Treating a CV episode with abortive therapy

Steve Wartenberg: Welcome back and thank you for joining our ongoing series on cyclic vomiting syndrome with Dr. V. I'm Steve Wartenberg, and this is Dr. Thangam Venkatesan. In our previous episode, Dr. V talked about prophylactic treatment, which is treatment and procedures that can reduce and prevent episodes.

In this episode, we'll look at what's called abortive treatment, which is treating a CVS episode once it has started. So what happens when inevitably someone does have one?

Thangam Venkatesan, MD: So many patients have what we call a prodrome, and CVS actually has four phases. So you have the prodromal phase and then you have the emetic phase and recovery phase, and then you go back to what we call an interepisodic phase.

So during the prodromal phase, you can actually take medications that can prevent an episode from progressing. We have something called Sumatriptan, which is also used in migraine, but we have found it to be effective in a CVS episode. We also have standard anti-emetics, anti-nausea, vomiting, medications that you can take and sometimes even over-the-counter medications to kind of sedate you a little bit.

So we ask the patient to take all of these medications and hopefully this will actually prevent the episode from progressing. So if somebody has say nausea or headache or they just feel bad and they know that an episode is going to happen, they can actually take these medications and stop it.

Steve Wartenberg: I find it interesting that a medication for migraines would help with CVS, and I am guessing that goes back to your information about how it's a disease of the brain and the gut interaction. Is that why a migraine medicine would work in some ways?

Thangam Venkatesan, MD: Well, yes. Actually, so the basic thing is CVS and migraine seem to be interconnected and there seems to be some overlap in pathophysiology. In fact, several patients with cyclic vomiting syndrome also have a family history of migraine or even a history of migraine headaches.

They might not have a migraine headache at the time of their CVS episode, but they can also have concurrent migraine headaches. And the other interesting thing is if you look at the pediatric population, about 70% of children who have cyclic vomiting syndrome actually outgrow their symptoms and they can develop migraine headaches as adults.

Steve Wartenberg: So they don't have CVS anymore, but they still have migraines?

Thangam Venkatesan, MD: Correct. It seems to morph into a migraine headache.

Steve Wartenberg: Are there triggers in someone's life that would make them more prone to have an episode that you can work on them with?

Thangam Venkatesan, MD: There are several triggers. One is stress is a huge trigger, and again, it's just negative stress. Negative stress can include, say, examinations. I have a lot of patients who are students and they're cramming or they're pulling all-nighters and then they finished the exam and they have a full-blown CVS episode.

I think it's important to have patients address these types of triggers. So if you had a student or if you had somebody who didn't have good sleep hygiene, you might want to tell them, hey, why don't you manage your time a little better and try to get at least eight hours of sleep regardless of what's going on in your life? So that's sleep deprivation is a trigger, and so that's something you can address.

The other thing, of course, is stress. And so sometimes there are positive stresses as well. So patients are very excited. Say they could be having a birthday or some kids actually have... There was this child who would have a CVS flare on his birthday. So it's really important to manage those triggers.

Steve Wartenberg: So in many ways when you talk to patients and work with them, it's adjusting their lifestyle to prevent and reduce these episodes.

Thangam Venkatesan, MD: Yeah, absolutely. So there are some easy things you can do like sleep hygiene, make sure you get eight hours of sleep and cell phones and social media, all of these interfere with your sleep patterns. So suddenly, there are some simple things that you can do.

Steve Wartenberg: I don't know because sleeping isn't simple for everyone, a lot of people struggle with that.

Thangam Venkatesan, MD: No, that is true. So I think it requires some discipline, it requires some work, and of course, there are some supplements that you can use and if it's really bad, then maybe you need to send them to an expert in sleep medicine.

Steve Wartenberg: Now, cannabis use is a topic connected with CVS, so does that create more episodes? How does that fit in or what do you tell patients?

Thangam Venkatesan, MD: One of the things about cannabis is that it's very important to distinguish between heavy use and occasional use. And really, the concentration of cannabis products has really dramatically changed over the last two decades.

Steve Wartenberg: Meaning they're more powerful?

Thangam Venkatesan, MD: Yes, exactly. They're very potent and using them every day really there is data to show or at least suggest that they make CVS worse and can lead to what we call hyperemesis.

Steve Wartenberg: Is there anything more about medication that you want to talk about?

Thangam Venkatesan, MD: Yeah, like I said, it's very important to really be able to tell your patient that there are certain things they can do, because I think the most stressful thing about CVS is that one, your episode is unpredictable, and if you don't give them tools to manage their CVS episodes, it's really something they can't control.

And so by giving them a toolbox and really tools to try and address this, not just with medications but with lifestyle modification, I think you give the patient a sense of control over how they can prevent and actually how they can treat their CVS episodes and these medications can be quite effective.

Steve Wartenberg: Okay. Another great episode. And again, can you summarize what people need to know or what to do once they have the warning signs of an episode?

Thangam Venkatesan, MD: Absolutely. So in a patient who has cyclic vomiting syndrome, whether it's mild, moderate to severe in general, providers should really give them medications or offer them medications in what we call abortive medication. So when you take an abortive medication, you can try and stop or prevent an episode from progressing.

So if you have nausea or so on and so forth, which is your first symptom, you really want to take the medications that your doctor gives you and try and prevent it. And so you can go on with your day and you won't be vomiting and so on and so forth.

Steve Wartenberg: These are medications people will have at home that have been prescribed, they don't have to go to the doctor to get them?

Thangam Venkatesan, MD: Well, some of them are prescribed and some are over-the-counter.

Steve Wartenberg: Oh, okay. But they can have them on their own. They don't need to go to the doctor or the ER to get them. They have them there. They have that peace of mind of knowing I could have it, now's the time to take it?

Thangam Venkatesan, MD: So these are abortive medications that they should take. The other thing is the Sumatriptan, I do want to emphasize is that you want to avoid the oral route if possible. So I actually have them take it intranasally so that it gets absorbed.

Steve Wartenberg: It's a spray type thing?

Thangam Venkatesan, MD: Yes, you get it as a spray. You also get it as an injection, a subcutaneous injection. And so you can use either, but a lot of patients seem to be quite comfortable with the spray, and it's also important to address triggers and really try to manage your CVS better.

Steve Wartenberg: And reduce stress.

Thangam Venkatesan, MD: And reduce stress, yes.

Steve Wartenberg: Okay. Thank you Dr. V for another great episode. And thank you for watching.

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