Capsaicin for cannabinoid hyperemesis syndrome – It’s is one hot therapy.

As a result of cannabis liberalization policies in many states, interest in methods to manage cyclic vomiting syndromes are heating up. By now, many ED providers are aware of the common complaint of patients with excessive vomiting with reported histories of marijuana consumption.[1,2] These cases, patients describe vomiting that was once resolved by hot showers, is no longer controlled. For a more in-depth review, check out this post on EM PharmD.

A purported remedy for these patients was topical capsaicin. Capsaicin resolves emesis and nausea is via activation of the TRPV1 and subsequent depletion of substance P. Other agents which may modulate TRPV1 include droperidol (yay), haloperidol, ondansetron, or olanzapine. But there have been inconsistent reports in terms of efficacy. Some anecdotes make it seem as though its an effective therapy. But when combined, analyses of case reports suggest no consistent benefit. Perhaps in these cases, it’s been a function of dose. Specifically, we were WAAAYYYY off.

Muy Caliente

A new report in ClinTox brought forth attention to using capsaicin 8% for cannabinoid-induced vomiting.[3] Now, if you’re like me, I had no idea if this was high/low/normal. Turns out the typical OTC capsaicin topical product (the one available in hospitals as well) is somewhere between 0.025% to 0.1%. So 8% capsaicin is one hot therapy indeed.

This case report in ClinTox highlights this therapy in an individual complaining of cannabis-induced vomiting. After failing numerous antiemetics (metoclopramide, ondansetron, diazepam, and phloroglucinol), the patient was prescribed two (yes, 2) 8% (179 mg) transdermal capsaicin patches. One patch was on his back and the other on his left arm. The patient reported relief of nausea and vomiting. 

After dozing off in the ED (with the patches on), he awoke 4 hours later complaining of painful local redness where the patches were located. The patches were removed and alcohol swabs applied, which provided relief. The patient was then discharged home.

The authors of the case report suggest an alternative administration regimen. After clinical assessment, they suggest applying 1 to 4 (yikes) patches to dry, intact skin and remain in place for up to 60 minutes.  Anyone applying the patches should wear NITRILE gloves since latex does not provide enough protection. 

Hot wings and alcohol

The application should be done by slowly rolling the adhesive side inward while removing the patch to avoid capsaicin aerosolization which may result in respiratory irritation. After the 1 hour application time, the patch should be removed followed by a cleansing gel applied to the area, left to dwell for one minute, then itself removed with dry gauze. If the patient can’t take the heat (from capsaicin), alcohol is recommended to remove capsaicin. Topical isopropyl works like a beer and hot wings.  

But wait, there’s something I forgot. Oh, yea: 8% capsaicin (Qutenza) is $1000 PER PATCH. Holy shit.

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Reference

  1. Samantha Wagner, Jason Hoppe, Matthew Zuckerman, Kerry Schwarz & Julie McLaughlin (2019) Efficacy and safety of topical capsaicin for cannabinoid hyperemesis syndrome in the emergency department, Clinical Toxicology, DOI: 10.1080/15563650.2019.1660783
  2. Shelby K. Shelton, Eleanor Mills, Jessica L. Saben, Michael Devivo, Kayla Williamson, Diana Abbott, Katelyn E. Hall & Andrew A. Monte (2019) Why do patients come to the emergency department after using cannabis?, Clinical Toxicology, DOI: 10.1080/15563650.2019.1657582
  3. Bruno Mégarbane, Isabelle Malissin, Nicolas Deye & Sebastian Voicu (2019) Topical Capsaicin To Treat Cannabinoid Hyperemesis Syndrome: Mind The Dose, Clinical Toxicology, DOI: 10.1080/15563650.2019.1694683