Capsaicin Cream for Treatment of Cannabinoidjessica Graham, MD,A Michael Barberio, Hyperemesispharmd,B George Sam Wang, Mda Syndrome
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Capsaicin Cream for Treatment of CannabinoidJessica Graham, MD, a Michael Barberio, HyperemesisPharmD, b George Sam Wang, MDa Syndrome in Adolescents: A Case Seriesabstract Cannabinoid hyperemesis syndrome (CHS) is an underrecognized diagnosis among adolescents. In the adult literature, it is characterized as nausea, vomiting, and abdominal pain in patients with chronic marijuana use. CHS is often refractory to the standard treatment of nausea and vomiting. Unconventional antiemetics, such as haloperidol, have been successful in alleviating symptoms; however, even 1 dose of haloperidol can lead to grave adverse effects, such as dystonia, extrapyramidal reactions, and aSection of Emergency Medicine, Department of Pediatrics, neuroleptic malignant syndrome. The use of topical capsaicin cream to University of Colorado Anschutz Medical Campus, and bDepartment of Pharmacy, Children’s Hospital Colorado, treat CHS has been well described in the adult literature. This treatment Aurora, Colorado is cost-effective and is associated with few serious side effects. Here, we describe 2 adolescent patients with nausea, vomiting, and abdominal pain Dr Graham drafted the initial manuscript; Drs Graham, Barberio, and Wang reviewed and revised in the setting of chronic cannabis use whose symptoms were not relieved by the manuscript; and all authors approved the final standard antiemetic therapies, but who responded well to topical capsaicin manuscript as submitted. ’ administration in our pediatric emergency department. We also discuss the DOI: https:// doi. org/ 10. 1542/ peds. 2016 3795 pathophysiology behind capsaicin s efficacy. These are the first reported Accepted for publication Mar 13, 2017 cases in which capsaicin was successfully used to treat CHS in pediatric Address correspondence to Jessica Graham, patients. MD, Pediatric Emergency Medicine, University of Colorado at Denver–Anschutz Medical Campus, 13123 E 16th Ave, B251, Aurora, CO 80045. Email: [email protected] PEDIATRICS (ISSN Numbers: Print, 00314005; Online, Cannabinoid hyperemesis syndrome department (ED) with 1 week of 10984275). (CHS) is a clinical diagnosis– that nausea, vomiting, and abdominal pain. Copyright © 2017 by the American Academy of has been described in patients1 5 who She reported chronic intermittent Pediatrics use cannabis chronically. It is epigastric pain that had significantly FINANCIAL DISCLOSURE: Dr Wang received a characterized by significant nausea, worsened over the previous week grant from the Colorado Department of Public abdominal– pain, and cyclic vomiting, and was now associated with nausea Health and Environment on the evaluation of the pharmacokinetics of cannabidiol in pediatric which are4 14 often relieved by hot and vomiting. She denied fever, bathing. Most patients receive diarrhea, dysuria, or hematuria. Her epilepsy patients. He also receives royalties from significant medical evaluation without last menstrual period was 1 week UpToDate for authorship contributions for related – topics. Drs Graham and Barberio have indicated significant findings and are refractory1, 3 7 before and she denied recent sexual they have no financial relationships relevant to this to standard medical therapies. activity. She denied ethanol use but ° article to disclose. We present 2 adolescent patients did admit to cannabis use. Vital signs FUNDING: No external funding. with delayed diagnosis of CHS whose were a temperature of 36.8 C, blood POTENTIAL CONFLICT OF INTEREST: The authors symptoms improved with application pressure (BP) of 106/63 mm Hg, heart have indicated they have no potential conflicts of of capsaicin cream. rate (HR) of 103 beats per minute, interest to disclose. CASE PRESENTATIONS respiratory rate (RR) of 16 breaths per minute, and pulse oxygen saturation O To cite: Graham J, Barberio M, Wang GS. Cap Case 1 (Sp 2) of 99%. She complained of saicin Cream for Treatment of Cannabinoid Hyper diffuse abdominal pain, but had a soft emesis Syndrome in Adolescents: A Case Series. abdomen without peritoneal signs. Pediatrics. 2017;140(6):e20163795 A previously healthy 16-year-old girl Laboratory testing, including a basic presented to an outside emergency metabolic panel, complete blood count, Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 140, number 6, December 2017:e20163795 CASE REPORT Graham et al 2017 ROUGH GALLEY PROOF Capsaicin Cream for Treatment of https://doi.org/10.1542/peds.2016-3795 December 2017 Cannabinoid Hyperemesis Syndrome in Adolescents: A Case Series 6 140 Pediatrics lipase, liver function tests, urinalysis, points and her nausea resolved. peritoneal signs. Laboratory testing, “ ” and a urine pregnancy test were The patient did report the side including a basic metabolic panel, significant only for a potassium level effect of a mild burning sensation complete blood count, liver function of 3.2 mmol/L, bicarbonate of 28 on her abdomen where the cream tests, and lipase, was significant mmol/L, and a urinalysis revealing had been applied but was overall only for bilirubin of 1.4 mg/dL. 40 mg/dL ketones, trace blood, and satisfied by the symptom relief. She An ultrasound of the abdomen 30 mg/dL protein. She received had improvement in abdominal was normal. Negative workup, 4 mg intravenous ondansetron, tenderness on examination and was chronic cannabis use, and symptom 10 mg metoclopramide, a 1000-mL Casedischarged 2 from the hospital. improvement with hot showers led normal saline bolus, and 30 mL of an to a presumed diagnosis of CHS. oral lidocaine/diphenhydramine/ The patient verbally agreed to try aluminum and magnesium hydroxide capsaicin cream for the treatment A 20-year-old man with moderate solution. She left against medical of CHS. Capsaicin cream, 0.025% persistent asthma was seen in advice before undergoing a computed (1-mm-thick coating), was applied our ED with abdominal pain and tomographic scan despite expressing to his abdomen. Thirty minutes after vomiting. He admitted to being that there was no improvement in application, the patient reported acutely intoxicated with marijuana. her symptoms. ° marked improvement in abdominal His vital signs were a temperature pain and nausea. He also complained of 36.8 C, BP of 139/85 mm Hg, The next evening, the patient of a burning sensation over his HR of 139 beats per minute, RR of presented to our institution with O abdomen but was satisfied with the 16 breaths per minute, and Sp 2 of continued abdominal pain, nausea, symptom relief and was discharged. 95%. Examination was significant and emesis. A detailed history for epigastric tenderness, but DISCUSSION revealed chronic cannabis use, he had a soft abdomen and no which increased over the last week peritoneal signs. He was given in attempts to treat her nausea and 4 mg oral ondansetron and 15 mL CHS was first described in 2004 abdominal pain (multiple times of an oral aluminum/magnesium in a case series of 9 patients who per day). She could not identify hydroxide/diphenhydramine/ used cannabis chronically and alleviating or worsening factors. ° lidocaine/simethicone solution. He who exhibited cyclic vomiting and Her vital signs were a temperature 1 subsequently tolerated oral fluids compulsive bathing with hot water. of 36.6 C, HR of 80 beats per and was sent home with ondansetron There have been several case series minute, BP of 113/74 mm Hg, RR O and ranitidine for presumed gastritis. and reports describing patients with of 16 breaths per minute, and Sp 2 – chronic marijuana use and similar of 97%. Her pain was 6 out of 10 One week later, he returned 4, 6, 8 15 associated symptoms. possible points. On examination, complaining of persistent abdominal Although CHS has mainly been she exhibited voluntary guarding pain and vomiting. Since his initial described in adult patients, health with tenderness in her left upper visit, he had been taking ranitidine care providers should also be aware quadrant and epigastric region; her twice daily and ondansetron nearly that this diagnosis can occur in abdomen was soft and nondistended daily, but suffered from worsening 7, 16 adolescents. In 1 published case, without peritoneal signs. She was pain. He reported that his pain was a 17-year-old presented to the ED given 4 mg sublingual ondansetron migratory, traveling from his right 5 times for abdominal pain, nausea, and 5 mg oral oxycodone without lower to right upper to left upper and vomiting over the course of improvement in her nausea or quadrant to his epigastric region. 7 1 year. He received an extensive abdominal pain. Due to a history of He had 3 additional episodes of medical workup, which was negative. cannabis use, the refractory nature nonbloody emesis since his last Consistent with CHS, his symptoms of abdominal pain, and an otherwise visit. He endorsed at least twice- were relieved by hot showers and negative diagnostic workup, CHS daily marijuana use for >1 year and only completely resolved after the became the working diagnosis. that his abdominal pain improved cessation of marijuana use. After the risks and benefits were with hot showers. He denied fever, discussed, she verbally agreed to try diarrhea, dysuria, or hematuria. The pathophysiology of CHS is not ° capsaicin cream for the treatment Vital signs were a temperature of well understood at this time. In of CHS. Capsaicin cream, 0.025% 36.3 C, BP of 125/73 mm Hg, HR some circumstances, cannabis has (1-mm-thick coating),