Treating cannabinoid hyperemesis syndrome in the emergency department

Both high-dose haloperidol and aprepitant were associated with discharge from the emergency department.

As more states legalize recreational marijuana, data has shown an increase in cannabis use among teens. Some of these teens may develop cannabinoid hyperemesis syndrome (CHS), a condition known for persistent vomiting resulting from habitual cannabis use. Benzodiazepines, droperidol, haloperidol, antiemetics, acid suppression therapy, or capsaicin are all currently recommended for treatment, although there is no consensus regarding the comparative effectiveness of the therapies, nor definitive dosage recommendations. A poster presented at the 2022 Pediatric Pharmacy Association Annual Meeting, held in Norfolk, Va., examined the management of CHS medications in a pediatric emergency department.

Investigators included children aged 12 or older who had an emergency department visit between August 2016 and July 2021 for CHS. Children were identified using the ICD-10 codes for nausea, vomiting without nausea, cyclic vomiting syndrome unrelated to migraine, nausea with vomiting, cannabinoid hyperemesis syndrome, Cannabis Hyperemesis Concomitant with and Due to Cannabis Abuse and Cannabis Hyperemesis Syndrome Concomitant with and Due to Cannabis Abuse. to cannabis addiction. Data were collected for age, gender, race/ethnicity, diagnosis or ICD-10 code, hospital admission, medications given at emergency department visit, discharge orders and electrocardiograms for each child.

Of a potential pool of 94 encounters, 30 met the inclusion criteria. Two patients received aprepitant; 3 received fosaprepitant; 8 received haloperidol, which was administered orally and intravenously/intramuscularly (IV/IM); 15 received capsaicin; 1 received haloperidol plus aprepitant; and 1 received capsaicin plus haloperidol.

When broken down into 5 components, investigators found a wide range of 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:
  • Oral haloperidol:
  • Capsaicin: ≤ 1 application low dose diet / > 1 application high dose diet

Sixty percent of patients required further hospitalization. High-dose haloperidol and aprepitant were most supportive of emergency department discharge, while fosaprepitant and capsaicin appeared ineffective in treating emetic symptoms of CHS. Prescriptions issued on discharge included aprepitant, ondansetron, scopolamine and prochlorperazine. Investigators noted that further study with a larger sample would be helpful in determining the optimal dosage for treating CHS in the emergency department.

Reference

1. Bryant D, Steinbrenner J. Assessment of cannabinoid hyperemesis syndrome in a pediatric emergency department. Presented at the 2022 Pediatric Pharmacy Association Annual Meeting; May 3-6, 2022; Norfolk, Virginia.