Tag Archives: aprepitant

Dr. B Li: Cyclic Vomiting Syndrome 2025

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Dr. B Li, emeritus professor of Pediatrics (Medical College of Wisconsin), gave this year’s Billy Meyers Lecture. Dr. Li is considered the world’s foremost authority on cyclic vomiting syndrome (CVS) (‘the emperor of emesis’). He gave a fantastic update.  I have taken some notes and shared many of his slides. There may be inadvertent omissions and mistakes in my notes. More information on the CVS 2025 guidelines is noted in a separate post: 2025 Pediatric Cyclic Vomiting Syndrome Guidelines

  • Historical background of CVS: Early descriptions of CVS date back to 1880s and Samuel Gee (who also is credited with the first modern description of celiac disease). Charles Darwin was likely affected by CVS
  • Epidemiology: CVS is not a rare disorder. It likely affects ~2% of kids and adults
  • There are several patterns of CVS. Many patients who have CVS do not have a cyclical pattern
  • Lethargy and pallor are common symptoms which make patients appear more ill
  • Retching on an empty stomach and severe emesis are hallmarks and likely indicate that the primary mechanism is not due to the GI tract. Though there are some food poisonings (eg. Bacillus cereus) that can have some of these symptoms but typically milder in severity
  • Previously, CVS patients were thought to be well in between episodes. However, ~40% have inter-episode symptoms
  • Quality of life is correlated mainly with anxiety/coping rather than the severity of episodes
  • Children with CVS often (~75%) develop migraines by adulthood
  • Underlying pathophysiology likely involves the autonomic nervous system
  • 2025 CVS Guidelines — took about 3 years to develop. It is noted that the 2008 guideline diagnostic criteria missed about 48% of cases (Bujarska et al. JPGN 2025; 80: 417)
  • 2025 Guidelines emphasize limited diagnostic workup at presentation (eg. UGI and basic labs) unless there are alarm symptoms. Alarm symptoms include the following:
  • For abortive therapy, the new guidelines favor aprepitant over ondansetron, and generally favor D5 over D10 IVFs.
  • For prophylactic therapy, there is now an emphasis on non-pharmacologic therapy in addition to pharmacologic agents and PENFS. Propranolol and aprepitant are favored prior to use of TCA agents like amitriptyline due to side effect profile
  • Action plan for ED may help speed care and lower likelihood of admission
  • PENFS for prophylactic therapy had a durable response (113 days) in a recent study
  • Cannaboid hyperemesis syndrome (CHS) was first described in 2004 and has been rapidly increasing related to increased use and potency of THC products. Haloperidol, topical capsaicin and hot water (prolonged) bathing are often effective
Variants include the CVS associated with mitochondrial dysfunction, the Sato variant associated with increased BP, increase ACTH/cortisol, Catmaenial CVS is related to menses, and CHS (CVS-like) associated with cannabis use

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Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition

Year in Review: My Favorite 2019 Posts

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Yesterday, I listed the posts with the most views.  The posts below were the ones I like the most.

General/General Health:

Nutrition:

Liver:

Endoscopy:

Intestinal Disorders:

 

Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

 

#NASPGHAN18 Highlights and Tweets (part 1)

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I did not make it to this year’s meeting but did get a chance to catch up on a lot information via the PG 2018 Syllabus and based on information posted online.

Here are a couple of highlights for me:

Slides from postgraduate course on CVS from Dr. Katja Kovacic

The slide from Dr. Lightdale (pg 22 in Syllabus) below suggests it is OK for scope if platelets >20K and OK for biopsies if platelets >50K. It is worth noting that some adult data indicate that even lower biospy thresholds are reasonable for biopsies (Post: Lower Endoscopic Thresholds for Thrombocytopenia). As always, one needs to consider carefully the risks compared with the benefits.

From Postgraduate Course

 

 

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Briefly noted: Mongersen, Aprepitant, and Anesthetic Outcomes

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BG Feagan et al. Gastroenterol 2018; 154: 61-4.  In this study of GED-0301 (Mongersen), an antisense oligodeoxynucleotide affecting Smad7, was randomly assigned to 63 patients with Crohn’s disease (160 mg/day).  Endoscopic improvement was observed in 37%  at week 12. Clinical remission (CDAI<150) was noted in  32% (4 weeks of Rx), 35%  (8 weeks of Rx) and 48% (12 weeks of Rx). No new safety signals were noted.

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PJ Pasricha et al. Gastroenterol 2018; 154: 65-76.  First of all, I have to say that I like the visual abstracts in many Gastro studies.  In this randomized, double-masked “APRON” study of 126 patients with chronic nausea or gastroparesis receiving Aprepitant, a neurokinin-1 receptor antagonist, or placebo, the key findings were the following:

  • Aprepitant did not reduce symptoms of nausea significantly compared to placebo
  • Apreptiant-treated patients had improvements in secondary outcomes of symptom severity for nausea (1.8 vs 1.0, P=.005 on Gastroparesis Clinical Symptom Index) and overall symptoms (1.3 vs. 0.7, P=.001)

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B Bielawska et al. Gastroenterol 2018; 154: 77-85. Using data (administrative databases) and propensity matching from more than 3 million outpatient colonoscopies (2005-2012), the authors noted that the use of anesthesia assistance (AA) was associated with an increased risk of aspiration pneumonia (OR 1.63) but not perforation (OR 0.99). Though this study is limited by its retrospective design and reliance on administrative data, the authors state “the potential for residual confounding by indication for AA [is] extremely unlikely, especially because AA use in Ontario appears to be driven by institutional policy or business model rather than by patient factors.”

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Bright Angel Trail