OnabotulinumtoxinA Injections for the Treatment of Cyclic Vomiting Syndrome

Assessments of protodioscin's antinociceptive and antidiarrheal properties: in vivo and in silico investigations on macromolecule binding affinity and modulatory effects

Protodioscin (PRO) is a furostanol saponin with antioxidant and anti-inflammatory properties. However, there is no proof against nociception and diarrhea. The study aims to investigate the antinociceptive and antidiarrheal effects of PRO, comparing its efficacy with diclofenac sodium (DFS) and loperamide (LOP) using in vivo and in silico methods. Antinociceptive activity was evaluated using the acetic acid-induced writhing and formalin-induced paw licking tests, and antidiarrheal effects were assessed via castor oil-induced diarrhea in mice. Mice were divided into groups receiving PRO (2.5 and 10 mg/kg, p.o.), DFS (25 mg/kg, p.o.), LOP (3 mg/kg, p.o.), or combinations. Molecular docking studies were conducted on COX-1, COX-2 enzymes, and the Mu-opioid receptor (MOR), with toxicity predictions performed for safety profiling. In vivo results demonstrated that PRO significantly (p < 0.05) reduced pain and diarrhea in animals. PRO at 10 mg/kg, showed comparable efficacy to DFS and LOP (25 and 3 mg/kg) in both models. Molecular docking revealed that PRO had stronger binding affinities with COX-1 (‒10.0 kcal/mol), COX-2 (‒9.6 kcal/mol) enzymes, and MOR (‒7.7 kcal/mol) compared to standard drugs. Toxicity predictions indicate PRO is relatively safe in some toxicity parameters. PRO exhibits significant antinociceptive and antidiarrheal activities comparable to DFS and LOP, making it a promising natural alternative for managing pain and diarrhea. Additional clinical trials and pharmacokinetic assessments are required to evaluate its long-term safety for use.

Cyclic vomiting syndrome: diagnostic approach and current management strategies

Cyclic vomiting syndrome (CVS) is a disorder characterized by episodes of nausea and vomiting lasting for 1-5 days followed by asymptomatic periods. The etiology of CVS is unknown, but it shares similar characteristics to migraine headaches. CVS is generally classified as having four phases: prodromal, acute/vomiting/hyperemesis, recovery, and remission/interepisodic. Current management strategies include trigger avoidance, abortive and prophylactic medication therapies, and supportive care. The goal of therapy for the remission phase is prophylaxis of further episodes. Antidepressant, antiepileptic, and antimigraine medications show an overall reduction or remission of CVS symptoms in more than 70% of patients. This article provides a summary of diagnostic strategies and reviews current management strategies for CVS.

Cyclic vomiting syndrome: a case series and review of the literature

OBJECTIVE

Cyclic vomiting syndrome (CVS) is under-recognised. Treatment is difficult as the pathophysiology is incompletely understood. We report our experience of treating patients with amitriptyline, and review the literature to summarise symptoms and associated features, epidemiology, potential pathophysiological mechanisms, differential diagnoses and treatment.

DESIGN

Consecutive adult patients with CVS were identified during a 5-year period from January 2010 until December 2015. Medical records were reviewed retrospectively, and age and sex of the patient, symptoms, associated features and response to treatment with amitriptyline were recorded.

SETTING

A luminal gastroenterology clinic at a teaching hospital.

RESULTS

Seventeen patients were identified (mean age 29.8 years, 13 (76.5%) female). Five had a history of cannabis use. Duration of symptoms prior to diagnosis ranged from 5 months to 15 years. Fourteen patients commenced amitriptyline, and in eight (57.1%) symptoms either ceased entirely or improved. Review of the literature suggested the prevalence of CVS was 0.5%. Symptoms are stereotypical, with acute episodes of nausea and vomiting, interspersed by periods when the patient is symptom-free. Proposed pathophysiologies include neuroendocrine dysfunction, mutations in mitochondrial DNA and re-intoxication effects from cannabis stored in fat tissues. Treatment during the acute phase is supportive, with rehydration, sedation and antiemetics. Prophylaxis to prevent future attacks with antihistamines, antimigraine drugs, antiepileptics and tricyclic antidepressants may be beneficial. Complete cessation of cannabis smoking should be advised.

CONCLUSIONS

Diagnosis of CVS is often delayed in adults. Once identified, patients respond well to amitriptyline.