Toxicology Tips: Cannabinoid Hyperemesis Syndrome

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January 7, 2016 by dailybolusoflr

Contributors: Candice Jordan, MD and Karolina Paziana, MD on behalf of the Toxicology FAST

Introduction
Cannabis is the most commonly used drug in the world behind alcohol and tobacco.  New laws legalizing marijuana across the United States have lead to a recent surge in use.  Cannabis is most often used recreationally, but can be prescribed for use in chronic pain, spasticity and as an antiemetic.  However, cannabinoid may also have the paradoxical presentation of cyclical nausea, vomiting and abdominal pain that is associated with chronic use.  Patients with this syndrome are frequently misdiagnosed as having cyclic vomiting syndrome (which is a functional GI disorder).
Patients are commonly young adults with long-standing history of cannabinoid use. Symptoms are usually delayed for years after initial chronic use. 


Pathophysiology (all theoretical)
  • THC is highly fat soluble, chronic use leads to high total body concentrations, prolonged diffusion, delayed elimination and subsequent toxicity.
  • THC binds to CB receptors on enterocytes inhibiting gastric motility.
  • THC induces hypothalamic thermo-dysregulation


Clinical course
  • Phase  I (Pre-emetic phase): early morning nausea, fear of vomiting- lasts months-years (may actually increase use of cannabis with the hope of reducing nausea)
  • Phase II (hyperemetic phase): 24-48 hours of severe nausea and vomiting, up to 5kg weight loss, possible dehydration and early pre-renal failure, patient takes repeated hot showers
  • Phase III (Recovery phase): symptoms resolve, weigh gained back
  • Cannabinoid use history should be sought in patients with multiple similar presentations of unexplained nausea, vomiting and abdominal pain. 
  • ED work-up may be extensive but will be largely unrevealing
  • Average time to diagnosis is 9 years



Treatment
  • Supportive care: antiemetics, IV fluids
  • Cannabis cessation
  • Hot showers: correction of hypothalamic thermoregulatory system vs. peripheral dilation and diversion of blood flow from GI tract
  • Some authors have recommended topical capsaicin cream (0.075%). This approach has not been rigorously studied but is low risk. 


References
  1. A. Galli, Jonathan, Ronald Andari Sawaya, and Frank K. Friedenberg. ‘Cannabinoid Hyperemesis Syndrome’. Current Drug Abuse Reviewse 4.4 (2011): 241-249. Web.
  2. ‘Cannabinoid Hyperemesis’. Internal Medicine Journal 39.11 (2009): 777-778. Web.
  3. LaPoint Jeff. Capsaicin cream for treatment of cannabinoid hyperemesis syndrome.
  4. http://www.acmt.net/Abstracts_41-60.html
  5. Ruffle, James K. et al. ‘Cannabinoid Hyperemesis Syndrome’. European Journal of Gastroenterology & Hepatology (2015): 1. Web.

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