Does capsaicin cream curb cannabinoid hyperemesis syndrome?

Last Updated: 2017-11-09

By David Douglas

NEW YORK (Reuters Health) - Topical capsaicin cream appears to have been successful in treating cannabinoid hyperemesis syndrome (CHS) in two adolescents who did not respond to other approaches, according to case reports from the University of Colorado at Denver, Anschutz Medical Campus in Aurora.

In their November 9 online article in Pediatrics, Dr. Jessica Graham of the University of Colorado at Denver and colleagues note that CHS is associated with chronic marijuana use and "is characterized by significant nausea, abdominal pain, and cyclic vomiting, which are often relieved by hot bathing."

Dr. Graham told Reuters Health by email that given growing concern "that the legalization of marijuana in multiple states will increase appeal and acceptance of recreational use of the drug among adolescents," pediatricians and emergency providers should have CHS on their differential diagnosis of such symptoms in teenagers.

She and her colleagues further observe, "In Colorado, where both retail and recreational marijuana is now legal, the number of patients presenting to the ED for cyclic vomiting nearly doubled after liberalization of medical marijuana."

In one case, the authors report that a previously healthy 16-year-old girl who said she used marijuana sought treatment at an emergency department (ED) after a week of nausea, vomiting, and abdominal pain.

She was given 4-mg intravenous ondansetron, 10-mg metoclopramide, a 1000-mL normal saline bolus, and 30 mL of an oral lidocaine/diphenhydramine/aluminum and magnesium hydroxide solution. She then insisted on leaving the ED despite no improvement in her symptoms.

The next evening she returned for further care and received sublingual ondansetron and oral oxycodone, which did not improve her nausea or abdominal pain. CHS became the working diagnosis, and she agreed to have capsaicin cream 0.025% applied to her abdomen.

Within 30 minutes, despite reporting a mild "burning sensation," the girl said her pain had greatly diminished and her nausea resolved. She also exhibited less abdominal tenderness and was discharged from the hospital.

In a second case, a 20-year-old male chronic user of cannabis presented with abdominal pain and vomiting. He was presumed to have gastritis and was treated for symptoms. Once he could tolerate oral fluids, he was sent home with ondansetron and ranitidine.

He came back a week later reporting persistent abdominal pain and vomiting. A normal ultrasound of the abdomen, normal general workup, and his report that hot showers improved his symptoms led to a presumed CHS diagnosis.

Capsaicin cream 0.025% was applied to his abdomen, whereupon he also reported a burning sensation. Within 30 minutes, his abdominal pain and nausea improved markedly. Satisfied with the treatment, he was discharged.

Neither of the case patients returned to the ED after capsaicin treatment.

The researchers concede the need for more research, but Dr. Graham said, "Once a history of extensive marijuana use and relief of gastrointestinal symptoms by showering in hot water is confirmed in adolescents with these symptoms, (improvement) after the application of capsaicin cream can corroborate the diagnosis and prevent unnecessary medical work-ups, return visits, and even hospital admissions."

"Proving that the drug, not another medical condition, is causing distressing GI symptoms," she concluded, "may ultimately help clinicians convince these adolescents to stop chronic marijuana use."

In an email to Reuters Health, Dr. Christian Georg Blumentrath of General Hospital Luebbecke-Rahden, in Germany, said, "Capsaicin cream is a treatment option in CHS. However, the main reason for symptom relief with capsaicin may also be application of heat. Given the fact that only a very small proportion of cannabis abusers develop CHS, cannabis abuse may only aggravate a problem in susceptible patients."

Dr. Blumentrath, lead author of a recent review covering the differential diagnosis of CHS and cyclic vomiting syndrome in adults, added, "One would expect that in countries such as the Netherlands, where cannabis has been legal for years, there would be hundreds of cases of CHS. There aren't. Thus, it seems that the patients who present to departments of emergency medicine for nausea, vomiting and abdominal pain in association with cannabis use may run a risk of being misdiagnosed as having CHS."

He concludes that "the oversimplifications in this article are unacceptable and do not increase the body of knowledge concerning CHS and cyclic vomiting syndrome and potential differential diagnosis. In particular, improvement of symptoms following capsaicin cream does not support the diagnosis of CHS."

SOURCE: http://bit.ly/2yJsVm1

Pediatrics 2017.