Treatment of cyclic vomiting syndrome

Posted by Doctor Mai Vien Phuong - Department of Medical Examination & Internal Medicine - Vinmec Central Park International General Hospital

Adult cyclic vomiting syndrome (CVS) is a disorder characterized by sudden recurrent episodes of nausea, vomiting, and abdominal pain, separated by different periods of normal health.

Treatment with tricyclic antidepressants requires starting with a low initial dose of amitriptyline 10 mg at night followed by a gradual increase in dose of 10 mg every 2 to 4 weeks to achieve the desired therapeutic effect. . There is no established dose to control symptoms but the goal is to prevent cycles of vomiting. Side effects of using tricyclic antidepressants include dry mouth, drowsiness, constipation, orthostatic hypotension, chronic fatigue, blurred vision, and mild hallucinations. Side effects can be minimized by slowly increasing the dose to 10 mg every 2-4 weeks. The rationale of this approach is to determine what is the lowest dose that can be treated in an individual and still limit the side effects that can occur with higher doses. Tricyclic antidepressants take more than 1 month to reach their full therapeutic effect after initiation and this must be communicated to the patient.
Other tricyclic antidepressants such as nortriptyline and doxepin can be substituted with fewer side effects but still have therapeutic benefit. More recently, the anticonvulsants zonisamide (100-600 mg daily) and the drug levetiracetam (500-1000 twice daily) have demonstrated efficacy in adult patients who do not respond to or are intolerant of antidepressants. tricyclic sensitizers, but their current role can only be considered as first-line therapy.

After achieving initial control with increasing doses of amitriptyline and concurrent lorazepam for anxiety, supportive therapy includes antiemetics including ondansetron, promethazine or prochlorperazine to reduce nausea. Antispasmodic (dicyclomine) for irritable bowel syndrome (IBS) such as abdominal pain, especially in patients with rapid gastric emptying and excessive gastro-intestinal reflex. Proton pump inhibitors may be used short-term for GERD symptoms associated with vomiting.

In the authors' experience at a gastrointestinal referral center, the authors found that 83.3% of patients who started on a low dose (10 mg) of amitriptyline at bedtime had May escalate gradually by approaching 10 mg increments every 2 to 4 weeks as tolerated and achieve symptom control by prevention of recurrence and emergency department visits. This titration to the dose of amitriptyline reduced symptoms in 8% of patients with a dose of 50-75 mg; 50% at 100mg; 21% at 150mg and 8% at 200mg. Failure to respond to standard therapy in adult cyclic vomiting syndrome patients occurs in approximately 13% and is not explained by sub-dose tricyclic antidepressants. of unresponsiveness to amitriptyline are: poorly controlled migraine, psychosis, chronic substance abuse, and ongoing drug use, which should be actively addressed as symptoms continue to increase in when trying to relieve cyclic vomiting syndrome with high doses of tricyclic antidepressant therapy.

Long-term results are now becoming apparent as treatment models are recognized. One model requires an additional increase in the overtime maintenance dose because some dose tolerance occurs gradually with a breakthrough vomiting cycle. Another group in which symptoms had been controlled for at least one year without an emergency visit were able to successfully reduce to a lower dose without an emergency visit. The dose of amitriptyline is tapered or even stopped over time, usually for at least 1 year. 21% of our patients were able to reduce the dose to 10-20mg per day. An additional incentive we have seen is to target pregnancy in women because amitriptyline is listed by the FDA as category C and is therefore not recommended during pregnancy.

Treatment with tricyclic antidepressants was an effective strategy in 87% of patients and significantly reduced the frequency of attacks, emergency room visits, and hospitalizations. Once symptoms are under control for at least 12 months, the dose of tricyclic antidepressants can be slowly tapered to reach very low doses or even stopped while maintaining symptom control. This is a new observation, namely that a diminishing effect can be achieved within 6 to 12 months. The theory to support this observation is that the CNS receptor hypersensitivity initially present in patients with cyclic vomiting syndrome has been successfully prevented during treatment with amitriptyline, providing a the timeframe in which recognized risk factors for migraine, stress, diabetes, and drugs can be better addressed and controlled.
The key message for our clinicians is that cyclic vomiting syndrome can be presented to the patient as a potentially reversible disease: After initial aggressive treatment to achieve remission and after effective resolution of comorbidities, the dose of amitriptyline may be tapered and even discontinued over time.

Cyclical vomiting syndrome in adults is under diagnosis, and improving awareness and recognition of its features can help reduce invasive and costly diagnostic work that negatively affects the nervous system. patient's health.
This is especially the case for physicians in the Emergency Department, who need a high clinical index when observing a pattern of acute episodes of acute nausea, vomiting, and acute abdominal pain of unknown origin on visit. regular check-ups and hospitalizations. Other major clinical clues for cyclic vomiting syndrome lie in the appreciation of comorbidities of anxiety, depression, migraine, and diabetes. Chronic addiction to addictive drugs has now become a new and very common etiology and should be added as an additional criterion.
Finally, patients with cyclic vomiting syndrome are capable of rapid or normal gastric emptying. This is a novel finding that separates cyclic vomiting syndrome from gastroparesis and we strongly recommend that gastric emptying status be added as one of the main criteria for diagnosis of the syndrome. cyclic vomiting.
>> See also: Cyclic vomiting syndrome - Article by Doctor Mai Vien Phuong - Department of Medical Examination & Internal Medicine - Vinmec Central Park International General Hospital

References
Venkatesan T, Prieto T, Barboi A, et al. Autonomic nerve function in adults with cyclic vomiting syndrome: a prospective study. Neurogastroenterol Motil. 2010; 22(12):1303-1307,e339. Sarosiek I, Alvarez A, Zamora A, et al. Etiologies of nausea and vomiting in patients referred to a gastroenterology motility clinic. The El Paso Physician. 2014; 37(2):14-18. Pareek N, Fleisher D, Abell T. Cyclic vomiting syndrome: what a gastroenterologist needs to know. AmJ Gastroenterol. 2007; 102(12):2832-2840. Duckett A, Pride P. Cyclic vomiting syndrome in an adult patient. J Hosp Med. 2010; 5(4):251–252. Lee LY, Abbott L, Moodie S, Anderson S. Cyclic vomiting syndrome in 28 patients: demographics, features and outcomes. EurJ Gastroenterol Hepatol. 2012; 24(8):939-943 Chad J. Cooper, Richard W. McCallum, Cyclic Vomiting Syndrome: Diagnostic Criteria and Insights into Long Term Treatment Outcomes, Gastrointestinal motility and functional bowel disorders, series
5, Practical gastroenterology • january 2015