How to prevent a cyclic vomiting episode with prophylactic therapy

Steve Wartenberg: Welcome back to our ongoing series on cyclic vomiting syndrome with Dr. V. I'm Steve Wartenberg, and this is Dr. Thangam Venkatesan. In past episodes, Dr. V has filled us in on the prevalence and impact of CVS and how it is diagnosed and sometimes misdiagnosed. Today, Dr. V will talk about treating CVS, and she'll do it in two parts. In this episode, we'll look at what's called prophylactic treatment, which is the treatment and procedures that can reduce and prevent episodes. In the next episode, Dr. V will discuss abortive treatment, which is treating a CVS episode once it's begun.

You led the team that created the guidelines for preventing episodes. Fill us in on how you did that, and then we'll go through the different steps that people can utilize to prevent an episode.

Thangam Venkatesan, MD: There was significant variation in how different physicians were treating patients with cyclic vomiting syndrome. Really to close that gap, I spearheaded the effort. We collaborated with the ANMS. That's the American Neurogastroenterology Motility Society, and also the Cyclic Vomiting Syndrome Association. We actually published the first-ever guidelines on the management of CVS in adults in 2019. This is what we call an open-access article. Really, anybody in the world can really go to your computer, and you can print it out. You should be able to know how to manage CVS.

Steve Wartenberg: What is in the guidelines? Start with... I'm not even sure, but there must be a step one.

Thangam Venkatesan, MD: When we really review all of the prophylactic medications and cyclic vomiting syndrome, we have certain classes of medications. The first class, and really the one that has the most amount of data is amitriptyline. It's a neuromodulator. It's also a tricyclic antidepressant.

Steve Wartenberg: When you say neuromodulator, what does that mean?

Thangam Venkatesan, MD: It really modulates the way your brain talks to your gut. There are various signals that go from your brain to the gut. CVS is what we call a DGBI. It's a disorder of gut-brain interaction. What the neuromodulator is doing is it's modulating the connection. By doing that, we can prevent CVS episodes.

Steve Wartenberg: What's the next area of medicines?

Thangam Venkatesan, MD: We do have another medication called topiramate that is also used in the prevention of cyclic vomiting syndrome. It's like a second-line agent. There is a newer medication. It's called aprepitant. It is an NK-I receptor antagonist. Aprepitant was actually developed for... It is an antiemetic. I want to make this very clear. It's not a cancer drug, but it is FDA-approved to prevent chemotherapy-induced nausea and vomiting. It's actually approved for chemotherapy-induced nausea and vomiting. It is not a cancer drug. I really-

Steve Wartenberg: Right. It's for a side effect of a cancer drug.

Thangam Venkatesan, MD: It's to treat a side effect of a cancer drug.

Steve Wartenberg: Chemotherapy.

Thangam Venkatesan, MD: Exactly.

Steve Wartenberg: And it can have some impact on CVS.

Thangam Venkatesan, MD: It does. While there are not what we call randomized prospective trials, we do have some studies. I myself did a study. It was actually very helpful in preventing CVS episodes in almost 70% of patients who actually didn't respond to other medicines. We looked at our data. We found that it was quite effective. The other nice thing is it really is very well tolerated in patients. Then, finally, we have some supplements that you can actually get over the counter. They call coenzyme-Q10 and riboflavin, which are also used in the prevention of CVS.

Steve Wartenberg: A lot of medicine is not an exact science. It's a bit of an art form. How do you determine which of these medications is going to work best for an individual patient?

Thangam Venkatesan, MD: Well, that's a very good question. Like I said, it really depends upon the patient profile. Say, there's somebody who comes in. I would try to start the first-line agent. That is amitriptyline, because, A, it's inexpensive. It's easily accessible, and it is effective in patients. However, if they develop side effects, if somebody says, "Oh, I've gained 40 pounds, and I can't go down this route," then we go to other medications. Like I said, there's a lot of work unfortunately that needs to be done in CVS. There's inadequate funding. We really need to develop newer therapies for cyclic vomiting syndrome. I'm hopeful that in the future we'll have better medications.

Steve Wartenberg: You've gone through all the medications. Is there anything that you recommend or the patients can do that doesn't involve medications that can be helpful?

Thangam Venkatesan, MD: It's very important to treat stress and anxiety, and so on. I can't emphasize enough about the mind-body connection. In fact, we did a study. We found that meditation can actually improve outcomes. It improves coping in patients with cyclic vomiting syndrome and improved their sleep and improved quality of life. These are also things that I really encourage patients to do in addition to taking a medicine.

Steve Wartenberg: Yeah. It's interesting how meditation and other stress-reducing exercises can help people in so many different ways to make their life better and reduce potential illness.

Thangam Venkatesan, MD: Yeah, absolutely. I think we really live in a society where there's so much of sensory bombardment if you will.

Steve Wartenberg: Oh, yes.

Thangam Venkatesan, MD: To quiet the mind down a little bit and really relax and help us manage that stress of daily life is very important, particularly in a condition like CVS.

Steve Wartenberg: Now, you obviously do not have CVS. But what do you do on a daily or regular basis to meditate or reduce stress?

Thangam Venkatesan, MD: I practice what is called heartfulness meditation. It's actually-

Steve Wartenberg: Heartfulness.

Thangam Venkatesan, MD: Heartfulness, like the heart.

Steve Wartenberg: Heart. Yeah.

Thangam Venkatesan, MD: At least the days I meditate, I feel very grounded. It helps me stay balanced. This is something I wanted to share really with the rest of the world and my patients. I said, why not? We did this study, which was very effective. Actually, now, we're conducting a study. We designed an app, and we are going to analyze our data pretty soon. I hope that we'll have an FDA-cleared app for this type of meditation and with scientific data backing it.

Steve Wartenberg: That was a great overview. As always, you're very good at summarizing, so summarize how people can prevent CVS.

Thangam Venkatesan, MD: Yeah. In a nutshell, cyclic vomiting syndrome can present either as mild disease or moderate to severe disease. We already spoke about how these CVS episodes can be so debilitating for patients. I think it's very important to really prevent these CVS episodes so that people can carry on with their lives. If you have moderate to severe CVS, the recommendation is that we start what is called prophylactic or preventive medications in these patients. We do have a few options. It's very important to learn how to administer these medications/get comfortable with these medications because there's actually data to show that even gastroenterologists are not comfortable prescribing some of these medications. I really do hope that people will download our guidelines and use it to treat these patients

Steve Wartenberg: Well, thank you for that great overview and information. Thank you for watching. Stay tuned for our next episode.
 
The Ohio State University Wexner Medical Center logo

For more information, visit wexnermedical.osu.edu/CVS