Capsaicin topical in emergency department treatment of cannabinoid hyperemesis syndrome

IntroductionCannabinoid hyperemesis syndrome (CHS) is an entity associated with cannabinoid overuse. CHS typically presents with cyclical vomiting, diffuse abdominal pain, and relief with hot showers. Patients often present to the emergency department (ED) repeatedly and undergo extensive evaluations including laboratory examination, advanced imaging, and in some cases unnecessary procedures. They are exposed to an array of pharmacologic interventions including opioids that not only lack evidence, but may also be harmful. This paper presents a novel treatment guideline that highlights the identification and diagnosis of CHS and summarizes treatment strategies aimed at resolution of symptoms, avoidance of unnecessary opioids, and ensuring patient safety.MethodsThe San Diego Emergency Medicine Oversight Commission in collaboration with the County of San Diego Health and Human Services Agency and San Diego Kaiser Permanente Division of Medical Toxicology created an expert consensus panel to establish a guideline to unite the ED community in the treatment of CHS.ResultsPer the consensus guideline, treatment should focus on symptom relief and education on the need for cannabis cessation. Capsaicin is a readily available topical preparation that is reasonable to use as first-line treatment. Antipsychotics including haloperidol and olanzapine have been reported to provide complete symptom relief in limited case studies. Conventional antiemetics including antihistamines, serotonin antagonists, dopamine antagonists and benzodiazepines may have limited effectiveness. Emergency physicians should avoid opioids if the diagnosis of CHS is certain and educate patients that cannabis cessation is the only intervention that will provide complete symptom relief.ConclusionAn expert consensus treatment guideline is provided to assist with diagnosis and appropriate treatment of CHS. Clinicians and public health officials should identity and treat CHS patients with strategies that decrease exposure to opioids, minimize use of healthcare resources, and maximize patient safety.

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“…13 , 18 This has led some to advocate for the use of topical capsaicin cream in the management of acute CHS. 18 – 21 …”

Section: Pathophysiology Of Chsmentioning

confidence: 99%

Cannabinoid Hyperemesis Syndrome: Public Health Implications and a Novel Model Treatment Guideline

Lapoint

Meyer

et al. 2018

WestJEM

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“…However, with accumulation of THC in the body fat over time, THC reserves may eventually achieve sufficiently high concentrations in the CNS to stimulate TRPV1 channels to their emetic threshold. This would explain why cannabinoid abstinence resolves symptoms [36]. It must also be noted that THC binds to CB1 receptors in the gastrointestinal (GI) tract, causing gastroparesis, which in and of itself can cause nausea and vomiting.…”

Section: Resultsmentioning

confidence: 99%

“…Similar to hot water, capsaicin provides symptomatic relief of CHS [95-97] but not other vomiting disorders. Topical capsaicin has been advocated for use as a diagnostic tool for CHS to differentiate it from other vomiting syndromes [36]. …”

Section: Resultsmentioning

confidence: 99%

Cannabinoid Hyperemesis

Pergolizzi Jr.,

LeQuang,

Bisney

2018

Med Cannabis Cannabinoids

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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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