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Treatment of Cyclic Vomiting Syndrome

Treatment of Cyclic Vomiting Syndrome

 

September 3, 2012

 

James L. Levenson, MD

 


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

 


 

Introduction

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.

Prophylactic Therapy

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.

Abortive Therapy

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

Psychiatric Interventions

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.


References:

1. Namin F, Patel J, Lin Z, et al. Clinical, psychiatric and manometric profile of cyclic vomiting syndrome in adults and response to tricyclic therapy. Neurogastroenterol Motil. 2007;19:196-202.

2. Prakash C, Clouse RE. Cyclic vomiting syndrome in adults: clinical features and response to tricyclic antidepressants. Am J Gastroenterol. 1999;94:2855-2860.

3. Nakazato Y, Tamura N, Shimazu K. An adult case of cyclic vomiting syndrome successfully responding to valproic acid. J Neurol. 2008;255:934-935.

4. Clouse RE, Sayuk GS, Lustman PJ, Prakash C. Zonisamide or levetiracetam for adults with cyclic vomiting syndrome: a case series. Clin Gastroenterol Hepatol. 2007;5:44-48.

5. Andersen JM, Sugerman KS, Lockhart JR, Weinberg WA. Effective prophylactic therapy for cyclic vomiting syndrome in children using amitriptyline or cyproheptadine. Pediatrics. 1997;100:977-981.

6. Pasricha PJ, Schuster MM, Saudek CD, Wand G, Ravich WJ. Cyclic vomiting: association with multiple homeostatic abnormalities and response to ketorolac. Am J Gastroenterol. 1996;91:2228-2232.

7. Vanderhoof JA, Young R, Kaufman SS, Ernst L. Treatment of cyclic vomiting in childhood with erythromycin. J Pediatr Gastroenterol Nutr. 1995;21(suppl 1):S60-S62.

8. Van Calcar SC, Harding CO, Wolff JA. L-carnitine administration reduces number of episodes in cyclic vomiting syndrome. Clin Pediatr (Phila). 2002;41:171-174.

9. Khasawinah TA, Ramirez A, Berkenbosch JW, Tobias JD. Preliminary experience with dexmedetomidine in the treatment of cyclic vomiting syndrome. Am J Ther. 2003;10:303-307.

10. Haghighat M, Rafie SM, Dehghani SM, Fallahi GH, Nejabat M. Cyclic vomiting syndrome in children: experience with 181 cases from southern Iran. World J Gastroenterol. 2007;13:1833-1836.

11. Pareek N, Fleisher DR, Abell T. Cyclic vomiting syndrome: what a gastroenterologist needs to know. Am J Gastroenterol. 2007;102:2832-2840.

12. Tack J, Talley NJ, Camilleri M, Holtmann G, Hu P, Malagelada JR, Stanghellini V. Functional gastroduodenal disorders. Gastroenterology. 2006;130:1466-1479.