Children 2 to 5 years old |
Antihistamines – Cyproheptadine (first choice) |
Dosing – 0.25 to 0.5 mg/kg/day orally divided into 2 or 3 daily doses, or given once daily at night to reduce daytime sedation (maximum of 12 mg per 24 hours). Available in 4 mg tablets and a 2 mg/5 mL syrup. |
Side effects – Increased appetite, weight gain, sedation, dry mouth, constipation, urinary retention; may also cause paradoxical excitation in young children. |
Alternatives – Pizotifen (available in United Kingdom and Canada). |
Beta blockers – Propranolol (second choice) |
Dosing – 0.25 to 1 mg/kg/day orally divided into 2 or 3 daily doses, most often 10 mg 2 or 3 times daily. Initiate at 0.25 mg/kg/day and increase every 1 to 4 weeks in increments of 5 or 10 mg as needed and tolerated. Maximum dose 80 mg per 24 hours. Available in tablet and liquid forms in various strengths and concentrations. |
Monitoring – Monitor and maintain resting heart rate ≥60 bpm. |
Side effects – Lethargy, reduced exercise tolerance, hypoglycemia, bradycardia, bronchospasm, hypotension, night terrors. |
Contraindications – Asthma, diabetes, heart disease. |
Discontinuation – Do not stop abruptly, must be tapered over 1 to 2 weeks. |
Children older than 5 years and adults |
Tricyclic antidepressants – Amitriptyline (first choice) |
Dosing:
|
Monitoring – Check ECG QTc interval before starting, during titration and after the target dose is reached. QTc interval should be maintained <460 msec for children, <470 msec for adult women, and <450 msec in adult men[1]. |
Side effects – Constipation, sedation, weight gain, dry mouth, arrhythmia, behavioral changes (especially in young children). |
Discontinuation – Gradually taper dose to minimize the incidence of withdrawal. |
Alternatives – Nortriptyline¶ (available in 10 mg/5 mL liquid). |
Beta blockers – Propranolol (second choice for children; not generally used for cyclic vomiting syndrome in adults) – Refer to section on younger children above for dosing. |
Formulation consideration – For adolescents, may use the extended-release form of propranolol (for once-daily dosing), after titration to a minimum daily dose of 60 mg. |
NK1 receptor antagonist – Aprepitant[1,2] |
Dosing for prophylaxis:Δ
|
Side effects – Hiccups, lethargy/fatigue, headache. |
Drug-drug interactions – Significant inhibitors and inducers of CYP3A4 increase and decrease levels of aprepitant, respectively, and should be avoided if possible. |
Other agents – For children older than 5 years and adults |
Antiseizure medications – Phenobarbital◊ (used primarily for children) |
Dosing – 2 mg/kg/day orally, administered at bedtime. Maximum dose 80 mg per 24 hours. |
Side effects – Sedation, cognitive impairment. |
Alternative antiseizure medications |
Topiramate |
Dosing:
|
Others – Levetiracetam and zonisamide (primarily in adults). |
Supplementsפ (used primarily in children, but also suggested as a consideration for adults[1]) |
Coenzyme Q10 |
Dosing:
|
Side effects: diarrhea. |
L-carnitine |
Dosing:
|
Side effects: diarrhea, fishy body odor. |
Riboflavin |
Dosing:
|
ECG: electrocardiogram; NK1: neurokinin 1.
* All medication recommendations are made for off-label use.
¶ Nortriptyline, a less sedating alternative to amitriptyline, has also been successfully used in adults and children with cyclic vomiting syndrome, based on clinical experience and very limited published evidence. Starting and target doses for nortriptyline are similar to those of amitriptyline. For both amitriptyline and nortriptyline, the effects typically take 1 to 2 months to become fully evident once the target dose is reached.
Δ Aprepitant has also been used for abortive therapy. For abortive dosing, refer to UpToDate table on supportive and abortive therapy for cyclic vomiting syndrome.
◊ Limited or no published experience regarding efficacy.
§ For children with cyclic vomiting syndrome, UpToDate authors suggest a trial of adjunctive treatment with coenzyme Q10 and/or L-carnitine and riboflavin, in addition to the first- or second-line therapies described above.Adapted from: Li BU, Lefevre F, Chelimsky GG, et al. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition consensus statement on the diagnosis and management of cyclic vomiting syndrome. J Pediatr Gastroenterol Nutr 2008; 47:379.
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