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تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
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Supportive and abortive treatment approaches for cyclic vomiting syndrome

Supportive and abortive treatment approaches for cyclic vomiting syndrome
Supportive care
Fluid, electrolyte, and nutritional management

Initial bolus – Administer isotonic saline (0.9% sodium chloride), 10 to 20 mg/kg (or 1 L for adults) as needed for hypovolemia.

Subsequent fluids:
  • Children – 10% dextrose, 0.45% sodium chloride solution with potassium chloride as appropriate.
  • Adults – 5% dextrose, 0.9% sodium chloride solution with potassium chloride as appropriate.

Infuse the above fluids at 1.5 times the maintenance fluid rate. Alternatively, 10% or 5% dextrose in water can be infused at 1 times the maintenance fluid rate, along with a separate 0.9% sodium chloride solution at 0.5 times the maintenance fluid rate, using a Y-connector.

Monitor urine output carefully because some patients develop SIADH and may require fluid restriction.
If no enteral intake for 3 to 5 days, initiate peripheral parenteral nutrition with 1.5 g of amino acids/kg/day and energy units above the catabolic threshold of 55 to 70 kcal/kg/day.
Antiemetic agents
Ondansetron (5-HT3 receptor antagonist)
Dosing:
  • Children – 0.3 mg/kg/dose intravenously, up to a maximum of 8 mg. May give an additional dose every 4 to 6 hours; do not exceed 32 mg/24 hours.
  • Adults – 8 mg intravenously. May give an additional dose every 4 to 6 hours; do not exceed 32 mg/24 hours[1].
Side effects – Headache, constipation, prolonged QTc interval.
Fosaprepitant (neurokinin-1 receptor antagonist)*
Dosing:
  • Children 2 to <12 years – 3 to 4 mg/kg/dose intravenously over 60 minutes (maximum dose 150 mg). If needed, administer 2 mg/kg intravenously (fosaprepitant) or orally (aprepitant) on days 2 and 3.
  • Children ≥12 years and adults – 150 mg intravenously over 30 minutes. If needed, administer 80 mg intravenously (fosaprepitant) or orally (aprepitant) or on days 2 and 3.
Side effects – Fatigue, diarrhea.
Sedating agents
Diphenhydramine (antihistamine)
Dosing:
  • Children – 1 to 1.25 mg/kg/dose intravenously every 6 hours (up to a maximum of 50 mg per dose).
  • Adults – 25 to 50 mg intravenously. May repeat every 6 hours (maximum of 400 mg per day).
Side effects – Drowsiness, dry mouth, paradoxical excitement or irritability in young children.
Lorazepam (benzodiazepine)
Dosing:
  • Children – 0.05 to 0.1 mg/kg/dose intravenously every 6 hours (up to a maximum of 2 mg per dose).
  • Adults – 1 to 2 mg intravenously. May repeat every 6 hours.
Side effects – Respiratory depression, dizziness, hallucinations, sedation, paradoxical excitement or irritability in young children.
Analgesic agents
Ketorolac (nonsteroidal antiinflammatory drug)
Dosing:
  • Children – 0.5 mg/kg intravenously every 6 to 8 hours, for 48 hours (up to a maximum of 30 mg per dose). Do not exceed a maximum daily dose of 120 mg.
  • Adults ≥50 kg – 30 mg intravenously. May repeat every 6 hours (maximum of 120 mg per day).
Side effects – Gastrointestinal hemorrhage, hypersensitivity.
Contraindications – Avoid in patients with dehydration or kidney function impairment (can cause acute kidney injury in dehydrated patients).
Alternatives – Narcotics, intravenous morphine or hydromorphone by bolus or by patient-control infusion.
Treatment of specific signs and symptoms
Epigastric pain – Acid suppression by H2RAs or PPIs, (eg, intravenous famotidine, pantoprazole).
Diarrhea – Antidiarrheals (eg, loperamide).
Hypertension (if persistent and severe) – Short-acting ACE inhibitors (eg, enalapril) or beta-2 adrenergic blockers (eg, labetalol).
Treatment of specific complications
Dehydration and electrolyte deficit – Replace calculated deficits.
Metabolic acidosis – Determine cause and treat accordingly.
SIADH – Restrict free water intake.
Hematemesis – Intravenous H2RAs or PPIs.
Weight loss – Nasogastric or parenteral nutrition.
Abortive care
SumatriptanΔ (serotonin agonist)
Start as soon as possible during the prodrome or within 1 hour of the onset of vomiting.
Dosing:
  • Age 5 to 11 years, or weight 20 to 39 kg – Intranasal dose 5 to 10 mg or subcutaneous dose 2 to 3 mg (by self-injection)◊.
  • Age 12 to 17 years, or weight 40 to 59 kg – Intranasal dose 20 mg or subcutaneous dose 3 to 6 mg◊.
  • Age ≥18 years, or weight ≥60 kg – Intranasal dose 20 mg or subcutaneous dose 6 mg. If there is no response or partial response to the first dose, the dose may be repeated after 2 hours for intranasal administration, or 1 hour for subcutaneous administration. Maximum of 6 doses per week[1].
Side effects – Neck pain/burning, tingling, numbness, dizziness.
Contraindications – Basilar artery migraine. Do not use in patients with underlying coronary artery disease, peripheral vascular disease, hypertension, or stroke.
Alternatives – Zolmitriptan (intranasal)§.
Aprepitant¥[1,2] (neurokinin-1 receptor antagonist)
Administer during the prodrome (at least 30 minutes before onset of vomiting) and on days 2 and 3.
Dosing:
  • <15 kg body weight – 80 mg orally on day 1, then 40 mg on days 2 and 3.
  • ≥15 to 20 kg body weight – 80 mg orally on day 1, then 80 mg on days 2 and 3.
  • >20 kg body weight and adults – 125 mg orally on day 1, then 80 mg on days 2 and 3.
Alternatives – Early administration of ondansetron may reduce the pace and amount of vomiting (refer to antiemetic agents above for dosing).
Recovery and refeeding
Feed ad libitum when child declares episode is over.

5-HT3: 5-hydroxytryptamine; ACE: angiotensin-converting enzyme; H2RAs: histamine-2 receptor antagonists; PPIs: proton pump inhibitors; SIADH: syndrome of inappropriate antidiuretic hormone.

* Fosaprepitant has a large evidence base from treatment of chemotherapy-induced nausea and vomiting; our clinical experience suggests that it is also useful for cyclic vomiting syndrome and may have fewer side effects than ondansetron. Dosing for cyclic vomiting syndrome is not standardized and varies among centers but is generally similar to that used for chemotherapy-induced vomiting, with minor variations for days 2 and 3 including route of administration and as-needed dosing.

¶ For sedation of pediatric patients, we typically begin with diphenhydramine and switch to lorazepam if sedation is not adequate. Adult guidelines suggest initiating treatment with lorazepam.

Δ Sumatriptan dosing is not well established, especially for young children. These doses are based on the authors' clinical experience, a few published case series[3,4], and extrapolation from doses used for treatment of migraines in children. In children with both migraines and cyclic vomiting, the vomiting symptoms sometimes respond to sumatriptan at lower doses compared with those needed to treat the migraines.

◊ For children 5 to 12 years of age, sumatriptan should be initiated at the lower dose initially, with a repeat dose in 2 hours for intranasal administration and 1 hour for subcutaneous administration. If this dose achieves an inadequate response and the patient has no adverse effects, then subsequent next treatment should be at the higher dose. For children age 12 to 18 years, the same approach should be used except for those who have entered puberty (ie, exhibiting secondary sexual characteristics), in which case, the higher dose may be used first. Some clinicians also use sumatriptan for children 3 to 5 years at lower doses (eg, 1 mg subcutaneously)[3].

§ Suggested intranasal dosing for zolmitriptan is 2.5 mg for age 5 to 12 years, 2.5 to 5 mg for 12 to 18 years, and 5 mg for ≥18 years[5-7].

¥ Aprepitant also may be used as a prophylactic therapy, given twice weekly (refer to UpToDate content and table on prophylactic therapy for cyclic vomiting syndrome)[1,2].
References:
  1. Venkatesan T, Levinthal DJ, Tarbell SE, et al. Guidelines on Management of Cyclic Vomiting Syndrome in Adults by the American Neurogastroenterology and Motility Society and the Cyclic Vomiting Syndrome Association. Neurogastroenterol Motil 2019; Suppl 2:e13604.
  2. Cristofori F, Thapar N, Saliakellis E, et al. Efficacy of the neurokinin-1 receptor antagonist aprepitant in children with cyclical vomiting syndrome. Aliment Pharmacol Ther 2014; 40:309.
  3. Hikita T, Kodama H, Kaneko S, et al. Sumatriptan as a treatment for cyclic vomiting syndrome: a clinical trial. Cephalalgia 2011; 31:504.
  4. Duquesnoy C, Mamet JP, Sumner D, Fuseau E. Comparative clinical pharmacokinetics of single doses of sumatriptan following subcutaneous, oral, rectal and intranasal administration. Eur J Pharmaceut Sci 1998; 6:99.
  5. Zhou W, Li J, Birmingham B, et al. Population pharmacokineteic analysis of zolmitriptan and its metabolite in adults and adolescents to support dose selection in children with migraine. J Clin Pharmacol 2017; 57:1258.
  6. McKeage K. Zolmitriptan nasal spray: a review in acute migraine in pediatric patients 12 years of age or older. Pediatr Drugs 2016; 18:75.
  7. FG Freitag, Director of Headache Medicine, Medical College of Wisconsin, Personal communication, 2019.

Adapted from: Li BU, Lefevre F, Chelimsky GG, et al. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition consensus statement on the diagnosis and management of cyclic vomiting syndrome. J Pediatr Gastroenterol Nutr 2008; 47:379.

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