Clinical characteristics and long-term outcomes in patients with cyclic vomiting syndrome: A 15-year experience at a tertiary referral center

Impact of Opioid and Cannabis Use on Low-Dose Amitriptyline Efficacy in Cyclical Vomiting Syndrome: A Real-World Study in the United Kingdom

BACKGROUND

Central neuromodulators, specifically tricyclic antidepressants (TCAs), are prescribed as prophylactic treatment for cyclical vomiting syndrome (CVS). It is unclear whether opioids and/or cannabis affect the treatment response to neuromodulators. The aims of this study were to assess: (i) the prevalence of opioid and cannabis use among outpatients with CVS, (ii) clinical characteristics associated with opioid/cannabis use and response to a three-tiered neuromodulator treatment algorithm, and (iii) the effect of opioid/cannabis cessation on response to the treatment algorithm.

METHODOLOGY

Data from consecutive patients newly diagnosed with Rome IV CVS at a single tertiary care neurogastroenterology outpatient clinic (January 2016-June 2024) were retrospectively collected. Patients were advised to stop consuming opioids and/or cannabis and commenced a low-dose TCA.

RESULTS

Sixty-one (46/75) percent of outpatients with CVS responded to the three-tiered treatment algorithm. Among responders, 42 (91%) patients responded to TCA alone (1st line therapy), 3 (7%) patients responded to TCA and selective serotonin reuptake inhibitor or serotonin norepinephrine reuptake inhibitor (2nd line therapy), and 1 (2%) patient required topiramate (3rd line therapy). The mean [SD] dosage of TCA among responders was 26.5 [18.3] mg. Twenty-five (33%) patients consumed opioids, 14 (19%) took cannabis, and five (7%) consumed both opioids and cannabis. While opioid cessation was associated with clinical response to the treatment algorithm (p = 0.03), opioid intake at the initial consultation was not (p = 0.2). Irritable bowel syndrome was independently associated with significantly greater odds (OR [95% CI]) of opioid consumption at baseline (6.59 [1.49-29.24], p = 0.01). Heartburn was independently associated with lower odds of response to the treatment algorithm (0.2 [0.05-0.65], p = 0.006).

CONCLUSION

Low-dose neuromodulators, along with opioid and cannabis cessation, may be important strategies in the management of CVS.

Treatment principles in adults and development of patient-reported outcomes in cyclic vomiting syndrome

BACKGROUND

Cyclic vomiting syndrome is a chronic disorder of gut-brain interaction that is present in both adults and children. It is characterized by severe nausea, vomiting, abdominal pain, and several non-GI symptoms. It is also associated with several comorbid conditions such as anxiety and depression, which affect overall health care outcomes.

METHODS

This article delineates treatment principles, encompassing both abortive interventions and prophylactic regimens currently recommended for CVS. However, it underscores a critical concern: the absence of FDA-approved medications for CVS treatment, with existing therapies relying on retrospective and open-labeled trials.

KEY RESULTS

This article emphasizes the pressing need for the development of CVS-specific outcome assessment tools to facilitate more accurate evaluation and robust data collection for the future studies. In exploring this deficiency, the manuscript also presents the up-to-date data and development that enhances our comprehension of patient-centric concepts, and the challenges faced in creating CVS-specific tools, and presents a roadmap for their development. Addressing this gap is crucial for advancing our understanding of CVS and optimizing patient care.

CONCLUSIONS AND INFERENCES

This elucidates the current state of CVS management but also advocates for a future where tailored tools enhance our ability to measure and improve the outcomes for individuals with this debilitating disorder.

Cyclic vomiting syndrome: Future clinical and research priorities for: Special supplement/proceedings of 3rd international symposium

BACKGROUND

An increasing number of studies have explored the clinical features, epidemiology, pathophysiology, and management of cyclic vomiting syndrome (CVS). CVS is common in adults and children and negatively impacts patients, families, and the healthcare system. A related condition, cannabinoid hyperemesis syndrome (CHS), has been a focus of interest in the lay press and published literature.

PURPOSE

Clinical presentations of CVS have been defined by small series and expert opinion, but recent prospective studies are refining our understanding of the spectrum of emetic episodes and the breadth of comorbid conditions. Large cross-sectional population analyses are clarifying CVS prevalence and factors related to age, ethnicity, and geographic region. CVS pathophysiology is multifactorial with contributions from migraines, dysautonomia, endogenous cannabinoids, mitochondrial dysfunction, genetic abnormalities, and rapid gastric emptying. CVS treatment relies on antiemetics and antimigraine therapies to abort acute episodes coupled with prophylactic regimens employing neuromodulators and antiepileptics. CHS represents a challenge partly because of difficulties in achieving sustained cannabis abstinence. Benefits of other therapies in CHS remain poorly defined. Several areas warrant further scrutiny including better identification of CVS triggers and characterization of different CVS subsets including those with frequent severe episodes, refined description of epidemiology to allow targeting of populations predisposed to CVS development, rigorous definition of pathogenic factors to provide a foundation for exploratory studies of novel therapies, and conduct of controlled trials by multicenter collaborations to confirm benefits of existing and new therapies in development. Progress in these areas will be facilitated by generous governmental and industry support.

Understanding the adult and adolescent patient experience with cyclic vomiting syndrome: a concept elicitation study

BACKGROUND

Cyclic vomiting syndrome (CVS) is a phasic disorder of gut-brain interaction characterized by episodes of severe nausea and vomiting. In-depth qualitative research on phase-specific CVS symptoms and impacts is lacking. The study objectives were to explore the experience of patients with CVS in the United States and to identify CVS symptoms and impacts on adults, adolescents, and caregivers.

METHODS

Qualitative, cross-sectional, semi-structured concept elicitation interviews were conducted with adults and adolescents with CVS and with adolescents' caregivers. Adolescents either participated alone or in a dyad format with their caregiver. Interview data were analyzed using an open coding approach.

RESULTS

Concept elicitation interviews were conducted with 13 adults (mean age 45.3 years [standard deviation (SD) 13.1]) and 15 adolescents (mean age 14.6 years [SD 1.8]). The most frequently reported prodrome phase symptoms were nausea (n = 12, 92.3%), anxiety (n = 10, 76.9%), and abdominal pain (n = 9, 69.2%) in adults, and nausea (n = 15, 100%), abdominal pain (n = 11, 73.3%), and headache (n = 11, 73.3%) in adolescents. All adults reported nausea, tiredness, and dry heaves in the emetic phase, and 12 (92.3%) reported vomiting and retching. The remaining patient said they no longer vomited due to abortive medications. All adolescents reported nausea and vomiting in the emetic phase; other common emetic phase symptoms were abdominal pain (n = 14, 93.3%), dehydration (n = 13, 86.7%), and tiredness (n = 13, 86.7%). The leading most bothersome impact reported by adults was anxiety associated with impending vomiting (n = 5, 38.5%). Among adolescents, the leading most bothersome impact was on school (n = 7/13 asked, 53.8%), and among their caregivers, it was seeing their child suffer (n = 6/11 asked, 54.5%).

CONCLUSIONS

Patients with CVS experience considerable gastrointestinal and extra-intestinal symptoms. CVS impacts the activities of daily life of patients and their caregivers, with patients reporting negative effects of CVS on their emotional status and their ability to maintain a normal school or work routine.

Symptom Patterns in Adults With Cyclic Vomiting Syndrome: A 6-Month Prospective Observational Study

BACKGROUND

Data are limited on the natural history and symptom patterns of cyclic vomiting syndrome (CVS), a disorder of gut-brain interaction characterized by recurrent stereotypical vomiting, retching, and nausea episodes.

METHODS

A 6-month, observational, remote study prospectively assessed symptom patterns in adults with CVS using an electronic daily diary. Patients recorded their disease experience, including CVS symptoms and associated severity, in the daily diary. The study defined a CVS episode start as the first day of 5 or more vomiting and/or retching (V + R) events. Episode end was defined as the first day of ≥ 7 (prespecified main analysis) or ≥ 4 (sensitivity analysis) days without any diary V + R events.

KEY RESULTS

Eighty-eight of 93 (94.6%) enrolled patients (62 female; mean age, 37.7 years) had daily diary data recorded during the study; 61 (69.3%) patients had at least one episode. In the prespecified main analysis, 191 episodes (median, 0.6 per 30 diary days) were reported (median duration, 3.0 days); 17.8% of the episodes lasted > 10 days. In the sensitivity analysis, 248 episodes (median, 0.7 per 30 diary days) were reported (median duration, 2.0 days). Thirteen of 88 (14.8%) patients with diary data had interepisodic V + R (reported V + R events without meeting the threshold for study-defined episode). Other CVS-related (non-V + R) symptoms (most frequently nausea, abdominal pain, and sweating) were reported more frequently during the episode versus the interepisodic period.

CONCLUSIONS AND INFERENCES

This prospective longitudinal study shows marked heterogeneity of CVS episodes and highlights the need to better define and characterize episodes in these patients.

AGA Clinical Practice Update on Diagnosis and Management of Cyclic Vomiting Syndrome: Commentary

DESCRIPTION

The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update (CPU) is to review the available evidence and provide expert advice regarding the diagnosis and management of cyclic vomiting syndrome.

METHODS

This CPU was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPUC and external peer review through standard procedures of Gastroenterology. This expert commentary incorporates important as well as recently published studies in this field, and it reflects the experiences of the authors who are experts in treating patients with cyclic vomiting syndrome.

Acute and Long-Term Effects of App-Delivered Heartfulness Meditation on Psychological Outcomes and the Endocannabinoid Signaling System in Cyclic Vomiting Syndrome

INTRODUCTION

Cyclic vomiting syndrome (CVS) is a disorder of gut-brain interaction often triggered by stress. Interventions such as meditation may improve psychological outcomes and health-related quality of life (HRQoL), but their efficacy and the underlying mechanism are unknown.

METHODS

We conducted a 6-week single-arm pilot study to assess the effects of heartfulness meditation (HFM) in CVS using a custom-designed meditation app. Primary outcomes included state and trait anxiety and mood state changes pre vs post-meditation, and secondary outcomes were psychological distress, coping, sleep quality, and HRQoL at baseline and at weeks 3 and 6. Serum concentrations of endocannabinoids N -arachidonylethanolamine and 2-arachidonoylglycerol and related lipids were measured pre- and post-HFM at baseline and week 6.

RESULTS

In 30 treatment completers, there was a significant improvement in state anxiety ( P < 0.001), total mood disturbance ( P < 0.001), and other mood states (all P values < 0.05) across the 3 time points. Trait anxiety was also improved at week 6. There was a significant improvement in psychological distress (Global Severity Index), sleep quality (daytime dysfunction), coping (using religion/spirituality), and HRQoL (mental and physical) across the 3 time points (all P < 0.05). Significant increases in N -arachidonylethanolamine and related lipids N -oleoylethanolamine and palmitoylethanolamide post vs pre-HFM were observed at week 6 ( P < 0.001, 0.002, 0.003, respectively). No adverse effects were noted.

DISCUSSION

App-delivered HFM is feasible, safe, and effective and improves psychological outcomes and augments endocannabinoids. This provides insight into the mechanism underlying HFM and has potential for widespread use as a digital therapeutic in CVS and other disorder of gut-brain interaction.

Perspectives, experiences, and concerns with cyclical vomiting syndrome: Insights from online targeted-disease forums

INTRODUCTION

There is limited research examining the biopsychosocial impact of cyclic vomiting syndrome (CVS) on patients. This study aims to assess individuals' experiences, fears, and concerns associated with CVS and the impact of CVS on their daily lives.

METHODS

We employed social netnography to analyze publicly available posts related to CVS that were identified from six US online forums and Twitter. A randomly selected sub-cohort of posts per pre-defined criteria was first qualitatively analyzed using an inductive thematic approach. Then, machine learning topic modeling was applied to explore themes in an unsupervised manner for the entire corpus of posts. Afterward, findings from the qualitative and quantitative approaches were integrated to generate a thematic network.

RESULTS

Based on the 39,179 collected posts, seven domain themes were identified. Overall, 41.4% of the posts were related to "biopsychosocial burden" of CVS, including physical impact, psychological impact, and social impact. In 22.3% of posts, individuals shared their experience of "interactions with the healthcare system", and 14.2% of posts were related to "perceived CVS triggers." Individuals also shared "solutions to alleviate their symptoms" and "mental health needs" in 10.2% and 8.8% of posts, respectively. Finally, 6.1% of the posts were about "seeking/sharing support" with others.

DISCUSSION

This is the first social netnography study to describe the in-depth experiences of individuals living with CVS and the marked impact on their physical, mental, and social health. The study also highlights the unmet need for effective therapies, both pharmacological and non-pharmacological, to alleviate the biopsychosocial impact of CVS.

Amitriptyline-Induced Insomnia in a Young Lady Diagnosed With Cyclic Vomiting Syndrome: A Case Report

The author reports a 19-year-old woman suffering from repeated episodes of non-bloody vomiting for 18 months. All routine and special investigations were normal. She was labeled as a case of cyclic vomiting syndrome (CVS), and she developed insomnia after the initiation of amitriptyline as a prophylactic treatment. The case was reported to increase awareness regarding the importance of monitoring medication side effects among clinicians when using different classes of medications to treat CVS.