Treatment

Current treatment for CVS can be divided into supportive (during episodes), prophylactic (to prevent episodes) (Table 20.6) and abortive therapy (to stop episodes) (Table 20.7). Other strategies for management of CVS include avoidance of identified triggers (e.g. dietary cheese),

INITIAL I-VALUATION Ol- RECURRENT VOMITINO l> EPISODES OF EMESIS - ABDOMINAL PAIN/3 MONTHS)

CHRONIC PATTERN CYCLIC PATTERN
  1. Frequent episodes 2/week) of vomit ing
  2. Mild vomiting << 4Vh ut peak) or abdominal pain Ì. May not be completely well in between episodes 4. Non-stereotypical episodes
  1. Infrequent discrete episodes (S 2/week) of vomiting - usually l-2/month
  2. Severe vomiting (> 4/h at peak) ± abdominal pain that lasts lor hours (o days
  3. Intervals of normul health or baseline between episodes
  4. Stereotypical as (o time of onset, episode duration, symptoms
  5. Often pale, listless, unable to walk or talk

DIAGNOSTIC EVALUATION

RULE OUT ORGANIC CAUSES CYCUC PATTERN t 1

+ RUQ PAIN

Algorithm Treatment Sumatriptan
Figure 20.2 Algorithm for diagnostic evaluation and acute management of recurrent (chronic and cyclic) vomiting.

Table 20.6 Prophylactic therapy

Drug

Side-effects

Anti-migraine

Amitryptyline (1-2 mg/kg per day) qhs

sedation, anticholinergic

Propranalol (0.5-1 mg/kg per day) bid or tid

hypotension, bradycardia, fatigue

Cyproheptadine (0.25-0.5 mg/kg per day) bid or tid

sedation, weight gain, anticholinergic

Anticonvulsants

Phenobarbital (2-3mg/kg per day) qd or bid

sedation

Valproate (500-1000mg ER qhs)

somnolence, hepatotoxicity

Carbamezapine (5-10mg/kg per day) bid

sedation, anticholinergic

Prokinetic

Erythromycin (10-20mg/kg per day) qid

gastric cramps in larger doses

Birth control

Norethindrone (1.5mg) ethinylestradiol (20-30 |ig) qd

estrogen-related, nausea, abdominal pain

qhs, at bed-time: bid, twice a day; tid, three times a day; qd, every day

Table 20.7 Abortive therapy

Drug

Side-effects

Anti-migraine

Sumatriptan 20 mg NAS and may repeat x1 or 25 mg po x1 Frovatriptan 2.5 mg po and may repeat x1 Rizatriptan 5-10 mg po x1, may repeat q 2h Ketorolac 0.5-1 mg/kg per dose q 6h iv/po

chest and neck burning (po form), headache coronary vasospasm, dizziness arrythmias, chest pain GI bleeding, dyspepsia

Antiemetic

Ondansetron 0.3-0.4 mg/kg per dose q 4-6h iv/po Granisetron 10|jg/kg iv q 4-6h

headache, drowsiness, dry mouth pancytopenia, headache

Sedative

Lorazepam 0.05-0.1 mg/kg per dose q 6 h iv/po

(useful adjunct to ondansetron) Chlorpromazine 0.5-1 mg/kg per dose q 6h iv/po Diphenhydramine 1.25mg/kg per dose q 6h iv/po (useful adjunct to chlorpromazine)

sedation, respiratory depression drowsiness, hypotension, seizures hypotension, sedation, dizziness

NAS, intranasally ; po, orally; q, every; iv, intravenous; GI, gastrointestinal

psychological interventions (e.g. stress management) and supportive care during attacks when all else fails.40 Avoidance of known triggers, especially dietary, can reduce the episode frequency. In some cases, stress management strategies through the aid of a psychologist can attenuate the effects of positive or negative stressors.41

Daily use of prophylactic medications is based on empiric therapy that is traditionally used to treat other disorders, including migraines, epilepsy, gastrointestinal dysmotility and birth control. Although there are no evidence-based guidelines, we generally consider prophylaxis in children who have either frequent episodes, e.g. more than one episode per month, or severe episodes (prolonged for more than 3-5 days), debilitating (associated with hospitalization) or disabling (e.g. missing school days).2 The goal of prophylaxis is to prevent attacks altogether, and if unsuccessful to at least to reduce the frequency, duration or intensity (number of emeses) of episodes.

A family history of migraines is a strong indicator (79%) of a positive response to anti-migraine therapy.5 In addition, associated symptoms of headache, photophobia and phonophobia should make one consider starting anti-migraine prophylaxis with propranolol, cyproheptadine, or amitriptyline with respective efficacy (more than 50% reduction in frequency or severity of episodes) rates of 52%, 39% and 67%, respectively, based on our data. Propranolol is contraindicated in asthmatics, has side-effects of tiredness and can be monitored by a resting pulse decline of 15-20 beats/min. Cyproheptadine can cause tiredness and an increase in appetite and weight.4 Pizotifen, available in Europe, Canada and Australia, acts similarly but with fewer side-effects.42 Amitriptyline has been the most effective prophylactic agent in our experience, but it can cause arrhythmias, especially in those with a prolonged QTc interval.43 Based on current recommendations, prior to starting amitriptyline, we evaluate all candidate patients by checking their QTc interval on electrocardiogram.

Other prophylactic agents that have been used include phenobarbital, valproate, gabapentin and carbamazepine.44 Although they are specifically indicated when spike and waves are noted on the electroencephalogram, they are increasingly used in both migraine and CVS prophylaxis. Erythromycin has been useful as a prokinetic agent34 and low-dose estrogen birth control can be useful in teenage girls who have catemenial CVS. We also note that the efficacy rates in the open-label trials above must be interpreted cautiously, because of the large placebo effect (70%) that has been described from consultation alone prior to instituting therapy.

Abortive therapy is medication taken at the onset of an episode or even earlier during the prodromal phase, ideally to abort the episode altogether or reduce the duration or severity of the episode. Abortive therapy should be considered for those who have sporadic episodes that occur less than once per month and who prefer not taking prophylaxis or those who have breakthrough episodes while on prophylaxis.2,40 Because patients with intractable emesis are unable to tolerate oral medication, these medications usually have to be administered parenterally.

The primary anti-migraine therapy includes 5-HT1B/1D agonists commonly used for migraine headaches. In our experience, success rates are higher in those children with migraine-associated CVS, when used early in the episode, and in those with episodes less than 24 h. In our patients, sumatriptan administered via oral, subcutaneous or intranasal routes has a 51% efficacy rate, as compared with 65% in headaches. The sensation of substernal and neck burning rarely occurs with intranasal administration.

Supportive care is used whenever the child is in a break-through episode that fails to respond to abortive therapy. Supportive care includes intravenous fluids, non-stimulating environment, antiemetics, sedation and analgesia.2,40 Intravenous fluids with high dextrose concentration (10%) and electrolytes have a 42% efficacy alone in our experience. A quiet, dark single room may be helpful. Analgesia is not routinely used in our experience but occasionally can include narcotic agents.

Ondansetron, a 5-HT3 antagonist, is primarily used as an antiemetic with efficacy rates around 62%.45 More effective at the higher dosing of 0.3-0.4mg/kg per dose, the side-effect profile has been excellent with few reports of drowsiness, dry mouth and headache.10 It generally reduces both nausea and vomiting, but only rarely aborts the episode. The addition of a y-aminobutyric acid (GABA) inhibitor, lorazepam, provides sedation that relieves intractable nausea. When all else fails, we use a combination of chlorpromazine and diphenhydramine primarily to provide sleep for relief from symptoms. In our experience, phenothiazine antiemetics (D2 antagonists), have poor (15%) efficacy in this disorder, even less than our placebo responses, suggesting that dopamin-ergic pathways are not involved.

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