CVS

 Q: 42 years old male with chronic and continuous use of cannabinoids is admitted to ICU with severe hypovolemic shock due to persistent vomiting. Patient has been to Emergency Department (ED) many times and has been diagnosed with Cyclic Vomiting Syndrome (CVS). What is the first line of drug for the treatment? (select one) 

A) dexamethasone 

B) metoclopramide 

C) naloxone 

D) sumatriptan 

E) ondansetron 

Answer: D 

It has been shown that CVS and migraines have associated pathology. The new data shows that the prevalence of CVS is as common in adults as in children. Apart from migraine other associated pathologies are mitochondrial dysfunction, autonomic dysfunction, hypothalamic-pituitary-adrenal axis hyperreactivity, estrogen sensitivity (also known as catamenial CVS), long cannabis abuse [also known as — Cannabis hyperemesis syndrome (CHS)], sensitivity to chocolate, cheese, monosodium glutamate, and other food items. 

The only drugs shown to have the effect to abort CVS once symptoms set in are sumatriptan and aprepitant. Surprisingly, all other potent anti-emetics (Choice A, B, C, and E) have a limited role in aborting CVS.

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#toxicology

#neurology

References:

1. Fleisher DR, Gornowicz B, Adams K, et al. Cyclic Vomiting Syndrome in 41 adults: the illness, the patients, and problems of management. BMC Med 2005; 3:20. 

2. Sagar RC, Sood R, Gracie DJ, et al. Cyclic vomiting syndrome is a prevalent and under-recognized condition in the gastroenterology outpatient clinic. Neurogastroenterol Motil 2018; 30. 

3. Aziz I, Palsson OS, Whitehead WE, et al. Epidemiology, Clinical Characteristics, and Associations for Rome IV Functional Nausea and Vomiting Disorders in Adults. Clin Gastroenterol Hepatol 2019; 17:878. 

4. Venkatesan T, Levinthal DJ, Tarbell SE, et al. Guidelines on management of cyclic vomiting syndrome in adults by the American Neurogastroenterology and Motility Society and the Cyclic Vomiting Syndrome Association. Neurogastroenterol Motil 2019; 31 Suppl 2:e13604.