Novel Treatments for Cyclic Vomiting Syndrome: Beyond Ondansetron and Amitriptyline

Cyclic vomiting syndrome (CVS) is a chronic functional gastrointestinal disorder that is characterized by episodic nausea and vomiting. Initially thought to only affect children, CVS in adults was often misdiagnosed with significant delays in therapy. Over the last decade, there has been a considerable increase in recognition of CVS in adults but there continues to be a lack of knowledge about management of this disorder. This paper seeks to provide best practices in the treatment of CVS and also highlight some novel therapies that have the potential in better treating this disorder in the future. Due to the absence of randomized control trials, we provide recommendations based on review of the available literature and expert consensus on the therapy of CVS. This paper will discuss prophylactic and abortive therapy and general measures used to treat an episode of CVS and also discuss pathophysiology as it pertains to novel therapy. Recent recognition of the association of chronic marijuana use with cyclic vomiting has led to the possibility of a new diagnosis called "Cannabinoid Hyperemesis Syndrome," which is indistinguishable from CVS. The treatment for this purported condition is abstinence from marijuana despite scant evidence that marijuana use is causative. Hence, this review will also discuss emerging data on the role for the endocannabinoid system in CVS and therapeutic agents targeting the endocannabinoid system, which offer the potential of transforming the care of these patients.