Cannabinoid Hyperemesis Syndrome

HYPER-Emesis sounds gross! It sounds like something from a horror movie and invokes thoughts of demonic possession. Of course we deal with vomiting a lot (ex, Pyloric Stenosis, Malrotation, Testicular Torsion, Ovarian Torsion, Vertigo, Ogilvie’s Syndrome) and fortunately, we have good therapies to fight off the potential dehydration; however, sometimes the demonic possess persists. Thanks to our good friend, Dr. Simone Lawson, I was reminded that some unique therapies may need to be employed in such cases. Let us take a minute to review one specific cause of vomiting that thwarts our common therapies – Cannabinoid Hyperemesis Syndrome:

Cannabinoid Hyperemesis Syndrome

  • Cannabis is commonly used and its potency has been increasing (3 times more potent over past 20 years). [Venkatesan, 2019; Richards, 2018]
  • Cannabis has been associated with a variant of Cyclic Vomiting Syndrome. [Venkatesan, 2019; Richards, 2018; Felton, 2015; Desjardins, 2015]
    • First described in 2004.
    • Pathophysiology is not well understood at this time. [Venkatesan, 2019; Richards, 2018; Graham, 2017]
    • Often leads to ED presentation for symptom relief.
    • Often leads to many tests being done: labs and imaging.
  • Clinical Features of Cannabinoid Hyperemesis Syndrome: [Venkatesan, 2019; Richards, 2018; Felton, 2015; Desjardins, 2015; Miller, 2010]
    • Frequent and Prolonged Marijuana Use (natural or synthetic)
      • Duration > 1 year preceding onset of symptoms [Venkatesan, 2019]
      • Frequency of use > 4 times a week on average [Venkatesan, 2019]
    • Abdominal Pain
    • Cyclic Nausea and Vomiting
    • Resolution with Cessation of Marijuana
    • Symptom Relief with HOT Showers/Baths
    • Weight loss often noted
    • Symptoms Worse in Morning
    • Normal Bowel Habits
    • No Radiographic, Laboratory, or Endoscopic Abnormalities (if performed)
  • 3 phases of Cannabinoid Hyperemesis Syndrome: [Richards, 2018]
    • Prodrome – nausea, anorexia, vague abdominal pain
    • Hyperemesis – episodic vomiting, diffuse abdominal pain, can last for hours.
    • Recovery – slow resolution of symptoms

Cannabinoid Hyperemesis Syndrome: Management

  • Don’t jump to conclusions!
    • Marijuana use may also be associated with other substance use that may cause other conditions, like pancreatitis!
    • Be diligent and vigilant and don’t jump to conclusions.
    • BUT, be reasonable and don’t order tests that you don’t think will help you manage the patient! (that is a generally good idea)
  • Interestingly, commonly used anti-emetics are not effective in controlling symptoms! [Richards, 2018]
    • Serotonin antagonists are often ineffective.
    • Dopamine antagonists may be somewhat more effective.
  • Off-label, non-traditional therapies are, therefore, tried: [Venkatesan, 2019; Richards, 2018]
    • Benzos
    • Haldol has been used with some positive improvement. [Witsil, 2017]
  • Other therapies that have been effective: [Venkatesan, 2019; Richards, 2018; Graham, 2017]
    • Hot Showering/Bathing
      • Often done by patients on their own.
      • Many cases of “compulsive” use of hot showers/baths [Witsil, 2017; Miller, 2010]
      • Consistently noted to be effective for short-term relief.
    • Capsaicin Topical Cream
      • Capsaicin: [Richards, 2018]
        • Is an alkaloid extract from a Capsicum, a plant from the night-shade family
        • It is a vanilloid – similar to substances from vanilla, ginger, and cloves.
        • It is responsible for the “Heat” from chili peppers
          • Pure capsaicin is 16 million Scoville Units
          • A red bell pepper is 0 and a habanero is ~350,000
      • Complex interactions between the endocannabinoid systems and transient receptor potential vanilloid 1 play a role in the symptoms and treatments. [Richards, 2018]
        • (nope, I don’t really understand that either … but smart pharmacologists do)
        • There are many theories that are being evaluated to elucidate the pathophysiology and the therapeutic mechanism. [Venkatesan, 2019; Miller, 2010]
      • Topical Capsaicin Therapy: [Richards, 2018]
        • Has been used for Nociceptive and Neuropathic pain
        • Available in some formulations over-the-counter
          • 0.025%, 0.075%, and 0.1% creams
          • An 8% patch also exists.
        • Can lead to local skin irritation and burning.
        • Applied to abdomen, back, and/or arms.
      • Found to help resolve symptoms within ~30-45 min. [Richards, 2018; Graham, 2017]
  • Long-Term Therapy = STOP USING CANNABINOIDS!

Moral of the Morsel

  • Don’t Jump to Conclusions! The use of Cannabis does not equate to Cannabinoid Hyperemesis Syndrome.
  • Zofran doesn’t fix everything! Sad, but true. You may need to consider utilizing other non-traditional therapies.
  • Chili-Peppers are useful for more than seasoning. Topical Capsaicin may be a way to avoid lots of Haldol… plus can be used at home!

References

McConachie SM1,2, Caputo RA1, Wilhelm SM1, Kale-Pradhan PB1,3. Efficacy of Capsaicin for the Treatment of Cannabinoid Hyperemesis Syndrome: A Systematic Review. Ann Pharmacother. 2019 May 18:1060028019852601. PMID: 31104487. [PubMed] [Read by QxMD]
Venkatesan T1, Levinthal DJ2, Li BUK3, Tarbell SE4, Adams KA5, Issenman RM6, Sarosiek I7, Jaradeh SS8, Sharaf RN9, Sultan S10, Stave CD8, Monte AA11, Hasler WL12. Role of chronic cannabis use: Cyclic vomiting syndrome vs cannabinoid hyperemesis syndrome. Neurogastroenterol Motil. 2019 Jun;31 Suppl 2:e13606. PMID: 31241817. [PubMed] [Read by QxMD]
Richards JR1, Lapoint JM2, Burillo-Putze G3. Cannabinoid hyperemesis syndrome: potential mechanisms for the benefit of capsaicin and hot water hydrotherapy in treatment. Clin Toxicol (Phila). 2018 Jan;56(1):15-24. PMID: 28730896. [PubMed] [Read by QxMD]
Graham J1, Barberio M2, Wang GS3. Capsaicin Cream for Treatment of Cannabinoid Hyperemesis Syndrome in Adolescents: A Case Series. Pediatrics. 2017 Dec;140(6). PMID: 29122973. [PubMed] [Read by QxMD]
Witsil JC1, Mycyk MB. Haloperidol, a Novel Treatment for Cannabinoid Hyperemesis Syndrome. Am J Ther. 2017 Jan/Feb;24(1):e64-e67. PMID: 25393073. [PubMed] [Read by QxMD]
Argamany JR1, Reveles KR1, Duhon B2. Synthetic cannabinoid hyperemesis resulting in rhabdomyolysis and acute renal failure. Am J Emerg Med. 2016 Apr;34(4):765. PMID: 26422191. [PubMed] [Read by QxMD]
Desjardins N1, Jamoulle O1, Taddeo D1, Stheneur C2. Cannabinoid Hyperemesis Syndrome in a 17-Year-Old Adolescent. J Adolesc Health. 2015 Nov;57(5):565-7. PMID: 26372366. [PubMed] [Read by QxMD]
Felton D1, Zitomersky N2, Manzi S3, Lightdale JR2. 13-year-old girl with recurrent, episodic, persistent vomiting: out of the pot and into the fire. Pediatrics. 2015 Apr;135(4):e1060-3. PMID: 25733759. [PubMed] [Read by QxMD]
Miller JB1, Walsh M, Patel PA, Rogan M, Arnold C, Maloney M, Donnino M. Pediatric cannabinoid hyperemesis: two cases. Pediatr Emerg Care. 2010 Dec;26(12):919-20. PMID: 21131803. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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