Treatment

The treatment of cyclic vomiting syndrome is directed toward preventing, shortening or managing the episodes of nausea and vomiting and reducing symptoms of abdominal pain. Treatment of this disorder is based upon experience and observation (empiric) as opposed to an evidence-based treatment regimen. Specific therapies should be tailored for each individual case.

To prevent (prophylactic therapy) episodes from occurring, some individuals are treated with certain anti-migraine medications, especially amitriptyline, as well as cyproheptadine (in preschool-aged children) or propranolol. Anti-migraine therapies seem particularly effective for individuals with a family history of migraine.

Two studies each for coenzyme Q10 and L-carnitine suggest that these mitochondrial-targeted cofactors can be helpful to prevent vomiting episodes. Both are natural substances that can be obtained in the United States without a prescription. Co-enzyme Q10 assists in energy production (electron transport) and L-carnitine aids with fuel transport (fat transport) and clearing of metabolic waste products. In some cases, vomiting episodes become less frequent when these cofactors are used alone. One study suggests that their effects are best used in combination with amitriptyline. Side effects of these cofactors are rare and generally mild; L-carnitine can cause nausea and diarrhea, as well as a fish-like odor.

Preventive drug therapy is usually recommended for individuals with equal to or more than one episode per two month period, especially if episodes are prolonged or severe. Although not all experts agree, erythromycin may also be used to reduce the severity of episodes, especially in individuals with CVS and poor stomach pumping. Drugs that prevent seizures (anticonvulsants), especially toparimate and phenobarbital have also been used to prevent episodes from occurring. Abortive therapy is generally used when episodes occur less frequently (i.e., less than once every 2 month) or when preventive therapy has not worked. Certain drugs may be used to stop an episode as it is about to begin (abortive therapy). Some affected individuals can sense (e.g. nausea) an episode coming on (warning phase). Drugs used to treat vomiting (anti-emetics) such as ondansetron or granisetron or certain anti-migraine drugs known as triptans may be used to stop an episode if they are administered at the beginning of an episode. About one-half of individuals with CVS respond favorably to attempts to abort or lessen the severity of episodes using to sugar-containing intravenous (IV) fluids. In particular, D10-containing (10% sugar) IV fluids may be helpful if given early. Sugar-containing drinks such as juices or sodas can also be helpful at home.

Since individuals respond to medications differently, no one therapy works for all affected individuals. Several attempts using different preventive and abortive therapies may be necessary until an effective regimen is found for an individual case. In particular, treatment failures are frequently the result of too little drug given too infrequently. For example, although most experts target 0.5 mg per kg body weight per day, amitriptyline is often required 1 to 1.5 mg/kg/day for over a month or two in order to prevent vomiting episodes. Blood levels of amitriptyline can be obtained to check that the dose given is adequate and not excessive.

When preventive and abortive therapy does not work, supportive care during an episode may include bed rest in a dimly lit, quiet room. The administration of intravenous fluids to prevent complications such as dehydration may be necessary. Anti-vomiting medications (especially ondansetron at 0.3 to 0.4 mg/kg/dose, maximum dose about 24 mg), ketorolac used for pain and lorazepam for sedation may also be used. When children or adults are asleep, they don’t experience nausea. Deep sleep may also reset their system and shorten the episode. In severe episodes, hospitalization may be necessary.

Avoidance of known triggers (when possible) may also help reduce the frequency of episodes. Treatment of underlying commonplace anxiety using cognitive behavioral therapy and stress management (deep breathing) is often the key to improvement and rehabilitation back to school. The support of family is considered essential by clinicians to help deal with the unpredictable, disruptive nature of CVS and the likelihood of a delay in attaining the proper diagnosis.