Treatment of Cyclic Vomiting Syndrome
Treatment of Cyclic Vomiting Syndrome
Professor of Psychiatry, Internal Medicine and Surgery; Vice-Chair, Department of Psychiatry; Chair, Division of Consultation/Liaison Psychiatry, Virginia Commonwealth University School of Medicine, Richmond, Va.
Snezana Sonje, MD
First published in Primary Psychiatry, Volume 16, Issue 9, September, 2009
Treatment of cyclic vomiting syndrome (CVS) is largely empirical because the pathophysiology is unknown, controlled drug trials have not been conducted, and the placebo response rate may be as high as 70%. A comprehensive approach includes lifestyle modification, prophylactic therapy, abortive therapy, and treatment during the vomiting phase, as well as psychiatric aspects of care and psychological support for the patient and family.
Treatment should be individualized and with help from a multidisciplinary team including a gastroenterologist, primary care provider, nursing support, and psychiatrist or psychologist. The patient should be educated about the syndrome (which can itself reduce anxiety) and about necessary lifestyle changes, and should be provided with documentation of the prior diagnostic evaluations. Lifestyle modification should be employed in the interepisode phase, aimed at avoidance of triggering factors: noxious stress, sleep deprivation, fasting, triggering foods (eg, chocolate, red wine), excessive caffeine intake, and marijuana.
Tricyclic antidepressants (TCAs) act centrally to modulate the vomiting process and are especially helpful for those with comorbid depression, anxiety disorder, or migraine. One uncontrolled study1 reported that low-dose amitriptyline (up to 1 mg/kg for at least 3 months) resulted in decreased symptoms in 93% of patients, with 26% achieving full remission. Another study2 reported that TCA therapy was associated with complete remission in 18% and partial response in 59%. Case reports and case series3-10 showing the benefits of other medications include triptans, nonsteroidal anti-inflammatory drugs (ketorolac, indomethacin), anticonvulsants (phenobarbitol, valproate, carbamazepine, zonisamide, levetiracetam), propranolol, cyproheptadine, antispasmodic agents (eg, dicyclomine), antiemetics (eg, ondasetron, promethazine, prochlorperazine), erythromycin, dexmedetomidine, L-carnitine, and other agents.
During the prodromal phase when the patient is still able to tolerate oral intake, treatment should be initiated in a quiet, nonstimulating environment with antiemetics (eg, ondansetron, promethazine, prochlorperazine). Diphenhydramine, sleep induction with a benzodiazapene, and analgesics may be helpful as well. When oral intake is not possible, antiemetics can also be administered parenterally, intranasaly, or as a suppository.11
Treatment During Vomiting Phase
Treatment ideally should start within 1 hour of onset of vomiting with IV rehydration, IV ondanserton, and analgesia. If the episode is resistant, infusion of sedation may be needed, eg, chlorpromazine with diphenhydramine.11
Psychotherapeutic modalities should be considered for CVS patients for whom anxiety appears to be a trigger. If anxiety or depression appear to be triggering CVS episodes, psychiatric care including anxiolytics, antidepressants (especially TCAs, as noted above), and/or CBT can ameliorate the severity and decrease the frequency of attacks.12 Abuse of cannabis as a trigger should be evaluated, and if confirmed, abstinence should be strongly advised.
Disclosure: Dr. Levenson has served as a consultant to Eli Lilly. Dr. Sonje reports no affiliation with or financial interest in any organization that may pose a conflict of interest.
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