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Perspectives in the treatment of cannabinoid hyperemesis syndrome/Perspectivas en el tratamiento del sindrome de hiperemesis por cannabis.

Cannabinoid hyperemesis syndrome (CHS) is a clinical condition described in 2004 (Allen, de Moore, Heddle & Twartz, 2004) with which healthcare professionals that treat cannabis users (Contreras Narvaez et al., 2016; Pelissier, Claudet, Gandia-Mailly, Benyamina & Franchitto, 2016) as well as Hospital Emergency Room (ER) staff who treat its acute effects (Aguilar-Salmeron et al., 2016) are becoming more familiarised. However, its etiological mechanism is still unclear, and is most likely multifactorial (Allen et al., 2014; Contreras Narvaez et al., 2016; Pelissier, Claudet, Gandia-Mailly, Benyamina & Franchitto, 2016). In Spain, its prevalence could reach 18% among chronic users (Bruguera, Lopez-Pelayo, Miquel & Balcells-Olivero, 2016). Nevertheless, it is quite probably even higher, given that many healthcare professionals are still unaware of its existence. In North American states in which marihuana use is legal, furthermore, visits of patients with CHS to ER have doubled in merely one year after the legalisation of this drug (Kim & Monte, 2016).

As is known, the only way for patients to alleviate their symptoms (in addition to ending cannabis use) entails bathing or showering compulsively with hot water, as their symptoms are unyielding to treatment with antiemetics (Contreras Narvaez et al., 2016; Pelissier, Claudet, Gandia-Mailly, Benyamina & Franchitto, 2016). Therefore, our contribution presents data on possible effective treatments to mitigate acute effects: the use of haloperidol and capsaicin.

There are 2 published cases that resolved vomiting, nausea and abdominal pain through the administration of haloperidol, both intravenously and orally, in doses of between 2.5 and 5 mg (Hickey, Witsil & Mycyk, 2013; Jones & Abernathy, 2016). The mechanism by which haloperidol reduces the symptoms could be related to blockade of postsynaptic dopamine receptors in the brain, ultimately reducing stimulation of vomiting at the medullary level (Jones & Abernathy, 2016).

On another hand, 9 cases presented the use of capsaicin-based creams, frequently applied as a topical analgesic for articular pain, that reduced or eliminated the symptoms between 30-45 minutes after its application on the torso, with neither local nor systemic side effects (Lapoint, 2014a; Lapoint, 2014b; Biary, Lapoint, Nelson, Hoffman & Howland, 2014; Roman, Llorens & Burillo-Putze, in press). Its mechanism of action could be related with the capsaicin receptor, the Transient Receptor Potential Vanilloid 1 (TRPV1), for its role in the transmission of pain (Carnevale & Rohacs, 2016). Recently, healthy volunteers have described improvement of esophageal peristalsis after the administration of capsaicin (Yi, et al., 2016). On an experimental level, TRPV1 may also be activated at temperatures above 42[degrees]C, wherefore the patients' use of very hot water could act this way.

Though clinical experience is still limited, these two drugs seem to be efficient and, a priori, have a plausible physiopathological base, to be explored through clinical trials (Biary, Lapoint, Nelson, Hoffman & Howland, 2014).


Aguilar-Salmeron, R., Martinez-Sanchez, L., Broto-Sumalla, A., Fernandez de Gamarra-Martinez, E., Garcia-Pelaez, M. & Nogue-Xarau, S. (2016). Recomendaciones de disponibilidad y utilizacion de antidotos en los hospitales segun su nivel de complejidad asistencial. Emergencias, 28, 45-54.

Allen, J. H., de Moore, G. M., Heddle, R. & Twartz, J. C. (2004). Cannabinoid hyperemesis: cyclical hyperemesis in association with chronic cannabis abuse. Gut, 53, 1566-1570. doi:10.1136/gut.2003.036350.

Biary, R., Oh, A., Lapoint, J., Nelson, L. S., Hoffman, R. S. & Howland, M. A. (2014). Topical capsaicin cream used as a therapy for cannabinoid hyperemesis syndrome. 2014 Annual Meeting of the North American Congress of Clinical Toxicology (NACCT). Clinical Toxicology. 52, 787.

Bruguera P., Lopez-Pelayo H., Miquel L. & Balcells-Olivero M. (2016). Elevada prevalencia del sindrome de hiperemesis cannabica en pacientes consumidores de cannabis. Emergencias, 28, 249-251.

Carnevale, V. & Rohacs, T. (2016). TRPV1: A Target for Rational Drug Design. Pharmaceuticals, 9, 52. doi:10.3390/ph9030052.

Contreras Narvaez, C., Mola Gilbert, M., Batlle de Santiago, E., Bigas Farreres, J., Gine Serven, E. & Canete Crespillo, J. (2016). Cannabinoid hyperemesis syndrome. A report of six new cases and a summary of previous reports. Adicciones, 28, 90-98. doi:10.20882/adicciones.776.

Hickey, J. L., Witsil, J. C. & Mycyk, M. B. (2013). Haloperidol for treatment of cannabinoid hyperemesis syndrome, The American Journal of Emergency Medicine, 31, 1003.e5-1003e6. doi:10.1016/j.ajem.2013.02.021.

Jones, J. L. & Abernathy, K. E. (2016). Successful Treatment of Suspected Cannabinoid Hyperemesis Syndrome Using Haloperidol in the Outpatient Setting. Case Report in Psychiatry, 2016, 3614053. doi:10.1155/2016/3614053.

Kim, H. S., & Monte A. A. (2016). Colorado Cannabis Legalization and Its Effect on Emergency Care. Annals of Emergency Medicine, 68, 71-75. doi:10.1016/j. annemergmed.2016.01.004.

Lapoint J. (2014a). Case series of patients treated for cannabinoid hyperemesis syndrome with capsaicin cream. 2014 Annual Meeting of the North American Congress of Clinical Toxicology (NACCT). Clinical Toxicology. 52, 707.

Lapoint, J. (2014b). Capsaicin cream for treatment of cannabis hyperemesis syndrome. The Journal of Medical Toxicology, 10, 77.

Pelissier, F., Claudet, I., Gandia-Mailly, P., Benyamina, A. & Franchitto, N. (2016). Cannabis Hyperemesis Syndrome in the Emergency Department: How Can a Specialized Addiction Team Be Useful? A Pilot Study. The Journal of Emergency Medicine, S0736-4679(16)30267-0. Avance de publicacion on-line. doi:10.1016/j. jemermed.2016.06.009.

Roman, F., Llorens, P. & Burillo-Putze, G. (in press). Topical capsaicin cream in the treatment for cannabinoid hyperemesis syndrome. Medicina Clinica (Barcelona).

Yi, C. H., Lei, W. Y., Hung, J. S., Liu, T. T., Orr, W. C.,.... Chen, C. L. (2016). Differences in the Control of Secondary Peristalsis in the Human Esophagus: Influence of the 5-HT4 Receptor versus the TRPV1 Receptor. PLoS ONE, 11, e0159452. doi:10.1371/journal.pone.0159452.


(*) Emergency Services. University Hospital of the Canary Islands, Tenerife, Spain; (**) Faculty of Health Sciences. Universidad Europea de Canarias, Tenerife, Spain; (***) Emergency Services, Short-term Hospitalization Unit and Home Hospitalization Unit. Alicante General Hospital, Spain.

Send correspondence to: Guillermo Burillo-Putze. Emergency Services. University Hospital of the Canary Islands. La Laguna, 38320, S/C de Tenerife, Spain E-mail:

Received: September 2016; Accepted: September 2016.
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Title Annotation:letters to the editor
Author:Burillo-Putze, Guillermo; Llorens, Pere
Date:Jun 1, 2017
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