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Chemotherapy-induced Nausea and Vomiting (CINV)

MEDICAL CANNABIS AS A TREATMENT OPTION

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:

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:

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:

“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.

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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