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Hyperemesis — Clinical Guidelines

Overview

Hyperemesis, encompassing both cannabinoid hyperemesis syndrome (CHS) and hyperemesis gravidarum (HG), refers to severe, intractable nausea and vomiting that can lead to significant morbidity. CHS is associated with chronic cannabis use, while HG primarily affects pregnant women.

Diagnosis

Key Criteria for CHS: Cyclical vomiting, chronic cannabis use, compulsive hot water bathing 1 3.

Recommended Tests for CHS: No specific diagnostic tests; clinical history crucial 1.

Key Criteria for HG: Unexplained intractable vomiting, dehydration, ketonuria, often requiring hospitalization 9 11.

Diagnostic Tests for HG: Laboratory tests to assess dehydration, electrolyte imbalances, and vitamin deficiencies (thiamine, vitamin K) 4 5.

Management

First-Line Treatments for CHS: Haloperidol (0.5-2 mg orally or IM), capsaicin cream for nausea relief 3.

Adjunctive Treatments for CHS: Consider supportive care, fluid resuscitation, and cessation of cannabis use 1 3.

First-Line Treatments for HG: Antiemetic therapy (e.g., ondansetron, metoclopramide), intravenous fluids, nutritional support 9 10.

Adjunctive Treatments for HG: Thiamine supplementation to prevent Wernicke encephalopathy, vitamin K supplementation 4 5.

Special Populations

Pregnancy (HG): Focus on nutritional support, antiemetic therapy, and monitoring for vitamin deficiencies (thiamine, vitamin K) 4 5 9.

Comorbidities: Consider potential interactions and complications, especially in managing HG with underlying conditions 9.

Key Recommendations

Cessation of Cannabis Use in CHS patients is crucial for symptom resolution (Evidence: Expert opinion) 1.

Thiamine Supplementation should be routinely considered in pregnant women with HG to prevent Wernicke encephalopathy (Evidence: Moderate) 4.

Supportive Care and Fluid Resuscitation are essential initial steps in managing both CHS and HG (Evidence: Moderate) 3 9.

Monitoring for Vitamin Deficiencies (especially thiamine and vitamin K) in HG is recommended to prevent severe complications (Evidence: Moderate) 5.

Use of Haloperidol can be effective in managing symptoms of CHS (Evidence: Moderate) 3.

References

1 Hsu J, Kashyap S, Hurd C, McCormack L, Herrmann Z, Schwartz AC et al.. Treatment of cannabinoid hyperemesis syndrome: A systematic review and treatment algorithm for consultation-liaison psychiatrists. General hospital psychiatry 2025. link 2 Rubio-Tapia A, McCallum R, Camilleri M. AGA Clinical Practice Update on Diagnosis and Management of Cannabinoid Hyperemesis Syndrome: Commentary. Gastroenterology 2024. link 3 Humphries C, Gillings M. RCEM best practice guideline: suspected cannabinoid hyperemesis syndrome in emergency departments. Emergency medicine journal : EMJ 2024. link 4 Clark AF. Use of Thiamine Supplementation in Pregnant Women Diagnosed With Hyperemesis Gravidarum and Wernicke Encephalopathy. Nursing for women's health 2024. link 5 Nijsten K, van der Minnen L, Wiegers HMG, Koot MH, Middeldorp S, Roseboom TJ et al.. Hyperemesis gravidarum and vitamin K deficiency: a systematic review. The British journal of nutrition 2022. link 6 Senderovich H, Waicus S. A Case Report on Cannabinoid Hyperemesis Syndrome in Palliative Care: How Good Intentions Can Go Wrong. Oncology research and treatment 2022. link 7 Wang GS, Buttorff C, Wilks A, Schwam D, Tung G, Pacula RL. Changes in Emergency Department Encounters for Vomiting After Cannabis Legalization in Colorado. JAMA network open 2021. link 8 Burillo-Putze G, Llorens P. Perspectives in the treatment for cannabinoid hyperemesis syndrome. Adicciones 2017. link 9 Tamay AG, Kuşçu NK. Hyperemesis gravidarum: current aspect. Journal of obstetrics and gynaecology : the journal of the Institute of Obstetrics and Gynaecology 2011. link 10 Tan PC, Omar SZ. Contemporary approaches to hyperemesis during pregnancy. Current opinion in obstetrics & gynecology 2011. link 11 Goodwin TM. Hyperemesis gravidarum. Obstetrics and gynecology clinics of North America 2008. link 12 Askling J, Erlandsson G, Kaijser M, Akre O, Ekbom A. Sickness in pregnancy and sex of child. Lancet (London, England) 1999. link04239-7)

Hyperemesis