Editorial: topiramate for cyclic vomiting syndrome—for refractory patients only?

This article is linked to Mooers et al papers. To view these articles, visit https://doi.org/10.1111/apt.16457 and https://doi.org/10.1111/apt.16516 Cyclic vomiting syndrome (CVS) an increasingly recognised disorder in adults. Tricyclic antidepressants (TCAs), particularly amitriptyline, are recommended as first-line prophylactic pharmacologic treatment.1 Topiramate alternate medication along with aprepitant, zonisamide, levetiracetam.1 Newer remedies like ramosetron2 ketamine3 have also been proposed. Notably, however, there a paucity of studies support the use medications for CVS. In their retrospective review 141 patients CVS who were treated topiramate, al4 found that topiramate led significant reduction annual number episodes, emergency department visits hospitalisations. Based on authors' criteria, 65% responders. The authors suggested target dose 150 mg/day, noting responders achieved higher daily experienced fewer side effects. A history anxiety predicted poor response topiramate. key question from this study whether may role agent. Indeed, noted high prevalence refractory disease among they studied probably lower rate Even proportion had previously failed TCAs, similar reported TCAs adults (partial 57%-93% complete remission 18%-43%).5-7 Although direct comparison not possible, suggests be very effective treatment-naïve patients. Its main disadvantage effects 55% patients, 32% discontinuing result. While common when using treat CVS,8 treatment discontinuation was than TCAs. Given it will remain those moderate-to-severe Future evaluate serve comorbid conditions commonly by (eg, migraine, obesity). study, personal or family migraine (noted over 60% participants) associated significantly increased likelihood has cited predictor non-response TCAs.9 relied chart rather validated survey instrument. Additionally, most concomitant prophylaxis (including nearly 50% TCAs), making difficult isolate effect Nonetheless, advances existing knowledge, largest date demonstrating effectiveness adult results reinforce current guideline recommendations appropriate further delineate exact treatment. Declaration interest: None. received no funding study. No writing assistance utilised.