
| | - Kelly M Hrelja
- Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, Canada
| | - Gavin N Petrie
- Department of Cell Biology and Anatomy, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada.,Department of Psychiatry, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Cheryl L Limebeer
- Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, Canada
| | - Erin M Rock
- Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, Canada
| | - Matthew N Hill
- Department of Cell Biology and Anatomy, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada.,Department of Psychiatry, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Linda A Parker
- Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, Canada
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19
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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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20
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Robson H, Braund R, Glass M, Ashton J, Tatley M. Synthetic cannabis: adverse events reported to the New Zealand Pharmacovigilance Centre. Clin Toxicol (Phila) 2020; 59:472-479. [DOI: 10.1080/15563650.2020.1828592] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Hunter Robson
- Department of Pharmacology and Toxicology, University of Otago, Dunedin, New Zealand
| | - Rhiannon Braund
- New Zealand Pharmacovigilance Centre, University of Otago, Dunedin, New Zealand
| | - Michelle Glass
- Department of Pharmacology and Toxicology, University of Otago, Dunedin, New Zealand
| | - Janelle Ashton
- New Zealand Pharmacovigilance Centre, University of Otago, Dunedin, New Zealand
| | - Michael Tatley
- New Zealand Pharmacovigilance Centre, University of Otago, Dunedin, New Zealand
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21
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Gajendran M, Sifuentes J, Bashashati M, McCallum R. Cannabinoid hyperemesis syndrome: definition, pathophysiology, clinical spectrum, insights into acute and long-term management. J Investig Med 2020; 68:1309-1316. [PMID: 33115959 DOI: 10.1136/jim-2020-001564] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2020] [Indexed: 12/15/2022]
Abstract
Although cannabinoid hyperemesis syndrome (CHS) was first reported more than 15 years ago, it still remains an unfamiliar clinical entity among physicians worldwide. CHS is categorized by Rome IV classification as a functional gastroduodenal disorder. It is characterized by stereotypical episodic vomiting in the setting of chronic, daily cannabis use, with cycles decreasing by the cessation of cannabis. CHS is also associated with abdominal pain reduced by hot baths and showers with comparative well-being between attacks. Thus, its clinical presentation resembles 'classic' cyclic vomiting syndrome, but eliciting a cannabis history is crucial in diagnosing this entity. In acute attacks, parenteral benzodiazepines are very effective. For prevention and long-term management, tricyclic antidepressants such as amitriptyline are the mainstay of therapy requiring doses in the range of 50-200 mg/d to achieve symptom control. In addition, counseling to achieve marijuana cessation, accompanied by antianxiety medications, is necessary for sustaining clinical outcomes. Once the patient is in remission and off marijuana for a period of 6-12 months, then tapering the dose of amitriptyline can be implemented, with the goal of no therapy being achieved in the majority of patients over time. With the legalization of marijuana in many states, CHS will become an increasingly prevalent clinical entity, so educating about CHS is an important goal, particularly for emergency department physicians who generally first encounter these patients.
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Affiliation(s)
- Mahesh Gajendran
- Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, Paul L Foster School of Medicine, El Paso, Texas, USA
| | - Joshua Sifuentes
- Department of Gastroenterology, Texas Tech University Health Sciences Center El Paso, Paul L Foster School of Medicine, El Paso, Texas, USA
| | - Mohammad Bashashati
- Department of Gastroenterology, Texas Tech University Health Sciences Center El Paso, Paul L Foster School of Medicine, El Paso, Texas, USA
| | - Richard McCallum
- Department of Gastroenterology, Center for Neurogastroenterology and GI Motility, Texas Tech University Health Sciences Center El Paso, Paul L Foster School of Medicine, El Paso, Texas, USA
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22
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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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23
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Venkatesan T, Hillard CJ, Rein L, Banerjee A, Lisdahl K. Patterns of Cannabis Use in Patients With Cyclic Vomiting Syndrome. Clin Gastroenterol Hepatol 2020; 18:1082-1090.e2. [PMID: 31352091 DOI: 10.1016/j.cgh.2019.07.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 07/12/2019] [Accepted: 07/19/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Some patients with cyclic vomiting syndrome (CVS) use cannabis to relieve stress and for its antiemetic properties. However, chronic cannabis use has been associated paradoxically with cannabinoid hyperemesis syndrome (CHS) and some patients with CVS are thought to have CHS. We sought to characterize patterns of cannabis use by patients with CVS and identify those who could be reclassified as having CHS. METHODS We performed a cross-sectional study of 140 patients with CVS (72% female; mean age, 37 ± 13 y) seen at a specialized clinic. Patients were screened for cannabis use with the cannabis use disorder identification test. Patients were classified as regular (use ≥4 times/wk) or occasional users (<4 times/wk). RESULTS Forty-one percent of patients were current cannabis users, with 21% reporting regular use. Regular users were more likely to be male and to report an anxiety diagnosis, and smoked cannabis with higher tetrahydrocannabinol content and for a longer duration. Most users reported that cannabis helped control CVS symptoms. Among all cannabis users, 50 of 57 (88%) reported that they had abstained for longer than 1 month, but only 1 user reported resolution of CVS episodes during the abstinence period. This patient subsequently resumed using cannabis but remains free of symptoms. CONCLUSIONS Cannabis is used commonly among patients with CVS-patients report relief of symptoms with use. We found 21% of patients with CVS to be regular users, but only 1 met the Rome IV criteria for CHS. Longitudinal studies are needed to determine the relationships among cannabis use, hyperemesis, and mood symptoms.
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Affiliation(s)
- Thangam Venkatesan
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Cecilia J Hillard
- Pharmacology and Toxicology, Neuroscience Research Center, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lisa Rein
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anjishnu Banerjee
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Krista Lisdahl
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin
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24
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Echeverria-Villalobos M, Todeschini AB, Stoicea N, Fiorda-Diaz J, Weaver T, Bergese SD. Perioperative care of cannabis users: A comprehensive review of pharmacological and anesthetic considerations. J Clin Anesth 2019; 57:41-49. [DOI: 10.1016/j.jclinane.2019.03.011] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 02/16/2019] [Accepted: 03/03/2019] [Indexed: 12/23/2022]
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25
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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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26
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Kopruszinski CM, Navratilova E, Vagnerova B, Swiokla J, Patwardhan A, Dodick D, Porreca F. Cannabinoids induce latent sensitization in a preclinical model of medication overuse headache. Cephalalgia 2019; 40:68-78. [PMID: 31311288 DOI: 10.1177/0333102419865252] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
AIM Evaluation of cannabinoid receptor agonists in a preclinical model of medication overuse headache. METHODS Female Sprague Dawley rats received graded intraperitoneal doses of WIN55,212-2 or Δ-9-tetrahydrocannabinol (Δ-9-THC). Antinociception (tail-flick test), catalepsy and hypomotility (open field test) and impairment of motor function (rotarod test) were assessed to establish effective dosing. Rats were then treated twice daily with equianalgesic doses of WIN55,212-2 or Δ-9-THC, or vehicle, for 7 days and cutaneous tactile sensory thresholds were evaluated during and three weeks following drug discontinuation. Rats then received a one-hour period of bright light stress (BLS) on two consecutive days and tactile sensory thresholds were re-assessed. RESULTS WIN55,212-2 and Δ-9-THC produced antinociception as well as hypomotility, catalepsy and motor impairment. Repeated administration of WIN55,212-2 and Δ-9-THC induced generalized periorbital and hindpaw allodynia that resolved within 3 weeks after discontinuation of drug. Two episodes of BLS produced delayed and long-lasting periorbital and hindpaw allodynia selectively in rats previously treated with WIN55,212-2, and Δ-9-THC. INTERPRETATION Cannabinoid receptor agonists including Δ-9-THC produce a state of latent sensitization characterized by increased sensitivity to stress, a presumed migraine trigger. Overuse of cannabinoids including cannabis may increase the risk of medication overuse headache in vulnerable individuals.
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Affiliation(s)
| | - Edita Navratilova
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Barbora Vagnerova
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Juliana Swiokla
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Amol Patwardhan
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - David Dodick
- Department of Neurology, Mayo Clinic, Phoenix, AZ, USA
| | - Frank Porreca
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, AZ, USA.,Department of Neurology, Mayo Clinic, Phoenix, AZ, USA
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Affiliation(s)
- Elena Fradkov
- New York University Medical Center, New York, NY, USA
| | - Grigoriy E Gurvits
- Clinical Professor of Medicine, New York University Medical Center, New York, NY, USA
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28
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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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29
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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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30
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DeVuono MV, Hrelja KM, Sabaziotis L, Rajna A, Rock EM, Limebeer CL, Mutch DM, Parker LA. Conditioned gaping produced by high dose Δ 9-tetrahydracannabinol: Dysregulation of the hypothalamic endocannabinoid system. Neuropharmacology 2018; 141:272-282. [PMID: 30195587 DOI: 10.1016/j.neuropharm.2018.08.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/24/2018] [Accepted: 08/28/2018] [Indexed: 11/17/2022]
Abstract
Δ9-tetrahydracannabinol (THC) is recognized as an effective treatment for nausea and vomiting via its action on the cannabinoid 1 (CB1) receptor. Paradoxically, there is evidence that THC can also produce nausea and vomiting. Using the conditioned gaping model of nausea in rats, we evaluated the ability of several doses of THC (0.0, 0.5, 5 and 10 mg/kg, i.p.) to produced conditioned gaping reactions. We then investigated the ability of the CB1 receptor antagonist, rimonabant, to block the establishment of THC-induced conditioned gaping. Real-time polymerase chain reaction (RT-PCR) was then used to investigate changes in endocannabinoid related genes in various brain regions in rats chronically treated with vehicle (VEH), 0.5 or 10 mg/kg THC. THC produced dose-dependent gaping, with 5 and 10 mg/kg producing significantly more gaping reactions than VEH or 0.5 mg/kg THC, a dose known to have anti-emetic properties. Pre-treatment with rimonabant reversed this effect, indicating that THC-induced conditioned gaping was CB1 receptor mediated. The RT-PCR analysis revealed an upregulation of genes for the degrading enzyme, monoacylglycerol lipase (MAGL), of the endocannabinoid, 2-arachidolyl glycerol (2-AG), in the hypothalamus of rats treated with 10 mg/kg THC. No changes in the expression of relevant genes were found in nausea (interoceptive insular cortex) or vomiting (dorsal vagal complex) related brain regions. These findings support the hypothesis that THC-induced nausea is a result of a dysregulated hypothalamic-pituitary-adrenal axis leading to an overactive stress response.
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Affiliation(s)
- Marieka V DeVuono
- Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, N1G 2W1, ON, Canada
| | - Kelly M Hrelja
- Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, N1G 2W1, ON, Canada
| | - Lauren Sabaziotis
- Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, N1G 2W1, ON, Canada
| | - Alex Rajna
- Department of Human Health and Nutritional Science, University of Guelph, Guelph, N1G 2W1, ON, Canada
| | - Erin M Rock
- Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, N1G 2W1, ON, Canada
| | - Cheryl L Limebeer
- Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, N1G 2W1, ON, Canada
| | - David M Mutch
- Department of Human Health and Nutritional Science, University of Guelph, Guelph, N1G 2W1, ON, Canada
| | - Linda A Parker
- Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, N1G 2W1, ON, Canada.
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Nourbakhsh M, Miller A, Gofton J, Jones G, Adeagbo B. Cannabinoid Hyperemesis Syndrome: Reports of Fatal Cases. J Forensic Sci 2018; 64:270-274. [DOI: 10.1111/1556-4029.13819] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 04/17/2018] [Accepted: 04/23/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Mahra Nourbakhsh
- Department of Pathology and Laboratory Medicine Foothills Medical Center Cumming School of Medicine University of Calgary McCaig Tower 7542, 1403 29 Street NW Calgary AB T2N 2T9 Canada
| | - Angela Miller
- Department of Pathology and Laboratory Medicine Foothills Medical Center Cumming School of Medicine University of Calgary McCaig Tower 7542, 1403 29 Street NW Calgary AB T2N 2T9 Canada
- Department of Laboratory Medicine and Pathology 4B1.18 Walter Mackenzie Centre University of Alberta 8440‐112 Street Edmonton AB T6G 2B7 Canada
- Office of the Chief Medical Examiner 4070 Bowness Rd NW Calgary AB T3B 3R7 Canada
| | - Jeff Gofton
- Office of the Chief Medical Examiner 4070 Bowness Rd NW Calgary AB T3B 3R7 Canada
- Office of the Chief Medical Examiner 400 East Jackson Street Richmond VA 23219‐3694
| | - Graham Jones
- Department of Laboratory Medicine and Pathology 4B1.18 Walter Mackenzie Centre University of Alberta 8440‐112 Street Edmonton AB T6G 2B7 Canada
- Office of the Chief Medical Examiner 4070 Bowness Rd NW Calgary AB T3B 3R7 Canada
| | - Bamidele Adeagbo
- Department of Pathology and Laboratory Medicine Foothills Medical Center Cumming School of Medicine University of Calgary McCaig Tower 7542, 1403 29 Street NW Calgary AB T2N 2T9 Canada
- Department of Laboratory Medicine and Pathology 4B1.18 Walter Mackenzie Centre University of Alberta 8440‐112 Street Edmonton AB T6G 2B7 Canada
- Office of the Chief Medical Examiner 4070 Bowness Rd NW Calgary AB T3B 3R7 Canada
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Ullah I, Subhan F, Alam J, Shahid M, Ayaz M. Suppression of Cisplatin-Induced Vomiting by Cannabis sativa in Pigeons: Neurochemical Evidences. Front Pharmacol 2018; 9:231. [PMID: 29615907 PMCID: PMC5865282 DOI: 10.3389/fphar.2018.00231] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 02/28/2018] [Indexed: 01/03/2023] Open
Abstract
Cannabis sativa (CS, family Cannabinaceae) has been reported for its anti-emetic activity against cancer chemotherapy-induced emesis in animal models and in clinics. The current study was designed to investigate CS for potential effectiveness to attenuate cisplatin-induced vomiting in healthy pigeons and to study the impact on neurotransmitters involved centrally and peripherally in the act of vomiting. High-performance liquid chromatography system coupled with electrochemical detector was used for the quantification of neurotransmitters 5-hydroxytryptamine (5HT), dopamine (DA) and their metabolites; Di-hydroxy Phenyl Acetic acid (Dopac), Homovanillic acid (HVA), and 5-hydroxy indole acetic acid (5HIAA) centrally in specific brain areas (area postrema and brain stem) while, peripherally in small intestine. Cisplatin (7 mg/kg i.v.) induce emesis without lethality across the 24 h observation period. CS hexane fraction (CS-HexFr; 10 mg/kg) attenuated cisplatin-induced emesis ∼ 65.85% (P < 0.05); the reference anti-emetic drug, metoclopramide (MCP; 30 mg/kg), produced ∼43.90% reduction (P < 0.05). At acute time point (3rd h), CS-HexFr decreased (P < 0.001) the concentration of 5HT and 5HIAA in the area postrema, brain stem and intestine, while at 18th h (delayed time point) CS-HexFr attenuated (P < 0.001) the upsurge of 5HT caused by cisplatin in the brain stem and intestine and dopamine in the area postrema. CS-HexFr treatment alone did not alter the basal neurotransmitters and their metabolites in the brain areas and intestine except 5HIAA and HVA, which were decreased significantly. In conclusion the anti-emetic effect of CS-HexFr is mediated by anti-serotonergic and anti-dopaminergic components in a blended manner at the two different time points, i.e., 3rd and 18th h in pigeons.
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Affiliation(s)
- Ihsan Ullah
- Department of Pharmacy, University of Swabi, Swabi, Pakistan.,Department of Pharmacy, University of Peshawar, Peshawar, Pakistan
| | - Fazal Subhan
- Department of Pharmacy, University of Peshawar, Peshawar, Pakistan
| | - Javaid Alam
- Department of Pharmacy, University of Peshawar, Peshawar, Pakistan.,Drug and Herbal Research Centre, Faculty of Pharmacy, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Muhammad Shahid
- Department of Pharmacy, University of Peshawar, Peshawar, Pakistan
| | - Muhammad Ayaz
- Department of Pharmacy, University of Malakand, Chakdara, Pakistan
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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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Vadivelu N, Kai AM, Kodumudi G, Sramcik J, Kaye AD. Medical Marijuana: Current Concepts, Pharmacological Actions of Cannabinoid Receptor Mediated Activation, and Societal Implications. Curr Pain Headache Rep 2018; 22:3. [PMID: 29349551 DOI: 10.1007/s11916-018-0656-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW The purpose of the following review is to summarize the history and current policies related to marijuana use and prevalence, basic and clinical science pharmacological literature regarding efficacy, subpopulations of concern, and varying policies regarding its use at present. RECENT FINDINGS With the increasingly widespread utilization of marijuana, there is also a growing complexity of public health policy, regulation, and necessity to further assess the medical indications and adverse long-term effects of marijuana use. Health care providers as well as the general public must be prepared to become familiar and up-to-date with medical literature, legislation, and educational material regarding medical marijuana.
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Affiliation(s)
- Nalini Vadivelu
- Department of Anesthesiology, Yale University, TMP3 333, Cedar Street, New Haven, CT, 06520, USA.
| | - Alice M Kai
- Department of Internal Medicine, NYU Winthrop Hospital, 259 First Street, Mineola, NY, 11501, USA
| | - Gopal Kodumudi
- California Northstate University College of Medicine, 9700 West Taron Drive, Elk Grove, CA, 95757, USA
| | - Julie Sramcik
- Department of Anesthesiology, Yale University, TMP3 333, Cedar Street, New Haven, CT, 06520, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, 1542 Tulane Ave, Suite 656, New Orleans, LA, 70112, USA
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Cannabinoid hyperemesis syndrome: Review of the literature and of cases reported to the French addictovigilance network. Drug Alcohol Depend 2018; 182:27-32. [PMID: 29132050 DOI: 10.1016/j.drugalcdep.2017.09.038] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 09/12/2017] [Accepted: 09/12/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND Cannabinoid hyperemesis syndrome is a variant of cyclical vomiting syndrome in a context of chronic cannabis usage. Our aim was to compare French cases to those identified in the international literature in order to further our knowledge of the clinical criteria, pathophysiology and treatments for cannabinoid hyperemesis syndrome. METHODS We analysed cases reported in the international literature up to 30 June 2017, obtained from the MEDLINE, PsycINFO and The Cochrane Library databases; we selected relevant articles based on title and abstract. We also analysed cases of cannabinoid hyperemesis syndrome reported to the French addictovigilance network. RESULTS A systematic search through the three databases enabled us to identify 137 articles. Finally, 55 articles were selected as they involved reported cases. In total, 113 cases were reported in these 55 articles. We were thus able to analyse 29 reported French cases of cannabinoid hyperemesis syndrome. Cannabinoid hyperemesis syndrome mainly affects young male subjects who have been smoking cannabis daily for several years. Taking hot baths or showers is the most effective means of relieving the symptoms, while antiemetics and dopamine antagonists do not appear to effective for relieving nausea and vomiting. CONCLUSIONS French cases display the same characteristics as the cases identified in the international literature. The pathophysiology of cannabinoid hyperemesis syndrome is unclear and several hypotheses have been put forward in the literature. We have only begun to characterise the syndrome, though there is an outbreak of cannabinoid hyperemesis syndrome in France.
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Trappey BE, Olson APJ. Running Out of Options: Rhabdomyolysis Associated with Cannabis Hyperemesis Syndrome. J Gen Intern Med 2017; 32:1407-1409. [PMID: 28664257 PMCID: PMC5698212 DOI: 10.1007/s11606-017-4111-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 04/28/2017] [Accepted: 06/12/2017] [Indexed: 12/18/2022]
Abstract
Cannabis hyperemesis syndrome (CHS) is a condition in which some patients with long-term, frequent use of cannabis paradoxically develop recurrent episodes of nausea and vomiting. The pathophysiology underlying this condition is poorly understood, as is the explanation for its common association with patients' discovery that hot-water bathing alleviates symptoms. We describe the case of a 24-year-old male with daily marijuana use and a history of CHS who was found to have rhabdomyolysis induced by a period of 15 h of continuous jogging after he discovered that this activity helped to alleviate his symptoms. To our knowledge, this is the first reported case of exercise-alleviated CHS symptoms, and we propose that this case provides support to the theory of redistribution of enteric blood flow as the mechanism behind the learned hot-water bathing behavior seen so commonly in CHS.
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Affiliation(s)
- Bernard E Trappey
- Division of General Internal Medicine, Department of Medicine, University of Minnesota, MMC 741. 420 Delaware St SE, Minneapolis, MN, 55455, USA. .,Division of Hospital Pediatrics, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA.
| | - Andrew P J Olson
- Division of General Internal Medicine, Department of Medicine, University of Minnesota, MMC 741. 420 Delaware St SE, Minneapolis, MN, 55455, USA.,Division of Hospital Pediatrics, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
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37
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38
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Richards JR, Lapoint JM, Burillo-Putze G. Cannabinoid hyperemesis syndrome: potential mechanisms for the benefit of capsaicin and hot water hydrotherapy in treatment. Clin Toxicol (Phila) 2017; 56:15-24. [DOI: 10.1080/15563650.2017.1349910] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- John R. Richards
- Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, CA, USA
| | - Jeff M. Lapoint
- Department of Emergency Medicine, Southern California Permanente Medical Group, San Diego, CA, USA
| | - Guillermo Burillo-Putze
- Área de Toxicología Clínica, Servicio de Urgencias, Universidad Europea de Canarias, Tenerife, Spain
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39
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Richards JR. Cannabinoid hyperemesis syndrome: A disorder of the HPA axis and sympathetic nervous system? Med Hypotheses 2017; 103:90-95. [DOI: 10.1016/j.mehy.2017.04.018] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 04/22/2017] [Indexed: 12/26/2022]
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Richards JR, Gordon BK, Danielson AR, Moulin AK. Pharmacologic Treatment of Cannabinoid Hyperemesis Syndrome: A Systematic Review. Pharmacotherapy 2017; 37:725-734. [PMID: 28370228 DOI: 10.1002/phar.1931] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cannabinoid hyperemesis syndrome (CHS) has become more prevalent with increasing cannabis use. CHS is often resistant to standard antiemetics. The objective of this study is to review the current evidence for pharmacologic treatment of CHS. Medline, PsycINFO, DARE, OpenGrey, Google Scholar, and the Cochrane Library were searched from inception to February 2017. Articles were selected and reviewed independently. Evidence was graded using Oxford Center for Evidence-Based Medicine guidelines. The search resulted in 1262 articles with 63 of them eligible for inclusion (205 human subjects). There were 4 prospective level-2, 3 retrospective level-3 studies, 12 level-4 case series, and 44 level-5 case reports. Among level-2 studies (64 subjects), tricyclic antidepressants (TCAs) and lorazepam were discussed as effective long- and short-term treatments, respectively, in two studies. Ondansetron, promethazine, diphenhydramine, and opioids were also mentioned, but the authors did not comment on their efficacy. Among level-3 studies (43 subjects), one reported effective treatment with antiepileptics zonisamide and levetiracetam, but not TCAs. Another reported favorable response to morphine, ondansetron, and lorazepam but did not specify the actual number of patients receiving specific treatment. Among the level-4 case series (54 subjects), benzodiazepines, haloperidol, and capsaicin were reported as helpful. For level-5 case reports (44 subjects), benzodiazepines, metoclopramide, haloperidol, ondansetron, morphine, and capsaicin were reported as effective. Effective treatments mentioned only once included fentanyl, diazepam, promethazine, methadone, nabilone, levomepromazine, piritramide, and pantoprazole. Hot showers and baths were cited in all level-4 and -5 articles as universally effective. High-quality evidence for pharmacologic treatment of CHS is limited. Benzodiazepines, followed by haloperidol and capsaicin, were most frequently reported as effective for acute treatment, and TCAs for long-term treatment. As the prevalence of CHS increases, future prospective trials are greatly needed to evaluate and further define optimal pharmacologic treatment of patients with CHS.
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Affiliation(s)
- John R Richards
- Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, California
| | - Brent K Gordon
- Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, California
| | - Aaron R Danielson
- Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, California
| | - Aimee K Moulin
- Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, California
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41
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Blumentrath CG, Dohrmann B, Ewald N. Cannabinoid hyperemesis and the cyclic vomiting syndrome in adults: recognition, diagnosis, acute and long-term treatment. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2017; 15:Doc06. [PMID: 28400711 PMCID: PMC5360975 DOI: 10.3205/000247] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 02/10/2017] [Indexed: 11/30/2022]
Abstract
The cannabinoid hyperemesis syndrome (CHS) and the cyclic vomiting syndrome in adults (CVS) are both characterized by recurrent episodes of heavy nausea, vomiting and frequently abdominal pain. Both syndromes are barely known among physicians. Literature is inconsistent concerning clinical features which enable differentiation between CVS and CHS. We performed a literature review using the LIVIVO search portal for life sciences to develop a pragmatic approach towards these two syndromes. Our findings indicate that complete and persistent resolution of all symptoms of the disease following cannabis cessation is the only reliable criterion applicable to distinguish CHS from CVS. Psychiatric comorbidities (e.g. panic attacks, depression), history of migraine attacks and rapid gastric emptying may serve as supportive criteria for the diagnosis of CVS. Compulsive bathing behaviour, a clinical observation previously attributed only to CHS patients is equally present in CVS patients. Long-term follow-up is essential in order to clearly separate CHS from CVS. However, long-term follow-up of CVS and CHS cases is seldom. We provide a standard operating procedure applicable to a broad spectrum of health care facilities which addresses the major issues of CVS and CHS: awareness, diagnosis, treatment, and follow-up.
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Affiliation(s)
| | - Boris Dohrmann
- Department of Internal Medicine, General Hospital Luebbecke-Rahden, Rahden, Germany
| | - Nils Ewald
- Department of Internal Medicine, General Hospital Luebbecke-Rahden, Rahden, Germany; Justus-Liebig-University Giessen, Germany
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42
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Sorensen CJ, DeSanto K, Borgelt L, Phillips KT, Monte AA. Cannabinoid Hyperemesis Syndrome: Diagnosis, Pathophysiology, and Treatment-a Systematic Review. J Med Toxicol 2017; 13:71-87. [PMID: 28000146 PMCID: PMC5330965 DOI: 10.1007/s13181-016-0595-z] [Citation(s) in RCA: 197] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 11/25/2016] [Accepted: 12/01/2016] [Indexed: 12/28/2022] Open
Abstract
Cannabinoid hyperemesis syndrome (CHS) is a syndrome of cyclic vomiting associated with cannabis use. Our objective is to summarize the available evidence on CHS diagnosis, pathophysiology, and treatment. We performed a systematic review using MEDLINE, Ovid MEDLINE, Embase, Web of Science, and the Cochrane Library from January 2000 through September 24, 2015. Articles eligible for inclusion were evaluated using the Grading and Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Data were abstracted from the articles and case reports and were combined in a cumulative synthesis. The frequency of identified diagnostic characteristics was calculated from the cumulative synthesis and evidence for pathophysiologic hypothesis as well as treatment options were evaluated using the GRADE criteria. The systematic search returned 2178 articles. After duplicates were removed, 1253 abstracts were reviewed and 183 were included. Fourteen diagnostic characteristics were identified, and the frequency of major characteristics was as follows: history of regular cannabis for any duration of time (100%), cyclic nausea and vomiting (100%), resolution of symptoms after stopping cannabis (96.8%), compulsive hot baths with symptom relief (92.3%), male predominance (72.9%), abdominal pain (85.1%), and at least weekly cannabis use (97.4%). The pathophysiology of CHS remains unclear with a dearth of research dedicated to investigating its underlying mechanism. Supportive care with intravenous fluids, dopamine antagonists, topical capsaicin cream, and avoidance of narcotic medications has shown some benefit in the acute setting. Cannabis cessation appears to be the best treatment. CHS is a cyclic vomiting syndrome, preceded by daily to weekly cannabis use, usually accompanied by symptom improvement with hot bathing, and resolution with cessation of cannabis. The pathophysiology underlying CHS is unclear. Cannabis cessation appears to be the best treatment.
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Affiliation(s)
- Cecilia J Sorensen
- Denver Health Residency in Emergency Medicine, Denver Health and Hospital Authority, Denver, CO, 80204, USA.
| | - Kristen DeSanto
- Health Sciences Library, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Laura Borgelt
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kristina T Phillips
- School of Psychological Sciences, University of Northern Colorado, Greeley, CO, USA
| | - Andrew A Monte
- Denver Health Residency in Emergency Medicine, Denver Health and Hospital Authority, Denver, CO, 80204, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Rocky Mountain Poison & Drug Center, Denver Health and Hospital Authority, Denver, CO, USA
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Abstract
Cannabis sativa, a subspecies of the Cannabis plant, contains aromatic hydrocarbon compounds called cannabinoids. [INCREMENT]-Tetrahydrocannabinol is the most abundant cannabinoid and is the main psychotropic constituent. Cannabinoids activate two types of G-protein-coupled cannabinoid receptors: cannabinoid type 1 receptor and cannabinoid type 2 receptor. There has been ongoing interest and development in research to explore the therapeutic potential of cannabis. [INCREMENT]-Tetrahydrocannabinol exerts biological functions on the gastrointestinal (GI) tract. Cannabis has been used for the treatment of GI disorders such as abdominal pain and diarrhea. The endocannabinoid system (i.e. endogenous circulating cannabinoids) performs protective activities in the GI tract and presents a promising therapeutic target against various GI conditions such as inflammatory bowel disease (especially Crohn's disease), irritable bowel syndrome, and secretion and motility-related disorders. The present review sheds light on the role of cannabis in the gut, liver, and pancreas and also on other GI symptoms, such as nausea and vomiting, cannabinoid hyperemesis syndrome, anorexia, weight loss, and chronic abdominal pain. Although the current literature supports the use of marijuana for the treatment of digestive disorders, the clinical efficacy of cannabis and its constituents for various GI disorders remains unclear.
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Woods JA, Wright NJD, Gee J, Scobey MW. Cannabinoid Hyperemesis Syndrome: An Emerging Drug-Induced Disease. Am J Ther 2016; 23:e601-5. [PMID: 24413371 DOI: 10.1097/mjt.0000000000000034] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cannabinoid hyperemesis is a relatively rare but significant adverse effect of chronic marijuana use characterized by severe, cyclic nausea, vomiting, and abdominal pain and marked by compulsive hot-water bathing for temporary symptom relief. A 37-year-old African American male with no significant medical history other than the habitual abuse of marijuana was admitted for intractable nausea, vomiting, and abdominal pain. With the exception of abdominal skin hyperpigmentation and scarring secondary to the direct application of heat through a heating pad, physical examination of the abdomen was unremarkable. Laboratory studies revealed a mild leukocytosis and acute renal dysfunction. All diagnostic examinations were found to be unremarkable or noncontributory to the patient's presenting state. Consistent with previous admissions, the patient's urine toxicology screening was found to be positive for marijuana. After several days of aggressive IV fluid hydration and as needed antiemetics and pain management, all laboratory studies and vital signs returned to baseline and the patient was subsequently discharged. Symptoms of cannabinoid hyperemesis resolve with cannabis cessation and recur when cannabis use is reinitiated, supporting an association between chronic use and cyclic vomiting. A Naranjo algorithm score of 5 revealed a probable incidence of cyclic vomiting associated with chronic cannabis abuse in our patient. Marijuana use, both legal and illegal, is becoming more prevalent in the United States. Given the nationwide increase in marijuana use for recreational and medical reasons, pharmacists and other health care providers should be aware of this interesting drug-induced phenomenon.
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Affiliation(s)
- J Andrew Woods
- 1Wingate University School of Pharmacy, Wingate, NC; 2Departments of Pharmacy, 3Internal Medicine, and 4Gastroenterology, Carolinas Medical Center, Charlotte, NC
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Cannabinoid Hyperemesis Syndrome: A Case Report of Cyclic Severe Hyperemesis and Abdominal Pain with Long-Term Cannabis Use. Case Rep Gastrointest Med 2016; 2016:2815901. [PMID: 27980870 PMCID: PMC5131230 DOI: 10.1155/2016/2815901] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 10/25/2016] [Indexed: 11/18/2022] Open
Abstract
Introduction. Cannabinoid Hyperemesis Syndrome (CHS) is a rare condition that includes cyclic severe vomiting in subjects who have been consuming large doses of cannabis for several years. One of the major diagnostic criteria is the alleviation of symptoms by hot showers. The syndrome was first described in 2004 and is so far neither completely understood nor well known. The latter leads to continued morbidity in concerned subjects and unnecessary expenses for futile investigations. Standard treatments of vomiting as 5-HT3 or D2-receptor antagonists have been shown to be ineffective in alleviating the symptoms. The only long-term satisfying treatment option is the complete abstinence from cannabis consumption. Case Summary. In this case report we describe a 26-year-old male Caucasian long-term cannabis consumer who repeatedly presented in our emergency room with cyclic severe nausea and vomiting ceased by hot showers and resistant to all other treatments. The final diagnosis was not established until his third visit to the ER. Conclusion. CHS is an important differential diagnosis in patients who present with cyclic vomiting and abdominal pain with a history of long-term cannabis use. Recognition of this syndrome is important in order to avoid unnecessary clinical testing and to help the patients break the cycle of drug use.
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Sharkey KA, Wiley JW. The Role of the Endocannabinoid System in the Brain-Gut Axis. Gastroenterology 2016; 151:252-66. [PMID: 27133395 PMCID: PMC4961581 DOI: 10.1053/j.gastro.2016.04.015] [Citation(s) in RCA: 143] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 03/21/2016] [Accepted: 04/11/2016] [Indexed: 12/17/2022]
Abstract
The actions of cannabis are mediated by receptors that are part of an endogenous cannabinoid system. The endocannabinoid system (ECS) consists of the naturally occurring ligands N-arachidonoylethanolamine (anandamide) and 2-arachidonoylglycerol (2-AG), their biosynthetic and degradative enzymes, and the cannabinoid (CB) receptors CB1 and CB2. The ECS is a widely distributed transmitter system that controls gut functions peripherally and centrally. It is an important physiologic regulator of gastrointestinal motility. Polymorphisms in the gene encoding CB1 (CNR1) have been associated with some forms of irritable bowel syndrome. The ECS is involved in the control of nausea and vomiting and visceral sensation. The homeostatic role of the ECS also extends to the control of intestinal inflammation. We review the mechanisms by which the ECS links stress and visceral pain. CB1 in sensory ganglia controls visceral sensation, and transcription of CNR1 is modified through epigenetic processes under conditions of chronic stress. These processes might link stress with abdominal pain. The ECS is also involved centrally in the manifestation of stress, and endocannabinoid signaling reduces the activity of hypothalamic-pituitary-adrenal pathways via actions in specific brain regions, notably the prefrontal cortex, amygdala, and hypothalamus. Agents that modulate the ECS are in early stages of development for treatment of gastrointestinal diseases. Increasing our understanding of the ECS will greatly advance our knowledge of interactions between the brain and gut and could lead to new treatments for gastrointestinal disorders.
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Affiliation(s)
- Keith A. Sharkey
- Hotchkiss Brain Institute and Snyder Institute of Chronic Diseases, Department of Physiology and Pharmacology, University of Calgary, Calgary, AB T2N 4N1, Canada,Corresponding author: Dr. Keith Sharkey, Department of Physiology and Pharmacology, University of Calgary, 3330 Hospital Drive NW, Calgary, AB T2N 4N1, Canada, , Tel: 403-220-4601
| | - John W. Wiley
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
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Sawni A, Vaniawala VP, Good M, Lim WY, Golec AS. Recurrent Cyclic Vomiting in Adolescents: Can It Be Cannabinoid Hyperemesis Syndrome? Clin Pediatr (Phila) 2016; 55:560-3. [PMID: 26149847 DOI: 10.1177/0009922815594233] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Anju Sawni
- Hurley Children's Hospital/Hurley Medical Center, Flint, MI, USA Michigan State University, College of Human Medicine, E Lansing, MI, USA
| | - Vishwas P Vaniawala
- Hurley Children's Hospital/Hurley Medical Center, Flint, MI, USA Michigan State University, College of Human Medicine, E Lansing, MI, USA
| | - Meredith Good
- Hurley Children's Hospital/Hurley Medical Center, Flint, MI, USA Michigan State University, College of Human Medicine, E Lansing, MI, USA
| | - Whei Ying Lim
- Hurley Children's Hospital/Hurley Medical Center, Flint, MI, USA Michigan State University, College of Human Medicine, E Lansing, MI, USA
| | - Alexander S Golec
- Michigan State University, College of Human Medicine, E Lansing, MI, USA
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48
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Bajgoric S, Samra K, Chandrapalan S, Gautam N. Cannabinoid hyperemesis syndrome: a guide for the practising clinician. BMJ Case Rep 2015; 2015:bcr-2015-210246. [PMID: 26698198 DOI: 10.1136/bcr-2015-210246] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Cannabis is the most widely used illicit drug in the world. The medicinal value of cannabis as an antiemetic is well known by the medical fraternity. A less well-recognised entity is the potential for certain chronic users to develop hyperemesis. We describe the case of a young man who presented to us with features of cannabinoid hyperemesis syndrome. We review the current literature on this condition, its pathogenesis and management.
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Affiliation(s)
- Sanjin Bajgoric
- Department of Gastroenterology, University Hospitals of North Midlands, Stoke-on-Trent, UK
| | - Kiran Samra
- Department of Gastroenterology, University Hospitals of North Midlands, Stoke-on-Trent, UK
| | - Subashini Chandrapalan
- Department of Gastroenterology, University Hospitals of North Midlands, Stoke-on-Trent, UK
| | - Nishant Gautam
- Department of Gastroenterology, University Hospitals of North Midlands, Stoke-on-Trent, UK
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Smith LA, Azariah F, Lavender VTC, Stoner NS, Bettiol S. Cannabinoids for nausea and vomiting in adults with cancer receiving chemotherapy. Cochrane Database Syst Rev 2015; 2015:CD009464. [PMID: 26561338 PMCID: PMC6931414 DOI: 10.1002/14651858.cd009464.pub2] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Cannabis has a long history of medicinal use. Cannabis-based medications (cannabinoids) are based on its active element, delta-9-tetrahydrocannabinol (THC), and have been approved for medical purposes. Cannabinoids may be a useful therapeutic option for people with chemotherapy-induced nausea and vomiting that respond poorly to commonly used anti-emetic agents (anti-sickness drugs). However, unpleasant adverse effects may limit their widespread use. OBJECTIVES To evaluate the effectiveness and tolerability of cannabis-based medications for chemotherapy-induced nausea and vomiting in adults with cancer. SEARCH METHODS We identified studies by searching the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO and LILACS from inception to January 2015. We also searched reference lists of reviews and included studies. We did not restrict the search by language of publication. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared a cannabis-based medication with either placebo or with a conventional anti-emetic in adults receiving chemotherapy. DATA COLLECTION AND ANALYSIS At least two review authors independently conducted eligibility and risk of bias assessment, and extracted data. We grouped studies based on control groups for meta-analyses conducted using random effects. We expressed efficacy and tolerability outcomes as risk ratio (RR) with 95% confidence intervals (CI). MAIN RESULTS We included 23 RCTs. Most were of cross-over design, on adults undergoing a variety of chemotherapeutic regimens ranging from moderate to high emetic potential for a variety of cancers. The majority of the studies were at risk of bias due to either lack of allocation concealment or attrition. Trials were conducted between 1975 and 1991. No trials involved comparison with newer anti-emetic drugs such as ondansetron. Comparison with placebo People had more chance of reporting complete absence of vomiting (3 trials; 168 participants; RR 5.7; 95% CI 2.6 to 12.6; low quality evidence) and complete absence of nausea and vomiting (3 trials; 288 participants; RR 2.9; 95% CI 1.8 to 4.7; moderate quality evidence) when they received cannabinoids compared with placebo. The percentage of variability in effect estimates that was due to heterogeneity rather than chance was not important (I(2) = 0% in both analyses).People had more chance of withdrawing due to an adverse event (2 trials; 276 participants; RR 6.9; 95% CI 1.96 to 24; I(2) = 0%; very low quality evidence) and less chance of withdrawing due to lack of efficacy when they received cannabinoids, compared with placebo (1 trial; 228 participants; RR 0.05; 95% CI 0.0 to 0.89; low quality evidence). In addition, people had more chance of 'feeling high' when they received cannabinoids compared with placebo (3 trials; 137 participants; RR 31; 95% CI 6.4 to 152; I(2) = 0%).People reported a preference for cannabinoids rather than placebo (2 trials; 256 participants; RR 4.8; 95% CI 1.7 to 13; low quality evidence). Comparison with other anti-emetics There was no evidence of a difference between cannabinoids and prochlorperazine in the proportion of participants reporting no nausea (5 trials; 258 participants; RR 1.5; 95% CI 0.67 to 3.2; I(2) = 63%; low quality evidence), no vomiting (4 trials; 209 participants; RR 1.11; 95% CI 0.86 to 1.44; I(2) = 0%; moderate quality evidence), or complete absence of nausea and vomiting (4 trials; 414 participants; RR 2.0; 95% CI 0.74 to 5.4; I(2) = 60%; low quality evidence). Sensitivity analysis where the two parallel group trials were pooled after removal of the five cross-over trials showed no difference (RR 1.1; 95% CI 0.70 to 1.7) with no heterogeneity (I(2) = 0%).People had more chance of withdrawing due to an adverse event (5 trials; 664 participants; RR 3.9; 95% CI 1.3 to 12; I(2) = 17%; low quality evidence), due to lack of efficacy (1 trial; 42 participants; RR 3.5; 95% CI 1.4 to 8.9; very low quality evidence) and for any reason (1 trial; 42 participants; RR 3.5; 95% CI 1.4 to 8.9; low quality evidence) when they received cannabinoids compared with prochlorperazine.People had more chance of reporting dizziness (7 trials; 675 participants; RR 2.4; 95% CI 1.8 to 3.1; I(2) = 12%), dysphoria (3 trials; 192 participants; RR 7.2; 95% CI 1.3 to 39; I(2) = 0%), euphoria (2 trials; 280 participants; RR 18; 95% CI 2.4 to 133; I(2) = 0%), 'feeling high' (4 trials; 389 participants; RR 6.2; 95% CI 3.5 to 11; I(2) = 0%) and sedation (8 trials; 947 participants; RR 1.4; 95% CI 1.2 to 1.8; I(2) = 31%), with significantly more participants reporting the incidence of these adverse events with cannabinoids compared with prochlorperazine.People reported a preference for cannabinoids rather than prochlorperazine (7 trials; 695 participants; RR 3.3; 95% CI 2.2 to 4.8; I(2) = 51%; low quality evidence).In comparisons with metoclopramide, domperidone and chlorpromazine, there was weaker evidence, based on fewer trials and participants, for higher incidence of dizziness with cannabinoids.Two trials with 141 participants compared an anti-emetic drug alone with a cannabinoid added to the anti-emetic drug. There was no evidence of differences between groups; however, the majority of the analyses were based on one small trial with few events. Quality of the evidence The trials were generally at low to moderate risk of bias in terms of how they were designed and do not reflect current chemotherapy and anti-emetic treatment regimens. Furthermore, the quality of evidence arising from meta-analyses was graded as low for the majority of the outcomes analysed, indicating that we are not very confident in our ability to say how well the medications worked. Further research is likely to have an important impact on the results. AUTHORS' CONCLUSIONS Cannabis-based medications may be useful for treating refractory chemotherapy-induced nausea and vomiting. However, methodological limitations of the trials limit our conclusions and further research reflecting current chemotherapy regimens and newer anti-emetic drugs is likely to modify these conclusions.
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Affiliation(s)
- Lesley A Smith
- Department of Psychology, Social Work and Public Health, Oxford Brookes University, Jack Straws Lane, Marston, Oxford, UK, OX3 0FL
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Cannabinoid Hyperemesis Syndrome: A Paradoxical Cannabis Effect. Case Rep Gastrointest Med 2015; 2015:405238. [PMID: 26266060 PMCID: PMC4525754 DOI: 10.1155/2015/405238] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 06/09/2015] [Accepted: 06/16/2015] [Indexed: 01/22/2023] Open
Abstract
Despite well-established antiemetic properties of marijuana, there has been increasing evidence of a paradoxical effect in the gastrointestinal tract and central nervous system, given rise to a new and underrecognized clinical entity called the Cannabinoid Hyperemesis Syndrome. Reported cases in the medical literature have established a series of patients exhibiting a classical triad of symptoms: cyclic vomiting, chronic marijuana use, and compulsive bathing. We present a case of a 29-year-old man whose clinical presentation strongly correlates with cannabinoid hyperemesis syndrome. Despite a diagnosis of exclusion, this syndrome should be considered plausible in the setting of a patient with recurrent intractable vomiting and a strong history of cannabis use as presented in this case.
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