Cyclic Vomiting Syndrome In Adults Research Articles

Zonisamide or Levetiracetam for Adults With Cyclic Vomiting Syndrome: A Case Series

Management of cyclic vomiting syndrome in adults is limited by the small number of effective medications for maintenance therapy. The clinical response to treatment with 2 newer antiepileptic drugs was evaluated retrospectively to see whether they might have a prophylactic role in this syndrome. Outpatient records from 20 adult patients with cyclic vomiting syndrome attending a university-based practice were reviewed. Each had received zonisamide (median dose, 400 mg/d) or levetiracetam (median dose, 1000 mg/d) because tricyclic antidepressants alone were unsatisfactory as maintenance medications. Outcome was graded from chart review and directed interview; characteristics of the vomiting episodes were compared before and after initiation of antiepileptic drug therapy. At least moderate clinical response was described by 15 (75.0%) subjects, and 4 of these (20.0% of the total) reported symptomatic remission during 9.5 +/- 1.8 months of follow-up. Rate of vomiting episodes decreased from 1.3 +/- 0.3 to 0.5 +/- 0.2 per month (P = .01). Tricyclic antidepressants were discontinued in 11 (61.1%) of the 18 subjects who were still taking the medications when antiepileptic drug therapy was initiated. Moderate or severe side effects were reported by 45.0%, but by switching drugs, intolerance to antiepileptic drug therapy occurred in only 1 subject. Newer antiepileptic drugs, specifically zonisamide and levetiracetam, appeared beneficial as maintenance medications for nearly three fourths of adults with cyclic vomiting syndrome in this uncontrolled clinical experience. Although side effects occur in a large proportion of subjects, newer antiepileptic drugs might offer an alternative for patients who fail conventional treatment.

Clinical, Psychiatric, and Manometric Profile of Cyclic Vomiting Syndrome in Adults and Response to Tricyclic Therapy

Purpose: Our goal was to prospectively investigate 31 adult patients (mean age 29 years, range 18–62) meeting Rome II criteria for cyclic vomiting syndrome (CVS). Methods: All subjects completed a clinical questionnaire, Hamilton Rating Scale for Anxiety (HAM-A) and Zung Depression inventory. Gastric emptying time (GET) was assessed in 30 subjects and electrogastrogram (EGG) in 11 between acute attacks. 27 patients treated with Amitriptyline at a goal dose of 1 mg/kg per day completed a follow up questionnaire, which included global assessment of symptom status and quality of life score. Results: The mean age of onset of CVS was 29, range 14–53 years and cycles of nausea and vomiting were accompanied by severe epigastric and diffuse abdominal pain. A typical attack ranged from 1 to 14 days with majority being 4–6 days. The HAM-A revealed that 84% had an anxiety disorder and based on Zung Depression inventory 78% suffered from mild to severe depression. Only 4 (13%) patients reported migraine, but 14 had a family history of migraine. GET was rapid in 23 (77%), normal in 4 and delayed in 3. The EGG was abnormal in 7 of 11 patients with 4 having tachygastria. Of 13 patients using marijuana, 7 believed it was therapeutic while 2 had resolution of CVS after stopping use. For acute attacks IV lorazepam was the most effective in our clinical experience. For long-term prevention patients were treated with Amitriptyline with a target dose of 1 mg/kg and 15 patients achieved 75 mg/day (range: 50–150 mg) for 16.8 months (range: 12–24 months). The average number of ER visits and hospitalizations were significantly diminished from 27 to 6 when annually adjusted. 26% achieved full remission and 93% had a favorable response. The major side effect of amitriptyline was hypersomnia and dizziness that caused two subjects to stop the treatment. Conclusions: This large single center experience of CVS in adults has the following hallmarks: 1) Prominence of abdominal pain and increased prevalence of anxiety and depression. 2) Rapid gastric emptying and tachygastric EGG findings. 3) Successful suppression of attacks can be achieved by long-term high dose amitriptyline therapy.

Cyclic Vomiting Syndrome in Adults

Cyclic Vomiting Syndrome in Adults

Cyclic vomiting syndrome in adults: clinical features and response to tricyclic antidepressants

OBJECTIVE: Cyclic vomiting syndrome (CVS) has been described infrequently in adults, and treatment in both children and adults remains unsatisfactory. We report clinical features of a group of adults with CVS and anecdotal outcome from open-label treatment with tricyclic antidepressants, medications that have some efficacy in other unexplained gastrointestinal disorders. METHODS: Clinical data were examined from 17 adult patients with CVS seen over a 10-yr period, each having been treated with a tricyclic antidepressant. Outpatient records were reviewed, clinical outcome was extracted using a priori criteria, and findings were compared with 37 patients having usual functional nausea and vomiting who also received tricyclic antidepressant therapy. RESULTS: Symptoms in CVS began at age 35 yr (range 14–73 yr); the average episode length was 6 days (range 1–21 days) and the symptom-free interval averaged 3.1 months (range 0.5–6 months). Vomiting cycles typically began without warning, and fewer than one-third of the subjects reported a prodrome or potential trigger event, such as menstrual periods, pregnancy, or large meals. Sleep was seemingly beneficial in 23.5%. Tricyclic antidepressant therapy was associated with complete remission in 17.6% and partial response in 58.8%, but was less effective than for functional nausea and vomiting ( p = 0.02). CONCLUSIONS: CVS is a rare diagnosis with distinctive features in adults. Duration of episodes and cycles varies considerably across subjects. In open-label, uncontrolled use, tricyclic antidepressants appear beneficial for some subjects but are less effective in CVS than in chronic, persistent functional nausea and vomiting.

Cyclic vomiting syndrome in adults: clinical features and response to tricyclic antidepressants.

Cyclic vomiting syndrome (CVS) has been described infrequently in adults, and treatment in both children and adults remains unsatisfactory. We report clinical features of a group of adults with CVS and anecdotal outcome from open-label treatment with tricyclic antidepressants, medications that have some efficacy in other unexplained gastrointestinal disorders. Clinical data were examined from 17 adult patients with CVS seen over a 10-yr period, each having been treated with a tricyclic antidepressant. Outpatient records were reviewed, clinical outcome was extracted using a priori criteria, and findings were compared with 37 patients having usual functional nausea and vomiting who also received tricyclic antidepressant therapy. Symptoms in CVS began at age 35 yr (range 14-73 yr); the average episode length was 6 days (range 1-21 days) and the symptom-free interval averaged 3.1 months (range 0.5-6 months). Vomiting cycles typically began without warning, and fewer than one-third of the subjects reported a prodrome or potential trigger event, such as menstrual periods, pregnancy, or large meals. Sleep was seemingly beneficial in 23.5%. Tricyclic antidepressant therapy was associated with complete remission in 17.6% and partial response in 58.8%, but was less effective than for functional nausea and vomiting (p = 0.02). CVS is a rare diagnosis with distinctive features in adults. Duration of episodes and cycles varies considerably across subjects. In open-label, uncontrolled use, tricyclic antidepressants appear beneficial for some subjects but are less effective in CVS than in chronic, persistent functional nausea and vomiting.