Favorite Posts 2022

Posted on December 30, 2022 by gutsandgrowth

Thank you to those who have helped me this past year with this blog –colleagues, friends and family. Wishing all of you a good 2023. Here are some of my favorite posts from this past year:

GI:

Nutrition:

Liver:

Endoscopy:

Health Policy:

Humor:

Grammar at a Funeral (Very British & Funny)

Most Popular 2022 Posts

Posted on December 29, 2022 by gutsandgrowth

The list of the most viewed gutsandgrowth blog posts in 2022.

Links to Posts:

Cyclic Vomiting ED Protocol

Posted on January 12, 2021 by gutsandgrowth

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

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

Most Popular 2020 Posts

Posted on December 31, 2020 by gutsandgrowth

I want to thank all of you who take an interest in my blog, particularly those who give suggestions, references, and encouragement. The following posts were the most popular from the past year.

Does Stopping Cannabis Improve Cyclic Vomiting Syndrome?

Posted on June 2, 2020 by gutsandgrowth

Cannabis use has been linked to hyperemesis. However, a recent cross-sectional study (T Venkatesan et al. Clin Gastroenterol Hepatol 2020; 18: 1082-90) that stopping cannabis rarely results in improvement in cyclic vomiting syndrome (CVS).

This study enrolled 140 patients who had CVS with a mean age of 37 years, all seen at a specialized clinic; 41% were current cannabis users and were classified as regular users (≥4/wk, n=30) or occasional users (<4/wk, n=26).

Key findings:

Only 1 of 56 (2%) reported that cannabis abstinence (for a month) resolved their CVS symptoms and 1 of 56 (2%) noted improvement with cannabis abstinence.
27 of 56 (56%) reported that cannabis abstinence worsened their CVS symptoms; 19 (40%) reported no change with cannabis abstinence
Only 1 patient taking cannabis met Rome IV criteria for cannabinoid hyperemesis syndrome (CHS). This patient subsequently resumed cannabis with a higher proportion of CBD (less THC) without recurrence of CVS symptoms. This provides some support to the idea that THC in cannabis is responsible for CHS.

My take: (borrowed from authors) “If a patient with CVS and chronic regular cannabis use is refractory to standard therapy, we recommend a period of abstinence of at least 6 months or a duration of time that exceeds at least 3 consecutive cycles.”

Related blog posts:

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

Most Popular Posts of 2019

Posted on December 31, 2019 by gutsandgrowth

The following are the most viewed posts from the past year:

Wishing friends, family and colleagues a healthy and happy New Year.

Morning in Sandy Springs, GA

Aprepitant for CVS

Posted on May 23, 2019 by gutsandgrowth

Last year at NASPGHAN meeting (NASPGHAN Highlights and Tweets), there was data presented on aprepitant for cyclic vomiting syndrome (CVS). This came up at a recent hospital PNT meeting as well.

Aprepitant (Emend) is an anti-emetic that works by blocking the NK1 receptor.
It has FDA approval for prevention of nausea and vomiting in moderate and highly emetogenic chemotherapy (adults and pediatrics) and prevention of post-operative nausea and vomiting (adult only).

Supporting Data for use of Aprepitant

An abstract published in 2006 reported on the use of aprepitant in 11 children (3-16 years)². Patients were refractory to/had poor response to pizotifen (not available in US – serotonin and histamine antagonist), propranol, and ondansetron. Aprepitant was dosed at 80 mg/m2 up to twice weekly in combination with ondansetron. Nine out of 11 patients had reduction in cycle frequency, duration of vomiting episodes and intensity of vomiting. Three patients achieved complete cycle abolishment.

Cristoferi et al retrospectively reviewed 41 patients (age range 4-16.5 years, median 8 years) treated acutely or prophylactically with aprepitant.³ The primary outcome was decrease in frequency and intensity of CVS episodes. The follow up period was 18-60 months. The majority of patients failed cyproheptadine/pizotiphen, ondansetron, and amitriptyline as prophylactic medications.

Dosing regimens utilized in Cristoferi paper:

Prophylactic regimen (oral):

< 40 kg, 40 mg twice/week = $220/week (average wholesale price)
>40 kg to < 60 kg, 80 mg twice/week = $408/week
> 60 kg, 125 mg twice/week = $612/week

Acute regimen (oral):

>20 kg, 125 mg x 1 followed by 80 mg on day 2 and day 3 = $714
15-<20 kg, 80 mg x 3 days = $612
< 15 kg, 80 mg x 1 followed by 40 mg on day 2 and day 3 = $424

Response rates:

With the prophylactic regimen, the authors reported a complete response in 3/16 (19%) and a partial response 10/16 (62%) [partial response was considered if there was ≥50% decrease in CVS episode frequency and intensity].
With the acute regimen, the authors reported 19/25 (76%) with a complete response and 3/25 (12%) with a partial response.

My take: Aprepitant appears promising as an agent for children who fail first-line therapies like periactin, tricyclic antidepressants, and ondansetron.

References

Bhandari S and Venkatesan T. Novel treatments for cyclic vomiting syndrome: beyond ondansetron and amitriptyline. Curr Treat Options Gastro 2016;14:495-506.
Russell RK, et al. NK1 receptor antagonism ameliorates nausea and emesis in typical and atypical variants of treatment refractory cyclical vomiting syndrome. J Pediatr Gastroenterol Nutr 2006;42:E13.
Cristoferi F, et al. Efficacy of the neurokin-1 receptor antagonist aprepitant in children with cyclical vomiting syndrome. Aliment Pharmacol Ther 2014;40:309-17.

Related blog posts:

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.

#NASPGHAN18 Highlights and Tweets (part 1)

Posted on November 2, 2018 by gutsandgrowth

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

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Pediatric Gastroenterology

Tag Archives: cyclic vomiting syndrome