Recently, I was reading information from the Cyclic Vomiting Syndrome Association (Winter 2020 issue). On page 12, there is a pretty good protocol for emergency department treatment with the caveat that this “represents a sample template and should be tailored based on individual needs.” In addition, this protocol was derived from an article by Venkatesan et al (Neurogastroenterology and Motility 2019; S2.https://doi.org/10.1111/nmo.13604 Full text: Guidelines on management of cyclic vomiting syndrome in adults by the American Neurogastroenterology and Motility Society and the Cyclic Vomiting Syndrome Association)

Key points from guidelines article:

• “The committee strongly recommends that adults with moderate‐to‐severe CVS receive a tricyclic antidepressant (TCA) such as amitriptyline, as a first‐line prophylactic medication. “
• Topiramate, Aprepitant, “Zonisamide or levetiracetam and mitochondrial supplements (Coenzyme Q10, L‐carnitine, and riboflavin) are conditionally recommended as alternate prophylactic medications, either alone or concurrently with other prophylactic medications.”
• “For acute attacks, the committee conditionally recommends using serotonin antagonists such as ondansetron, and/or triptans such as sumatriptan or newer agents such as aprepitant (NK1 receptor antagonist) to abort symptoms.”
• Evidence, dosing regimens, and algorithms are detailed in article

Sample ED CVS Protocol (for Adults):

____[name]____________ has an established diagnosis of Cyclic Vomiting Syndrome

Operational definition

* A recurring pattern of discrete episodes of severe vomiting, accompanied by profound nausea and/or severe abdominal pain * Patient returns to usual health status between episodes (may have inter‐episodic nausea and or dyspepsia) * In some patients, CVS episodes resemble a migraine attack * Patients may be restless, anxious, and distressed * Patients are not customarily dehydrated until late in the episode

Therapeutic goal

Rapid recognition and intervention may decrease severity of the attack and promote prompt resolution of symptoms

ED management

1. Clinical assessment: Pulse/Temp/BP/Weight, consciousness, and hydration 2. Laboratories/evaluation: CBC, urea, creatinine, LFT’s, lipase, glucose, and electrolytes EKG Urine analysis Diagnostic imaging at discretion of attending physician

Treatment

1. Intravenous fluids a. IV saline bolus if clinically dehydrated b. IV D5NS at 100%‐150% maintenance (suggested rate is 200 cc/h for a 70 kg adult.) 2. For vomiting and nausea a. IV ondansetron 8 mg IV × 1—may repeat q 4‐6 h if ondansetron is ineffective b. Consider diphenhydramine 50 mg IV and metoclopramide 10 mg IV c. Consider IV fosaprepitant 150 mg if available 3. For sedation a. IV lorazepam 1‐2 mg and b. IV diphenhydramine 50 mg for additional sedation 4. For migraine‐like presentation a. Sumatriptan nasal 20 mg (head forward technique) or b. Sumatriptan subcutaneous injection 6 mg/0.5 mL 5. For pain a. IV ketorolac 30 mg if > 60 minutes from onset; may repeat 15 mg q 6 h x 2 (maximum 60 mg/d) b. Opioids may be considered as part of an ongoing treatment plan in refractory patientsa

Reassess

1. Treatment failure—intensify treatment as indicated above or admit patient 2. Positive treatment response—discharge a. Continue ondansetron (soluble tablets) q 6‐8 h × 24‐48 h if initially effective b. Continue lorazepam × 24‐48 h if initially effective c. Continue NSAIDs for pain as needed

My take: This reference is very useful. The pediatric NASPGHAN guidelines (BUK Li et al. JPGN 2008; 47:379–393. Full text: North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Consensus Statement on the Diagnosis and Management of Cyclic Vomiting Syndrome) probably need to be updated, especially as there are newer agents available (eg. aprepitant, fosaprepitant).

Related blog posts:

• Diet or Drugs for Cyclic Vomiting Syndrome
• Aprepitant for Cyclic Vomiting Syndrome (now Fosaprepitant is also available)
• Costs/Yield of Diagnosing Cyclic Vomiting Syndrome

Resources:

• More resources also available at CVSAonline.org
• 2018 article for BUK Li: Managing cyclic vomiting syndrome in children: beyond the guidelines

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