Treating Cannabinoid Hyperemesis Syndrome in the Emergency Department

As more states legalize marijuana for recreational use, data have shown an increase in cannabis use among teenagers. Some of those teenagers may develop cannabinoid hyperemesis syndrome (CHS), a condition noted for persistent vomiting resulting from habitual cannabis use. Benzodiazepines, droperidol, haloperidol, antiemetics, acid suppression therapy, or capsaicin are all currently recommended for treatment, although no consensus exists regarding the comparative efficacy of the therapies, nor are there definitive dosing recommendations. A poster presented at the Pediatric Pharmacy Association’s 2022 Annual Meeting, heldin Norfolk, Virginia, examined the medication management of CHS in a pediatric emergency department.

The investigators included children aged 12 years or older who had an emergency department visit between August 2016 and July 2021 for CHS. The children were identified using ICD-10 codes for nausea, vomiting without nausea, cyclical vomiting syndrome unrelated to migraine, nausea with vomiting, cannabinoid hyperemesis syndrome, cannabis hyperemesis syndrome concurrent with and due to cannabis abuse, and cannabis hyperemesis syndrome concurrent with and due to cannabis dependence. Data were collected for each child’s age, sex, race/ethnicity, diagnosis or ICD-10 code, hospital admission, the medications administered during the emergency department visit, discharge prescriptions, and electrocardiograms.

From a potential pool of 94 encounters, 30 met the inclusion criteria. Two patients were given aprepitant; 3 were given fosaprepitant; 8 were given haloperidol, which was given both orally and intravenous/intramuscular(IV/IM); 15 were given capsaicin; 1 was given haloperidol plus aprepitant; and 1 was given capsaicin plus haloperidol.

When broken down to the 5 components, the investigators found a wide range in dosage:

• Aprepitant: 80 mg low dose regimen/125 mg high dose regimen
• Fosaprepitant: 125 mg low dose regimen/150 mg high dose regimen
• Haloperidol IV/IM: < 0.05 low dose regimen/≥ 0.05 high dose regimen
• Haloperidol oral: < 0.05 low dose regimen/≥ 0.05 high dose regimen
• Capsaicin: ≤ 1 application low dose regimen/ > 1 application high dose regimen

Sixty percent of patients required further hospitalization. High-dose haloperidol and aprepitant were the most favorable for discharge from the emergency department, whileboth fosaprepitant and capsaicin appeared to be ineffective at treating the emetic symptoms of CHS. Prescriptions provided at discharge included aprepitant, ondansetron, scopolamine, and prochlorperazine. The investigators noted that further study with a larger sample size would be helpful in determining optimal dosing for treating CHS in the emergency department.

Reference

1. Bryant D, Steinbrenner J. Evaluation of cannabinoid hyperemesis syndrome within a pediatric emergency department. Presented at: Pediatric Pharmacy Association 2022 Annual Meeting; May 3-6, 2022; Norfolk, VA.