REBEL EM - January 07, 2021 - By Muhammad Durrani
Paper: Ruberto KH et al. Intravenous Haloperidol Versus Ondansetron for Cannabis Hyperemesis Syndrome (HaVOC): A Randomized, Controlled Trial. Ann Emerg Med. 2020. PMID: 33160719
"Clinical Question: Is haloperidol superior to ondansetron in the treatment of abdominal pain and nausea in adult emergency department patients with cannabis hyperemesis syndrome?
Author Conclusion: “In this clinical trial, haloperidol was superior to ondansetron for the acute treatment of cannabis-associated hyperemesis. The efficacy of haloperidol over ondansetron provides insight into the pathophysiology of this now common diagnosis in many EDs.”
Clinical Take Home Point: In this small randomized controlled trial of patients with cannabis hyperemesis syndrome, the use of haloperidol was associated with improvement in the rates of acute (less than 120 minutes) nausea and abdominal pain, shorter emergency departments length of stay, shorter time to discharge, and less use of rescue medications over the commonly used antiemetic ondansetron. The findings need to be interpreted in the context of inadequate sample size, narrow inclusion and exclusion criteria, as well as unpaired analysis due to low crossover rates.
The bottom line is that only cannabis cessation at this time appears to be the most effective treatment modality but supportive care with intravenous fluids, topical capsaicin cream, avoidance of narcotic medications, and the use of dopamine antagonists such as haloperidol (at a lower dose of 0.05mg/kg) are potentially promising adjunct modalities based on the level of evidence that we have to date."