To Your Good Health
DEAR DR. ROACH: I have read numerous articles regarding the use of marijuana but have not seen a reference to cannabinoid hyperemesis syndrome. This is a condition that was recently identified and is increasing in frequency due to legalization and potency. I would appreciate your thoughts on this syndrome. — D.L.
ANSWER: Cannabis use is indeed increasing, and one unusual side effect is the hyperemesis (literally, "too much vomiting") syndrome. This most often occurs in daily users of cannabis, usually after years of use. The vomiting tends to occur in cycles: nausea, abdominal pain and vomiting, which can be severe, occur without warning and last 24-48 hours. This is followed by a recovery phase lasting weeks or months, where people feel generally well. The diagnosis can be confused with cyclical vomiting syndrome, and the correct diagnosis is often missed for years.
Physicians sometimes fail to think of the diagnosis or have never learned of it — it was first described in 2004. Cannabis users are sometimes highly resistant to the idea that the cannabis is causing these symptoms, as they have often been using for years with no problems. Further, cannabinoids are sometimes used to relieve nausea, so the mechanism of cannabinoid hyperemesis syndrome is not understood. The patients I have seen with this syndrome — including one yesterday, coincidentally — often have had very extensive evaluations, such as CT scans and endoscopies.
One clue that points toward cannabinoid hyperemesis syndrome is that most people learn that taking a hot shower temporarily relieves symptoms, and they will take several hot showers or baths during the day.
During the acute phase, treatment is supportive care, sometimes including anti-nausea drugs. However, the long-term treatment is cannabis cessation. It may take months before it is clear that the symptoms have resolved with cannabis cessation. Unfortunately the risk of relapse is high if the patient returns to cannabis use.
DEAR DR. ROACH: I’m a 71-year-old male in reasonably good health. At a recent routine checkup, my primary-care physician suggested I consider taking Lipitor 10 mg. My total cholesterol is in the 150-160 mg/dL range, although my LDL is slightly elevated, and my HDL is slightly low and has been for many years. My usual blood pressure is 130/80, and I have never needed treatment. I have no heart disease or family history of heart disease, am not overweight, exercise regularly and eat a healthy diet.
The only reason my doctor gave me for recommending Lipitor was that I am over 70. He indicated it was up to me, and gave me the impression that, if it were him, he would probably opt not to take it. Is the need to take a statin indicated just based on age? I try to avoid taking medications unless it is clearly necessary. — C.L.
ANSWER: Statin drugs reduce the risk of developing a heart attack. The amount of risk they reduce depends on a person’s baseline risk. Although elevated cholesterol levels and blood pressure are risk factors, being 71 and male is your biggest risk factor.
According to validated calculator, your risk of having a heart attack or stroke in the next 10 years is about 19%. Note that your absence of family history, good diet and regular exercise, all important factors, are NOT considered by the calculator, so the 19% is probably an overestimate of the risk in your case. Treatment with a statin like atorvastatin (Lipitor) would be expected to reduce your risk by 3.5% to 4% over 10 years, to about 15%. Guidelines would clearly recommend a statin drug, such as Lipitor, and most would recommend a high dose, 40 mg or so, rather than the low dose your doctor has suggested. There is not a single decision that is right for everybody, and your preferences really do matter. If you don’t mind taking the medication, it would be a reasonable plan to try it.