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Nortriptyline and doxepin have fewer adverse effects and provide substantial therapeutic benefits. The dose can be gradually increased in 10 mg increments every 1–2 weeks until the G.I. Benzodiazepines, such as lorazepam, have proven acute treatment for CHS 65,66. Intravenous lorazepam administered in doses of 1 to 2 mg every 4 to 6 h has shown symptom relief 65,66.
- It’s important to be honest about your marijuana use if you have symptoms of CHS.
- 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.
- The primary treatment objectives are intravenous hydration and correction of electrolyte imbalances.
- We fix this by giving the water back through the veins and giving drugs to stop the sick feeling and lower the acid in the stomach.
- However, 1 week earlier, the results of urine drug screening had been negative for THC, amphetamines, methamphetamine, benzodiazepines, cocaine, opiates, fentanyl, methadone, and oxycodone.
The average length of time between the onset of symptoms and a CHS diagnosis was 6.1 years (range 1–10 years) and patients visited the ED at average of 10 times before diagnosis was made. All patients found relief in hot showers and all were described as “uncooperative” with a CHS diagnosis. Upon being hospitalized, 100% of patients had complete resolution of all symptoms an average of 3.6 days after discontinuation of marijuana (range 2–5 days). In this case series, the investigators noted that this latter patient − who continued to use cannabis − had the greatest number of acute episodes of CHS 129. Thus, severe symptoms may not be sufficient to compel an individual to discontinue marijuana or cannabis may have an adverse effect on the individual’s ability to make sound decisions 129.
Clinical Presentation, work up and differential diagnosis of Cannabinoid Hyperemesis Syndrome
Since the 1990s, there has been a progressive change in the composition of the plant, with increases in the tetrahydrocannabinol (THC) and a reduction of cannabidiol (CBD).6 This trend correlates with increased cannabis use. Some individuals, for instance, also admitted to smoking 2000 mg of THC per day. From sinus infections and high blood pressure to preventive screening, we’re here for you.
- THC is excreted in feces (60-85%) and urine (20-35%) as acid metabolites.
- In addition to frequent and severe vomiting, patients may have difficulty eating and drinking, and only find (temporary) relief in hot showers and baths.
- Evidence-based management of CHS is based on case series and small clinical trials 63.
- It is crucial to exclude other entities such as Addison’s disease, migraines, hyperemesis gravidarum, bulimia, and psychogenic vomiting, which can mimic CHS symptoms and may also occur alongside it.
- It is not unusual for CHS patients to present frequently at the ED and to be hospitalized multiple times per year.
Cannabinoid Hyperemesis Syndrome: A Rising Complication
When cannabis is the underlying cause, learning about CHS can be a life-changing discovery. A typical person diagnosed with CHS might have smoked or ingested marijuana for about 19 years. Many only get a correct diagnosis after making multiple emergency room visits for unstoppable vomiting. It’s worth noting that you don’t always need that full 19-year timeline, as some people can develop CHS sooner, especially if they’re using especially potent cannabis or consuming it in large amounts. Many individuals either avoid seeking medical help or don’t mention their marijuana use during a doctor’s visit. In the brain, the cannabinoid system helps regulate several aspects of the endocrine system.
Bowel Sounds Ep. 14: Thangam Venkatesan – Cannabinoid Hyperemesis Syndrome
While it is possible that legalization has made patients more willing to seek emergency care, the burden of managing these cases ultimately falls on healthcare providers. Moreover, cannabis legalization has introduced higher-potency products to the market, which may be a significant factor contributing to the rising incidence of CHS. The prevalence of cannabis use disorder is expected to rise as legal restrictions on its recreational use decrease in several states. Nearly 20 years after CHS’s first report, current acute and long-term treatment strategies remain unfamiliar to many practitioners. And primary care providers, are vital in diagnosing and treating CHS as its prevalence rises. This will provide more data on CHS and facilitate the development of targeted novel therapeutic interventions for this condition in the future.
Throughout this phase, the patient maintains an average weight and returns to their baseline state 49. Psychological stress, such as post-traumatic stress disorder or a history of physical and sexual abuse, are potential triggers for disrupting the Alcoholics Anonymous expected anti-emetic effects of THC. Though the precise mechanisms remain unclear, higher amounts of marijuana consumption, genetic influences, and psychological stress lead to intoxication and paradoxically promote vomiting. Both CVS and CHS are complex gastrointestinal conditions influenced by several entities, including genetic, environmental, and lifestyle factors. While their genetic underpinnings are still not fully understood, research has suggested potential genetic predispositions for each. The CVS has strong links to mitochondrial dysfunction and neurobiological pathways related to migraine, while CHS is primarily influenced by chronic cannabis use and endocannabinoid system dysfunction.
What is Cannabinoid Hyperemesis Syndrome?
CHS is also underdiagnosed because people sometimes use marijuana to suppress nausea and vomiting. Doctors currently lack knowledge of the condition, and there are no clinical guidelines for its treatment and management. As CHS is a relatively recently recognized and studied phenomenon easily confused with other diseases, there is a paucity of sizeable randomized control studies.
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This episode is debilitating and overwhelming, with patients vomiting and retching up to five times per hour, requiring several emergency room Twelve-step program (E.R.) visits. Abdominal pain generally starts in the epigastric region and progresses to more diffuse abdominal pain. A sympathetic overactivity during this phase results in symptoms such as tachycardia, hypertension, hot flashes, sweating, and trembling 42. Due to excessive nausea and vomiting, patients are often found to have hypokalemia, volume depletion, acute renal failure, hypophosphatemia, and mild reactive leukocytosis 55,56,57.
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A recent review has explored numerous potential explanations regarding various pharmacokinetic and pharmacodynamic factors of the cannabinoids 72. The cannabis plant contains over four hundred different chemicals, with sixty possessing cannabinoid structures 76. The pro-emetic effects of two of these cannabinoids, CBD and CBG, have been discussed in this review and could conceivably play a role in the development of CHS. Additional pharmacological research is needed regarding the pro-emetic effects of additional cannabinoids and their metabolites. Another proposed explanation is that in susceptible individuals the pro-emetic effect of cannabis on the gut (e.g. delayed gastric emptying) overrides its anti-emetic CNS properties 62.
The 11-OH-THC metabolite is psychoactive and is equipotent to THC in terms of psychoactive effects; THC-COOH is not psychotropic and has anti-inflammatory and analgesic properties 41, 42. CBD is not psychotropic, has little affinity for the CB1/CB2 receptors, and appears to be a partial agnostic at the serotonin receptors 43. CBD enhances the expression of the CB1 receptors in the hypothalamus, plus it amplifies the hypothermic effects of THC 44. In preclinical studies, toxin-induced vomiting treated with CBD showed a biphasic response, that is, low doses of CBD had an antiemetic effect while higher doses had a proemetic effect 37, 45. CBG is not psychotropic and acts as an antagonist at both CB1 and serotonin receptors 46.
- As with similar series, they found the patients were typically young (25.8 years) males (65.5%) who had used cannabinoids daily for several years, found relief in hot showers, and for whom antiemetic therapy was ineffective.
- Cannabis withdrawal commonly presents with symptoms such as loss of appetite, anxiety, depression, physical tension, and insomnia, which increases the difficulty in ceasing cannabis use 93.
- When your internal electrolyte levels go off the rails, your body’s ability to function properly gets compromised.
- In this group, 9 patients smoked marijuana for recreation, while the other patient had been prescribed synthetic cannabinoids (nabilone 2 mg twice a day) to treat multiple sclerosis.
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- Since the Department of Justice issued a memo that it would not prosecute marijuana users and sellers who complied with state law in 2009, hospital discharges for compulsive vomiting have increased by 8% annually 13.
- During a flare-up, people with CHS also often take hot baths or showers, sometimes multiple times per day, to try to relieve their discomfort.
- Ancient Chinese texts document the use of Cannabis sativa for pain and cramp relief.
- As more states legalize cannabis, more people are learning whether cannabis is right for them.
- In older patients, especially those with hypertension, cardiovascular illnesses such as aortic pathology and atypical coronary artery syndromes may present as vague abdominal pain, nausea, and vomiting.
- In the CNS, activation of these receptors has a direct role in regulating the sympathetic and hypothalamic-pituitary-adrenal axis, preventing overstimulation.
Both conditions predominantly affect younger individuals, with CHS showing a higher prevalence in males, which aligns with the higher rates of cannabis use among men. While CVS tends to be more common in women according to some studies, gender biases in both conditions remain inconclusive 15. The difficulty in diagnosing CHS arises because its symptoms overlap with other gastrointestinal and metabolic disorders, such as gastroparesis, cyclic vomiting syndrome, or peptic ulcer disease. Overlapping symptoms such as abdominal pain and cyclic vomiting are especially difficult to pinpoint to a specific illness. Two treatment patterns were noted in Sifuentes et al.’s long-term follow-up study of CHS patients 105.