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Chemotherapy-induced Nausea and Vomiting (CINV)
MEDICAL CANNABIS AS A TREATMENT OPTION
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Overview
Managing CINV
Chemotherapy-induced nausea and vomiting is one of the most distressing side effects for
patients with cancer. It is equally a challenging symptom for doctors to manage, as the
stimulus for nausea is broad and can be caused by irritation at any point in the gastrointestinal
tract, toxic load due to renal or hepatic impairment, chemical imbalance, circulating toxins,
cerebral irritation, vestibular changes and emotional distress. Treatment is often suboptimal,
with many patients still experiencing sustained nausea even if antiemetic therapy successfully
halts or reduces vomiting.1
Persistent vomiting or nausea can interfere with cancer treatment if it is not well managed,
through severe dehyrdration, nutritional deficiency and weight loss, tearing of the oesophagus
or surgical wounds, or patient withdrawal.2
Reviewing the patient with persistent CINV
Consider:
- Clinical review – cough, reflux, anxiety, pain, psychological distress
- Medication review – NSAIDs and others may contribute to nausea
- Lifestyle measures – small plain meals, regular antiemetic adherence, bowel management
- Further investigations – rule out complications of advanced malignancy (bowel obstruction, hypercalcaemia).
Medicinal cannabis in the management of nausea and vomiting
Medicinal cannabis preparations are developed specifically to harness the therapeutic
properties of cannabinoids as adjunct therapy to manage a range of distressing symptoms and
conditions.
Cannabis-based medicines are thought to interfere with nervous system signals, at the
endocannabinoid (CB1) and serotonin (5-HT1A) receptors. The two main phytocannnabinoids
found in the cannabis plant – tetrahydrocannabinol (THC) and cannabidiol (CBD) – are both
antiemetic. The TGA have developed guidelines recommending that high-THC medicinal
cannabis products can be effective for nausea and vomiting.3
THC works on the CB1 receptors and also helps to stimulate appetite. CBD appears to work on
serotonin and CB2 receptors.
Patients can access treatment under prescriber authority through the Special Access Scheme
(SAS), through Authority Prescription, or by taking part in a clinical trial.
What are the therapeutic benefits?
The patient may experience:
- Improved control of nausea and/or vomiting
- Increased or improved appetite
- Fewer side effects than with alternative antiemetic therapy.
- Improved general sense of wellness and improved management of other symptoms including pain
Is it right for my patient?
If antiemetic treatments for managing CINV have been tried and are not successful, medicinal
cannabis products can provide relief from distressing symptoms.
Suitable patients include:
- Any patient experiencing ongoing nausea and/or vomiting using antiemetics
- Any patient experiencing increase in side effects with multiple antiemetics
- Those with concomitant pain or anxiety
- Patients contraindicated to common antiemetics such as haloperidol, metoclopramide and promethazine
- Patients with diabetes who require augmentation of standard antiemetic therapy with dexamethasone, leading to resultant hyperglycaemia
- Patients who respond only to restricted medications such as ondansetron but are no longer under the care of an oncologist.
“Start low, and go slow”
Dosage and administration
Dosage and recommended starting dose are not fixed, and data is not yet available on dose- response in the treatment of nausea and vomiting.
- Titrate doses until a therapeutic response is achieved
- Correct dose is the lowest that produces therapeutic benefit without associated adverse events (AEs)
Possible adverse effects
Patients and prescribing doctors should be aware of possible adverse effects, such as
somnolence, sleepiness, dizziness, euphoria or gastro-intestinal disturbance.
Adverse events of medicinal cannabis relate primarily to THC (tetrahydrocannabinol), whose
total daily dose-equivalent should generally be limited to 30 mg/day or less. Cannabidiol (CBD)
is less potent and may require higher doses to experience adjunctive benefits.4
Patients must be counselled on the need to only use medicinal cannabis, to enable dose
management and optimal titration. They should be counselled on driving laws in Australia if
they are taking any medication containing THC.
References
1. Matti Aapro; CINV: Still troubling patients after all these years. Supportive Care Cancer. 2018;26(Suppl 1): 5-9.
2. Rao KV, Faso A. Chemotherapy-induced nausea and vomiting: optimizing prevention and
management. Am Health Drug Benefits. 2012;5(4):232‐240.
3. Australian Government Department of Health, Therapeutic Goods Administration. Guidance for the use of
medicinal cannabis for the prevention or management of nausea and vomiting in Australia. Version 1, December
2017. Available at: https://www.tga.gov.au/sites/default/files/guidance-use-medicinal-cannabis-prevention-or-
management-nausea-and-vomiting-australia.pdf
4. MacCallum, C, Russo, E, Practical considerations in medical cannabis administration and dosing. Eur J Intern Med.
2018; 49:12-19.
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