title: High degree of efficacy in the treatment of cyclic vomiting syndrome with combined co-enzyme Q10, L-carnitine and amitriptyline, a case series.
abstract: BACKGROUND
  Cyclic vomiting syndrome (CVS), defined by recurrent stereotypical episodes of nausea and vomiting, is a relatively-common disabling and historically difficult-to-treat condition associated with migraine headache and mitochondrial dysfunction. Limited data suggests that the anti-migraine therapies amitriptyline and cyproheptadine, and the mitochondrial-targeted cofactors co-enzyme Q10 and L-carnitine, have efficacy in episode prophylaxis.
  
  
  METHODS
  A retrospective chart review of 42 patients seen by one clinician that met established CVS diagnostic criteria revealed 30 cases with available outcome data. Participants were treated on a loose protocol consisting of fasting avoidance, co-enzyme Q10 and L-carnitine, with the addition of amitriptyline (or cyproheptadine in those < 5 years) in refractory cases. Blood level monitoring of the therapeutic agents featured prominently in management.
  
  
  RESULTS
  Vomiting episodes resolved in 23 cases, and improved by > 75% and > 50% in three and one additional case respectively. Among the three treatment failures, two could not tolerate amitriptyline (as was also the case in the child with only > 50% efficacy) and one had multiple congenital gastrointestinal anomalies. Excluding the latter case, substantial efficacy (> 75% response) was 26/29 at the start of treatment, and 26/26 in those able to tolerate the regiment, including high dosages of amitriptyline.
  
  
  CONCLUSIONS
  Our data suggest that a protocol consisting of mitochondrial-targeted cofactors (co-enzyme Q10 and L-carnitine) plus amitriptyline (or possibly cyproheptadine in preschoolers) coupled with blood level monitoring is highly effective in the prevention of vomiting episodes.
authors.affiliation: Division of Medical Genetics and the Saban Research Institute, Children's Hospital Los Angeles, California, USA. rboles@chla.usc.edu
authors.forename: Richard G
authors.initials: RG
authors.lastname: Boles
mesh_terms: D000293:Adolescent; D018759:Adrenergic Uptake Inhibitors / Q000627:therapeutic use*; D000328:Adult; D000639:Amitriptyline / Q000627:therapeutic use*; D002331:Carnitine / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D004035:Diet Therapy; D005260:Female; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D014451:Ubiquinone / Q000031:analogs & derivatives* / Q000627:therapeutic use; D014815:Vitamins / Q000627:therapeutic use*; D014839:Vomiting / Q000178:diet therapy / Q000188:drug therapy*; D055815:Young Adult
chemical_list: D018759:Adrenergic Uptake Inhibitors; D014815:Vitamins; D014451:Ubiquinone; D000639:Amitriptyline; C024989:coenzyme Q10; D002331:Carnitine