CVS Treatments

The effective medications for CVS are prophylactic agents (preventive medication), anti-emetics (a drug effectively relieves vomiting and nausea), anxiolytics (a drug inhibits anxiety), analgesics (drugs that provide relief from pain) and sedatives (drug induces the nervous system to calm).

Prophylactic agents in CVS treatment

Prophylactic agents are acting to defend or preventive medication for cyclic vomiting syndrome.  CVS is considering a manifestation of migraine diathesis. The majority of children and adults have migraine diathesis as evidenced by the occurrence of migraine headaches in themselves and/or in their first or second-degree relatives. This leads to the attitude that CVS is a disease, which can be preventable with anti‐migraine medications. You can prevent CVS episode with migraine prophylaxis such as propranolol (Inderal), timolol (Blocadren), amitriptyline, divalproex (Depakote), sodium valproate, and topiramate (Topamax).

Anti-emetics agents in CVS treatment

An antiemetic is a drug that is effective in relieving vomit and nausea. Antiemetic suitable for the CVS treatment is 5-HT3 receptor antagonists. It blocks serotonin receptors in the central nervous system and gastrointestinal tract. Some of the medications in this class are:

  • Dolasetron (Anzemet), Granisetron (Kytril, Sancuso) - can be administered in tablet (Kytril), oral solution (Kytril), injection (Kytril), or in a single transdermal patch to the upper arm (SANCUSO).
  • Ondansetron (Zofran) - is administering as an oral tablet form, oral dissolving tablet form, or in an injection.
  • Tropisetron (Navoban) - is administering as an oral capsule or in injection form.
  • Palonosetron (Aloxi) - is administering as an injection or in oral capsules.
  • Mirtazapine (Remeron), an antidepressant that also has antiemetic effects.

The effective medications for CVS are prophylactic agents (preventive medication), anti-emetics (a drug that is effective against vomiting and nausea), anxiolytics (a drug that inhibits anxiety), analgesics (drugs that provide relief from pain) and sedatives (drug induces the nervous system to calm).

Anxiolytics agent in CVS treatment

Anxiety disorders affect 84% of adults; it may complicate by panic attacks in adult patients. Panic attacks trigger cyclic vomiting episodes in the majority of adult patients. At one end of the spectrum are those with migraine diathesis, but little or no pathologic anxiety. At the other-end are patients devoid of migraine diathesis, but afflicted with anxiety disorders complicated by panic attacks, which trigger their cyclic vomiting episodes. Most adults occupy neither end of the spectrum, but have various degrees of both migraine and pathologic anxiety. Thus treating with anxiolytics can help to prevent CVS episodes. You can prevent CVS episode with anxiolytics such as Benzodiazepines include Alprazolam (Xanax), Chlordiazepoxide (Librium), Clonazepam (Klonopin, Rivotril), Diazepam (Valium), Etizolam (Etilaam), Lorazepam (Ativan), and Oxazepam (Serax). Herbs that have anxiolytics property are Bacopa monnieri (Brahmi), Lactuca virosa (Opium Lettuce), Rhodiola rosea (Arctic Weed/Golden Root), Hypericum perforatum (St. John's Wort), Matricaria recutita (German Chamomile), Passiflora, Piper methysticum (Kava), Sceletium tortuosum (Kanna), Scutellaria spp. (Skullcap), Scutellaria lateriflora, Valeriana officinalis (Valerian), Salvia splendens (Not Salvia divinorum), Coriandrum sativum (Coriander), Myristica (Nutmeg), Salvia elegans (Pineapple Sage), Inositol, and Cannabidiol.

Analgesic’s agents in CVS treatment

Pain-killing agents provide relief from pain. If you are experiencing abdominal pain, then analgesic medication such as ibuprofen can help relieving from this pain. Over-the-counter analgesics include acetaminophen and medications from the NSAID family, such as ibuprofen and naproxen. Prescription opiates like codeine, morphine and hydrocodone may be administered in cases with severe pain.
For headache with features of common or classical migraine, try ibuprofen or sumatriptan (by tablet or nasal spray).

Sedative’s agent for CVS treatment

Take this drug for its calming or sleep-inducing effect. Although sedatives do not relieve pain in themselves, they can be a useful adjunct to analgesics. Medications used for sedation include propofol, etomidate, ketamine, fentanyl, and midazolam.
Sedation has three benefits:

  1. Deep sleep makes the centrally‐generated vomiting to cease immediately.
  2. It makes the patient insensible to his or her nausea, abdominal pain and emotional distress.
  3. Protecting from the misery lessens patients’ anticipatory anxiety between attacks and reverses the trend toward a coalescent pattern of episodes.

CVS treatment regimen

  • If you are in phase I without any symptoms and in a healthy state. You can prevent CVS episode with migraine prophylaxis such as cyproheptadine, amitriptylene, and propranolol.
  • If you are in phase II with a prodrome, just prior to attack, you can abort CVS with anti-anxiety drug such as lorazepam and/or anti-nausea drug with ondansetron. If you are having abdominal pain, analgesic medications such as ibuprofen can help. If you are having a headache, try ibuprofen or sumatriptan (by tablet or nasal spray).
  • If you are in phase III, that is during an attack. To avoid dehydration, include IV fluids (Na+, K+, Cl-, HCO3-) along with H2 blockers (acid reducers). You can terminate the CVS episode with anti-anxiety drug such as lorazepam and/or anti-nausea drug with ondansetron. You can use sedative until the episode passes; this helps to avoid nausea and vomiting; some of these medications are chlorpromazine plus diphenhydramine.
  • If you are in phase IV, recovering from CVS. To avoid relapse (recurrence of the CVS) add up healthy diet that is well tolerating by you.

The prodromal phase may last minutes or a day or more; two most important elements for success in stopping the vomiting phase during the prodrome are the timing and efficacy of abortive agents. They are individualizing based on the specific symptoms each patient experience during their prodromes.

For example,

  • For nausea, try ondansetron (Zofran) liquid, tablets or ODT’s (oral disintegrating tablets) at 0.3 – 0.4 mg/Kg/dose. (This is twice the dose recommended for chemotherapy patients.) Aprepitant (Emend), 80 mg, may use alone or with Zofran, although it is about twice as expensive as Zofran and/or Promethazine (Phenergan).
  • Anxiety increases nausea – thus for anxiety, try Lorazepam (Ativan) is anxiolytic, anti-emetic and promotes sleep. It works well together with ondansetron. Lorazepam tablets are almost tasteless and dissolve in the mouth without the patient having to drink. If the predominant prodromal symptoms are those of acute anxiety (e.g. chills and/or hot flushes, sweating, trembling, palpitations, pounding heart, dyspnea, light-headedness), alprazolam (Xanax), a rapidly acting anxiolytic, 1 to 2 mg orally taken immediately, may abort the anticipated vomiting.
  • For midline abdominal aches (the predominant symptom in abdominal migraine), try opiate (butorphanol), ibuprofen orally or if necessary, hydromorphone (Dilaudid), 3mg at a dose of about 0.08 mg/Kg/dose by rectal suppository.
  • For headache with features of common or classical migraine, try ibuprofen or sumatriptan (by tablet or nasal spray).
  • For epigastric distress and heartburn, try a proton pump inhibitor (e.g. Prilosec or Prevacid).
  • For diarrhea, try loperamide (Imodium) orally and/or hyoscyamine S-L.
  • For mild-to-moderate hypertension and tachycardia, caused by adrenergic discharge originating in the hypothalamus, may begin during the prodrome. Propranolol (Inderal), 0.1 – 2.0 mg/Kg/dose orally, may lessen these effects.

Patients may then take a nap, helped by the sedative effects of promethazine or lorazapam. If they awaken later feeling well, they would have successfully aborted their episode.

Opiates with anxiolytic properties are effective in ameliorating ongoing panic, usually within minutes. If a patient with cyclic vomiting episodes triggered by panic can able to administer butorphanol nasal spray at the onset of prodromal symptoms, the episode may abort, provided it is taking early enough. Therefore, anxiolytic opiates can be powerful tools for the management of panic‐triggered CVS.