Materiały źródłowe

• #1 Guidelines on management of cyclic vomiting syndrome in adults by the American Neurogastroenterology and Motility Society and the Cyclic Vomiting Syndrome Association

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6899751/

  The committee strongly recommends that adults with moderatetosevere CVS receive a tricyclic antidepressant (TCA), such as amitriptyline, as a firstline prophylactic medication and receive topiramate or aprepitant as alternate prophylactic medications. […] For acute attacks, the committee conditionally recommends using serotonin antagonists, such as ondansetron, and/or triptans, such as sumatriptan or aprepitant to abort symptoms. […] Treatment of CVS should be based on a biopsychosocial care model, integrating lifestyle modification, prophylactic and/or abortive medications, and evidencedbased psychotherapy to address psychiatric comorbidity. […] We recommend using prophylactic medications in moderatetosevere CVS and offering abortive medications to all patients to terminate an acute attack.

• #2 Cyclic vomiting syndrome – Diagnosis & treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/cyclic-vomiting-syndrome/diagnosis-treatment/drc-20352167

  There’s no cure for cyclic vomiting syndrome, though many children no longer have vomiting episodes by the time they reach adulthood. For those experiencing a cyclic vomiting episode, treatment focuses on controlling the signs and symptoms. […] You or your child may be prescribed: Anti-nausea drugs, Pain-relieving medications, Medications that suppress stomach acid, Antidepressants, Anti-seizure medications. […] The same types of medications used for migraines can sometimes help stop or even prevent episodes of cyclic vomiting. These medications may be recommended for people whose episodes are frequent and long lasting, or for people with a family history of migraine. […] Intravenous (IV) fluids may need to be given to prevent dehydration. Treatment is individualized based on the severity and duration of symptoms as well as the presence of complications.

• #3 Cyclic Vomiting Syndrome: Symptoms, Causes & Triggers, Treatment

  https://my.clevelandclinic.org/health/diseases/14894-cyclic-vomiting-syndrome

  Cyclic vomiting syndrome is when you experience cycles of severe nausea, vomiting and exhaustion that can last from a few hours up to a few days. […] Avoiding triggers and taking anti-seizure and anti-nausea medications can help. […] Treatment for cyclic vomiting syndrome depends on whether you’re experiencing an episode or trying to prevent one from happening. […] When symptoms first start, healthcare providers use medications to manage nausea, reduce stomach acid and relieve migraine symptoms and abdominal pain. […] Providers prescribe medicines to manage migraines and reduce your stomach acid and anxiety. […] You may receive medications to prevent future episodes. […] Medications stop an episode, reduce its intensity or prevent it from happening. […] Your prescription depends on your age, how severe your episodes are and how you’ve responded to other forms of treatment. […] Medications include: Anti-migraine medicines, Anti-nausea medicines, Anti-seizure medicines. […] You may also benefit from taking supplements, including coenzyme Q10, riboflavin and L-carnitine at doses recommended by your provider.

• #4 Treatment of Cyclic Vomiting Syndrome – NIDDK

  https://www.niddk.nih.gov/health-information/digestive-diseases/cyclic-vomiting-syndrome/treatment

  How do doctors treat cyclic vomiting syndrome depends on the phase. Your doctor may prescribe medicines […] Taking medicines early in this phase can sometimes help stop an episode from happening. Your doctor may recommend over-the-counter medicines or prescribe medicines such as ondansetron (Zofran) or promethazine (Phenergan) for nausea […] During this phase, you should stay in bed and sleep in a dark, quiet room. You may have to go to a hospital if your nausea and vomiting are severe or if you become severely dehydrated. Your doctor may recommend or prescribe the following for children and adults: medicines for nausea, migraines, anxiety, pain […] If you go to a hospital, your doctor may treat you with intravenous (IV) fluids for dehydration, medicines for symptoms, IV nutrition if an episode continues for several days

• #5 Cyclic Vomiting Syndrome Treatment & Management: Approach Considerations, Avoidance of Triggers, Prophylactic and Abortive Pharmacologic Therapy

  https://emedicine.medscape.com/article/933135-treatment

  In the absence of known pathophysiology, treatment of cyclic vomiting syndrome (CVS) remains empiric. The following management strategies are used for CVS: Avoidance of triggers, Prophylactic and abortive therapy, Supportive care during acute episodes, Family support. Consultation with a sympathetic gastroenterologist without drug therapy may decrease the frequency of vomiting episodes by as much as 70%. […] In some cases of CVS, avoiding identified dietary triggers such as chocolate, cheese, and monosodium glutamate (MSG) can prevent episodes without the use of medication. If psychological stressors trigger episodes, stress management techniques or benzodiazepine anxiolytics (eg, lorazepam or diazepam) may help to abort attacks in the early stages. […] Pharmacologic therapy is used to prevent episodes of vomiting or to decrease their frequency and also to abort or attenuate episodes once they begin. Preventive medications are normally used in patients with more than a single episode of CVS per month. The mainstays of prophylactic therapy include the following: Cyproheptadine, Amitriptyline, Anticonvulsants such as topiramate, zonisamide, and levetiracetam, Propranolol, Phenobarbital, Erythromycin.

• #6 CVS in Adults – About GI Motility

  https://aboutgimotility.org/learn-about-gi-motility/disorders-of-the-stomach/cyclic-vomiting-syndrome/cvs-in-adults/

  Treatment of cyclic vomiting syndrome remains largely based on clinical experience. In general, the treatment approach to a patient with CVS should include consideration of lifestyle changes including avoidance of potential triggering factors, drug therapy to prevent subsequent episodes, abortive and/or supportive care treatment during acute episodes, and support of the family. […] Medication treatment for patients with CVS is often divided into acute treatment of the vomiting episodes and chronic treatment to try to prevent the episodes. There is a lack of data on the outcomes of patients, particularly adult patients with CVS, to different types of treatment. […] A variety of agents are often tried to reduce the nausea and vomiting during the vomiting phase. Antiemetic agents can reduce the severity of episodes and are best used in conjunction with sedatives. This may include the antiemetic agents prochlorperazine (Compazine) and ondansetron (Zofran). Patients with CVS may respond well to intravenous lorazepam (Ativan), an anti-anxiety medication. Antimigraine triptans can also be used to try to abort episodes.

• #7 Cyclic Vomiting Syndrome Treatment & Management: Approach Considerations, Avoidance of Triggers, Prophylactic and Abortive Pharmacologic Therapy

  https://emedicine.medscape.com/article/933135-treatment

  When prophylactic medication fails or is not taken because of the sporadic and infrequent occurrence of cyclic vomiting episodes (1/month), abortive agents may be taken at the onset of an attack to stop progression. […] Guidelines on the management of CVS in adults from the American Neurogastroenterology and Motility Society and the Cyclic Vomiting Syndrome Association strongly recommend a tricyclic antidepressant, such as amitriptyline, as a first-line prophylactic medication for adults with moderate to severe CVS. […] When both prophylactic and abortive therapy fails, supportive care becomes an essential aspect of treatment during acute episodes. IV glucose-containing fluids may diminish the severity of episodes by as much as 42%. […] Sedatives such as diphenhydramine, lorazepam, and chlorpromazine have been administered to permit sleep and to provide temporary respite from unrelenting nausea. The combination of lorazepam and ondansetron appears to be more effective than ondansetron alone.

• #8 Cyclic Vomiting Syndrome: Pearls and Pitfalls – emDocs

  https://www.emdocs.net/cyclic-vomiting-syndrome-pearls-and-pitfalls/

  Supportive therapy: IV fluids with glucose can decrease illness severity by close to 40%! Provide sedative agents (such as diphenhydramine, chlorpromazine, or lorazepam) and place the patient in a quiet, dark room. Adequate sleep and hot showers can also assist in symptom relief. […] Patients unlikely to respond to treatment include those with chronic opiate use, psychiatric disease, and chronic marijuana use. […] Perhaps most importantly, patients and family members should contact the Cyclic Vomiting Syndrome Association. This international group provides numerous resources for patients including conferences, local support groups, and coping mechanisms.

• #9 Treatment of Cyclic Vomiting Syndrome – NIDDK

  https://www.niddk.nih.gov/health-information/digestive-diseases/cyclic-vomiting-syndrome/treatment

  During the recovery phase, you may need IV fluids for a while. Your doctor may recommend that you drink plenty of water and liquids that contain glucose and electrolytes […] Your doctor may prescribe medicines to help prevent future episodes. […] During the well phase, your doctor may prescribe medicines to help prevent episodes and how often and how severe they are, such as amitriptyline (Elavil), cyproheptadine (Periactin), propranolol (Inderal), topiramate (Topamax), zonisamide (Zonegran) […] Your doctor may also recommend coenzyme Q10, levocarnitine (L-carnitine), or riboflavin as dietary supplements to help prevent episodes.

• #10 Cyclic vomiting syndrome: From pathophysiology to treatment | Revista de Gastroenterología de México

  https://www.revistagastroenterologiamexico.org/en-cyclic-vomiting-syndrome-from-pathophysiology-articulo-S2255534X24000616

  Cyclic vomiting syndrome (CVS) is a disorder characterized by recurrent and unpredictable episodes of intense vomiting, interspersed with periods of apparent wellbeing. […] Management of CVS typically involves a multidisciplinary approach. Pharmacologic options are explored, such as antiemetics and preventive medications, as well as behavioral and psychologic support therapies. Treatment personalization is essential, adapting it to the individual needs of each patient. […] During the inter-episodic phase, treatment is prophylactic and is recommended in patients with moderate/severe disease, i.e., in patients with 4 episodes per year of nausea and severe vomiting that make the patient seek help at the emergency service or require hospitalization. TADs are the first-line drugs for CVS prophylaxis and have been shown to reduce the duration, severity, and frequency of episodes, as well as the number of emergency room visits and hospitalizations.

• #11 Guidelines on management of cyclic vomiting syndrome in adults by the American Neurogastroenterology and Motility Society and the Cyclic Vomiting Syndrome Association

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6899751/

  We strongly recommend that adults with moderatetosevere CVS receive tricyclic antidepressants (TCAs) such as amitriptyline, as a firstline prophylactic medication. […] We conditionally recommend that adults with moderatetosevere CVS receive topiramate as an alternate prophylactic medication. […] We conditionally recommend that adults with moderatetosevere CVS receive aprepitant as an alternate prophylactic medication. […] We conditionally recommend that adults with moderatetosevere CVS receive zonisamide or levetiracetam as an alternate prophylactic medication. […] We conditionally recommend using CoQ10, and riboflavin as prophylactic therapy in the treatment of CVS. […] We conditionally recommend using triptans like sumatriptan to abort symptoms of a CVS episode. […] We conditionally recommend using serotonin antagonists such as ondansetron to abort symptoms of a CVS episode.

• #12 Cyclic vomiting syndrome: A GI primer | MDedge

  https://www.mdedge.com/gihepnews/article/221281/mixed-topics/cyclic-vomiting-syndrome-gi-primer/page/0/1

  Recent guidelines recommend tricyclic antidepressants (TCAs) as the first-line agent in the prophylaxis of CVS episodes. Data from 14 studies determined that 70% (413/600) of patients responded partially or completely to TCAs. Amitriptyline should be started at 25 mg at night and titrated up by 10-25 mg each week to minimize emergence of side effects. The mean effective dose is 75-100 mg or 1.0-1.5 mg/kg. In addition to pharmacotherapy, addressing comorbid conditions such as anxiety and depression and counseling patients to abstain from heavy cannabis use is also important to achieve good health care outcomes. […] In summary, CVS is a common, chronic functional GI disorder with episodic nausea, vomiting, and often, abdominal pain. Symptoms can be disabling, and prompt diagnosis and therapy is important. Medications such as amitriptyline are effective in the prophylaxis of CVS, but side effects hamper their use. Recent recommendations for management of CVS have been published.

• #13 Cyclic Vomiting Syndrome in Children

  https://www.uspharmacist.com/article/cyclic-vomiting-syndrome-in-children

  In children with frequent attacks (more than 1 or 2 per month), repeated hospitalizations, or poor response to abortive treatment, prophylactic drug treatment may be initiated. In young children (5 years), the drug of choice is cyproheptadine, and an alternative is propranolol. Cyproheptadine has been shown to cause some weight gain in this population due to increased appetite, but this does not typically require discontinuation of the medication and may be beneficial in underweight patients. In children 5 years and older, amitriptyline is first-line treatment, followed by propranolol. Other drugs that are sometimes used, but lack supporting evidence, include anticonvulsants, erythromycin, L-carnitine, and coenzyme Q10.

• #14 Cyclic Vomiting Syndrome Medication: Antiemetic Agents, Antihistamines, 1st Generation, Antidepressants, TCAs, Beta-Adrenergic Blocking Agents, Anticonvulsants, Antibiotics, Anxiolytics, Benzodiazepines

  https://emedicine.medscape.com/article/933135-medication

  Propranolol is a beta-adrenergic blocker and an excellent first-line agent for prophylaxis when used at low doses. It has a 57% efficacy rate, with efficacy defined as a 50% reduction in the frequency and severity of episodes. […] Phenobarbital may be used in patients with or without electroencephalographic (EEG) changes. A 79% response rate has been observed in patients with CVS. […] Topiramate is a sulfamate-substituted monosaccharide with a broad spectrum of antiepileptic activity; it may have state-dependent sodium channel blocking action. […] Erythromycin is a gastric prokinetic that stimulates coordinated gastric emptying. A 75% response rate has been demonstrated in patients with CVS. […] The 5-HT1B/1D agonist sumatriptan may effectively terminate an episode of CVS by constricting the cerebral vasculature. High doses are more effective in patients with CVS. […] Lorazepam induces sedation and anxiolysis through central inhibition of gamma-aminobutyric acid (GABA). Its effects appear to be synergistic with the antinausea and antiemetic effects of 5-HT3 antagonists. Concomitant sedation and induction of sleep provide sustained relief from intractable nausea.

• #15 Cyclic vomiting syndrome – Diagnosis & treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/cyclic-vomiting-syndrome/diagnosis-treatment/drc-20352167

  Alternative and complementary treatments may help prevent vomiting episodes, although none of these treatments has been well studied. These treatments include: Coenzyme Q10 (ubiquinone), L-carnitine, Riboflavin (vitamin B-2). […] Be sure to see a doctor and have the diagnosis of cyclic vomiting syndrome confirmed before starting any supplements. Always check with your doctor before taking any supplements to be sure you or your child is taking a safe dose and that the supplement won’t adversely interact with any medications you’re taking. Some people may experience side effects from coenzyme Q10 and L-carnitine, including diarrhea and fishy body odor.

• #16

  https://www.healio.com/news/gastroenterology/20240716/aga-prompt-recognition-is-key-to-diagnosis-management-of-cyclic-vomiting-syndrome

  Abortive therapy is designed to avoid the emetic phase or drastically reduce its severity and is most effective when medication is taken as early into the prodromal phase as possible. […] The most common abortive therapy regimen includes sumatriptan, which can be administered via nasal spray, and an antiemetic agent, such as ondansetron, which is available in a sublingual tablet. […] ED management may be necessary for patients presenting with an episode of uncontrolled retching and vomiting and may include control of abdominal pain and IV fluids and antiemetics. […] Improving access to treatment for adults with CVS not only will improve patients quality of life, but also substantially reduce the burden on the health care system.

• #16

  https://www.healio.com/news/gastroenterology/20240716/aga-prompt-recognition-is-key-to-diagnosis-management-of-cyclic-vomiting-syndrome

  Cyclical vomiting syndrome should be considered in any adult presenting with episodes of repetitive vomiting. […] Treatment includes lifestyle measures, abortive medication, supportive therapy and rehydration. […] Most patients with cyclic vomiting syndrome (CVS) can benefit substantially from currently available treatments, but this disorder remains poorly recognized by clinicians. […] Levinthal and colleagues recommend addressing comorbid conditions related to CVS with assistance from referral and allied health services, which may include pharmacologic or nonpharmacologic therapies such as cognitive behavioral therapy or mindfulness meditation. Lifestyle modifications such as regular sleep, avoiding prolonged fasting and stress management are also advised. […] Researchers also recommend prophylactic therapy aimed at extending the length of the interepisodic phase and/or reducing the length and severity of the emetic phase for patients with moderate to severe CVS, defined as more than four episodes per year, each of which last at more than 2 days, with ED utilization. Tricyclic antidepressants are strongly recommended as first-line treatment, while topiramate, aprepitant, zonisamide and levetiracetam are second-line agents; however, the choice should be individualized based on the patient.

• #17 Guidelines on management of cyclic vomiting syndrome in adults by the American Neurogastroenterology and Motility Society and the Cyclic Vomiting Syndrome Association

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6899751/

  We conditionally recommend aprepitant to abort symptoms of a CVS episode. […] We suggest screening and treatment for comorbid conditions such as anxiety, depression, migraine headache, sleep disorders, autonomic dysfunction, and substance use. […] We suggest that techniques such as meditation, relaxation and biofeedback be offered as complementary therapy in CVS.

• #18 Cyclic Vomiting Syndrome: AGA Issues Practice Update on Diagnosis and Management – Gastroenterology Advisor

  https://www.gastroenterologyadvisor.com/features/cyclic-vomiting-syndrome-cvs/

  The ANMS-CVSA guidelines recommend the following prophylactic treatments based on case series and expert opinion: First line: Tricyclic antidepressants (amitriptyline, nortriptyline, doxepin) […] Abortive therapy is recommended to avoid the emetic phase or reduce its severity. […] The ANMS-CVSA guidelines recommend the following abortive treatments based on case series and expert opinion: Triptans (sumatriptan) […] While some patients respond to monotherapy, most patients require combination therapy with 2 or more agents to stop CVS episodes. […] Patients presenting to the ED with uncontrolled retching and vomiting should be treated, even if there is suspicion of CHS. […] It is recommended for patients to be placed in a quiet, dark room in addition to receiving intravenous (IV) benzodiazepines to induce sedation. […] Due to the fundamental lack of understanding of the pathophysiology of CVS, it remains a challenge to develop treatments.

• #19 Cyclical vomiting

  https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Cyclical-vomiting

  To date, there are no controlled therapeutic trials on treatment of cyclical vomiting, and the treatment remains largely empirical. […] In patients who experience a prodrome, use of oral anti-emetics, non-steroidal anti-inflammatories or sumatriptan may abort an episode before it becomes full-blown. […] Patients who are prone to severe attacks which cannot be controlled at home should be admitted to hospital, and treatment with intravenous fluid should be started as soon as possible. […] The treatment regimen that is instituted in individual patients is generally documented in their previous hospital records, and that treatment protocol should be followed. […] Acute management is based on supportive and symptomatic care: Administer IV hydration with sodium chloride 0.9% + glucose 5% fluid.

• #20 Cyclical vomiting

  https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Cyclical-vomiting

  Ondansetron is generally the first line anti-emetic (patient age 2 years) 0.15 mg/kg/dose IV (maximum 8 mg) every 8 hours. […] A proton pump inhibitor is useful for patients with epigastric pain and to prevent oesophagitis and haematemesis in Mallory Weiss tear. […] Chlorpromazine may be useful in patients where ondansetron does not control nausea and vomiting.

• #21 Cyclic Vomiting Syndrome: AGA Issues Practice Update on Diagnosis and Management – Clinical Advisor

  https://www.clinicaladvisor.com/features/cyclic-vomiting-syndrome-cvs/

  While some patients respond to monotherapy, most patients require combination therapy with 2 or more agents to stop CVS episodes. […] Fluid restoration is the priority in the recovery phase of CVS. […] Patients presenting to the ED with uncontrolled retching and vomiting should be treated, even if there is suspicion of CHS. […] Experts recommend intravenous ketorolac as the first-line, non-narcotic medication to treat severe abdominal pain in patients with CVS. […] Collaboration between health care services, including neurologists, psychiatrists, and sleep specialists, are important in managing patients with CVS. […] Some lifestyle modifications recommended to patients include attempting to avoid triggers, maintaining a regular sleep schedule, avoiding prolonged fasting, and practicing stress management techniques.

• #22 Cyclic vomiting syndrome – Symptoms & causes – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/cyclic-vomiting-syndrome/symptoms-causes/syc-20352161

  Cyclic vomiting syndrome is difficult to diagnose because vomiting is a symptom of many disorders. Treatment often involves lifestyle changes to help prevent the events that can trigger vomiting episodes. Medications, including anti-nausea and migraine therapies, may help lessen symptoms. […] If episodes occur more than once a month or require hospitalization, your doctor may recommend preventive medicine, such as amitriptyline, propranolol (Inderal), cyproheptadine and topiramate. […] Many people know what triggers their cyclic vomiting episodes. Avoiding those triggers can reduce the frequency of episodes. While you may feel well between episodes, it’s very important to take medications as prescribed by your doctor. […] Lifestyle changes also may help, including getting adequate sleep, for children, downplaying the importance of upcoming events because excitement can be a trigger, avoiding trigger foods, such as alcohol, caffeine, cheese and chocolate, and eating small meals and low-fat snacks daily at regular times.

• #23 Cyclic Vomiting Syndrome Treatment : Medical Hypnosis

  https://jefflazarusmd.com/cyclic-vomiting/

  Cyclic Vomiting Syndrome (CVS) is a condition in which patients: […] This is one of the most frustrating problems that patients and their clinicians experience because there is no medication for it. […] Relaxation-type exercises have been suggested to treat CVS, and, of course, medical hypnosis takes this to the next level. […] Patients who learn self-hypnosis can use the aura or beginning of the episode to use this technique to prevent the episode from occurring and there is typically significant improvement after only 2 to 3 visits. […] For individuals with CVS, I always incorporate cognitive behavioral therapy strategies, as these individuals usually also have anxiety. […] Fortunately, within a few visits, they were much better with fewer episodes and fewer visits to the hospital!

• #24 Cyclic Vomiting Syndrome in Children

  https://www.uspharmacist.com/article/cyclic-vomiting-syndrome-in-children

  Currently, there is no standard evidence-based treatment for CVS. Very few trials have been conducted to study treatments for CVS, so recommendations largely are based on expert opinion. […] Some children go through a stage lasting minutes to days where warning symptoms are present before the vomiting begins. This may involve extreme nausea with or without abdominal pain, lethargy, pallor, and anorexia. Sometimes, during the prodrome phase, it is possible to stop an episode from happening. The child should be placed in a dark, quiet room to decrease stimulation and should try to sleep. Diphenhydramine or lorazepam may be used for sedation, ondansetron for nausea, or ibuprofen for abdominal or epigastric pain to decrease symptoms and prevent progression to vomiting. […] Immediate treatment of vomiting attacks is crucial, since the physical stress of the episode predisposes the patient to more vomiting and perpetuates the cycle. Once a vomiting episode begins, treatment usually requires the person to stay in bed and sleep in a dark, quiet room. Attacks often progress to severe nausea and vomiting requiring hospitalization.

• #25 Cyclic Vomiting Syndrome in Children

  https://www.uspharmacist.com/article/cyclic-vomiting-syndrome-in-children

  First, the patient should be started on IV fluids, typically 10% dextrose and 0.45% normal saline with potassium chloride and an H2 blocker or proton pump inhibitor for fluid maintenance. In children above 12 years of age, antimigraine drugs such as sumatriptan may be prescribed to stop symptoms. These drugs have not been FDA approved for use in children and adolescents, but have been used. Sumatriptan can be administered intranasally or subcutaneously to circumvent medication loss due to vomiting. Zolmitriptan also comes in a nasal form. These drugs will either stop the attack within an hour or 2 or will not work at all, and therefore should not be dosed repeatedly. In children less than 12 years old, an attempt should be made to terminate the episode by giving 0.05 to 0.1 mg/kg IV lorazepam (maximum [max] 4 mg) and 0.3 to 0.4 mg/kg IV ondansetron (max 0.45 mg/kg/day). In either case, if the nausea clears, the patient should be given a 4- to 8-mg dose of ondansetron orally and sent home after demonstrating a tolerance for food and drink. If the nausea does not clear, or if it clears but returns, supportive care must be relied upon.

• #26 Cyclic Vomiting Syndrome Treatment & Management: Approach Considerations, Avoidance of Triggers, Prophylactic and Abortive Pharmacologic Therapy

  https://emedicine.medscape.com/article/933135-treatment

  Medications used for aborting episodes include the following: Ondansetron, Promethazine, Prochlorperazine, Triptans. […] Daily prophylactic pharmacotherapy may be used to prevent episodes that occur more than once a month or if they are extremely severe and disabling (eg, lasting 3 days or longer). […] The guidelines formulated by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) recommend cyproheptadine as first-line therapy in children younger than 5 years. However, cyproheptadine can cause substantial weight gain because of an increase in appetite. Amitriptyline is the first-line choice in children older than 5 years and adolescents. […] Although no randomized control trials have examined medications used in CVS, several open-label trials and retrospective studies support the use of amitriptyline as first-line therapy in patients with CVS who are older than 5 years.

• #27 Cyclic Vomiting Syndrome in Children

  https://www.uspharmacist.com/article/cyclic-vomiting-syndrome-in-children

  When an episode cannot be stopped, the best way to provide relief to the patient is by sedation. Sleep gives the child a break from the discomfort, and since the vomiting is not due to a physical GI problem, it will stop once the patient is asleep. It is believed that the brain is in some way responsible for the vomiting, although the mechanism is still unknown. The preferred regimen for sedation is a combination of chlorpromazine 0.5 to 1 mg/kg (5 years: max 40 mg/day; 5-12 years: max 75 mg/day) and diphenhydramine 0.5 to 1.25 mg/kg (max 5 mg/kg/day, not to exceed 300 mg) in 50 mL of normal saline infused over 15 minutes. This can be repeated every 6 hours as needed for wakefulness and nausea and may be required for several days depending on the patient. […] When the vomiting phase ends and the nausea subsides, patients may resume eating and drinking as soon as they are ready and as tolerated. Some will return immediately to a regular diet, while others will need a slow advancement from clear liquids to solid foods. The patient should be allowed to determine the pace. Prophylactic medications should be resumed as soon as possible.

• #28 Improvement of Cyclic Vomiting Syndrome | UPMC Physician Resources

  https://www.upmcphysicianresources.com/news/041221-cyclic-vomiting-syndrome

  Cyclic vomiting syndrome (CVS) is treated with outpatient ketamine infusions as therapy for refractory cases. […] Most patients with CVS respond well to traditional prophylactic and abortive treatments, but a smaller subset of CVS patients with chronic abdominal pain may not respond as well to standard therapies. […] In this case report, researchers describe a 63-year-old woman with a history of CVS who presented with abdominal pain and recurrent episodes of nausea and vomiting. […] Given her improvement, she was offered a series of outpatient ketamine infusions, which led to a significant reduction in her symptoms. […] This is the first case report to offer ketamine as a potential prophylactic treatment for CVS.

• #29 Cyclic vomiting syndrome: diagnostic approach and current management s | CEG

  https://www.dovepress.com/cyclic-vomiting-syndrome-diagnostic-approach-and-current-management-st-peer-reviewed-fulltext-article-CEG

  Sumatriptan is a proven abortive treatment option for CVS. […] Previous studies with propranolol have proven it should be considered as a prophylactic option to control symptoms and prevent attacks. […] A novel approach to treating CVS is the use of neurokinin (NK1) receptor antagonists. […] Other second-line therapies for nonresponders include medications that improve mitochondrial function (eg, l-carnitine or coenzyme Q10). […] Other therapies demonstrating successful CVS treatment in case reports and case series include chlorpromazine, gonadotropin releasing hormone analogue, mirtazapine, onabotulinumtoxinA, and risperidone.

• #30 Cyclic Vomiting Syndrome: Diagnostic Criteria and Insights into Long Term Treatment Outcomes – Practical Gastro

  https://practicalgastro.com/2015/01/05/cyclic-vomiting-syndrome-diagnostic-criteria-and-insights-into-long-term-treatment-outcomes/

  Long term treatment of CVS is based on trying to identify the etiologic subgroups particularly the role of psychological stress while prescribing prophylactic drug and abortive therapy and supportive measures to ameliorate acute vomiting episodes. […] Long term management is focused on reducing and actually preventing future hyperemesis episodes. […] At the forefront of CVS management, tricyclic antidepressants (TCA), especially amitriptyline, have been shown to be effective for pharmacological prophylaxis. […] The treatment approach with tricyclic antidepressants requires beginning with a low initial dose of amitriptyline 10 mg at night with incremental increases in 10 mg doses every 2 to 4 weeks to titrate to the desired therapeutic effect. […] Long term outcomes are now becoming apparent as treatment patterns become recognized. […] In Summary, treatment with TCA is an effective strategy in 87% of patients and significantly decreases the frequency of attacks, number of emergency room visits and hospitalizations.

• #31 A New Approach to the Prophylaxis of Cyclic Vomiting: Topiramate

  https://www.jnmjournal.org/journal/view.html?doi=10.5056/jnm16035

  The aim of this study was to compare the efficacy and tolerability of topiramate and propranolol in preventing pediatric cyclic vomiting syndrome. […] The efficacy of topiramate was superior to propranolol for the prophylaxis of pediatric cyclic vomiting syndrome. […] Preventive treatment with tricyclic antidepressants, -adrenoceptor antagonists (propranolol) or cyproheptadine have been shown to be safe and effective in pediatric patients with CVS. […] Also, drugs such as pizotifen, erythromycin, coenzyme Q10, and antiepileptics including valproate, phenobarbital, and topiramate can be used for CVS prophylaxis. […] In our study, we compared the efficacy and safety of propranolol and topiramate in preventing pediatric CVS. […] In our study, the response rate for topiramate was 94%. Our results were inconsistent with the findings of Kumar et al. […] The results of our study show that topiramate was superior to propranolol for the management of CVS. […] In conclusion, the efficacy of topiramate was superior to that of propranolol for pediatric CVS. Adverse effect rates did not differ between the treatment groups.

• #32 High degree of efficacy in the treatment of cyclic vomiting syndrome with combined co-enzyme Q10, L-carnitine and amitriptyline, a case series | BMC Neurology | Full Text

  https://bmcneurol.biomedcentral.com/articles/10.1186/1471-2377-11-102

  This case series demonstrates excellent efficacy of cofactor therapy (co-enzyme Q10, L-carnitine) combined with amitriptyline. […] In participants under age five years, efficacy appears to be good when cofactor therapy is combined with cyproheptadine, although the number of cases reported here is small. […] Combining the 22 cases age 5 years and 4 cases 5 years, overall substantial efficacy ( 75% response) of this protocol was 23/26 at the start of treatment, and 23/23 of those who could tolerate the regiment. […] Our data suggest that a protocol consisting of mitochondrial-targeted cofactors (co-enzyme Q10 and L-carnitine) plus amitriptyline (or possibly cyproheptadine in preschoolers) coupled with fasting avoidance and blood level monitoring is highly effective in the prevention of vomiting episodes.

• #33

  https://journals.lww.com/ajg/fulltext/2016/10001/adult_cyclic_vomiting_syndrome_is_treatable_and.2454.aspx

  Cyclic Vomiting Syndrome (CVS) in adults is underdiagnosed because it is not well recognized by physicians although it accounts for up to 20% of patients referred to a GI practice for evaluation of unexplained vomiting and abdominal pain. Goals of therapy are to induce remission while also addressing the predisposing trigger factors. […] All patients were treated with tricyclic antidepressants. Amitriptyline was the first choice, starting at 10mg at night, increasing by 10mg every 2-3 weeks until CVS improved. […] 1) Adult CVS is a treatable and reversible entity; 2) The treatment consisting of high dose TCA addressing the trigger factors was able to prevent cycles in 83% of patients, including 22% that were effectively cured and able to taper off medications without recurrence; 3) The approximately 17% of patients who have ongoing cycles require better control of the predisposing factors as well as reinforcing compliance with the treatment regimen.

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