NICE has published new guidance on cannabis-based medicinal products for people with intractable nausea and vomiting, chronic pain, spasticity and severe treatment-resistant epilepsy.
It recommends nabilone as an add-on treatment for adults (18 years and over) with chemotherapy-induced nausea and vomiting which persists with optimised conventional antiemetics. Potential adverse drug interactions should be taken into account such as with central nervous system depressants and other centrally active drugs.
For chronic pain, nabilone, dronabinol, THC (delta-9-tetrahydrocannabinol) and a combination of cannabidiol (CBD) with THC are not recommended unless as part of a clinical trial.
Adults who started cannabis-based medicinal products to manage chronic pain in the NHS before this guidance was published should be able to continue treatment until they and their NHS clinician think it appropriate to stop.
A 4-week trial of THC:CBD spray to treat moderate to severe spasticity in adults with multiple sclerosis can be offered if other pharmacological treatments for spasticity are not effective or if the company provides THC:CBD spray according to its pay-for-responders scheme.
After the 4-week trial,THC:CBD spray can be continued if the person has had at least a 20% reduction in spasticity-related symptoms on a 0 to 10 patient-reported numeric rating scale. Treatment should be initiated and supervised by a physician with specialist expertise in treating spasticity due to multiple sclerosis, in line with its marketing authorisation.
NICE has made research recommendations on the use of cannabis-based medicinal products for severe treatment-resistant epilepsy and is developing technology appraisal guidance on cannabidiol with clobazam for treating seizures associated with Lennox-Gastaut syndrome and Dravet syndrome.
Who can prescribe cannabis-based medicinal products?
The guidance states that initial prescription of cannabis-based medicinal products must be made by a specialist medical practitioner (a doctor included in the register of specialist medical practitioners [the Specialist Register]). They should also have a special interest in the condition being treated. For children and young people under the care of paediatric services, the initiating prescriber should also be a tertiary paediatric specialist.
After the initial prescription, subsequent prescriptions of cannabis-based medicinal products may be issued by another prescriber as part of a shared care agreement under the direction of the initiating specialist prescriber, if:
shared care is appropriate and in the person's best interest
the person's clinical condition is stable
the other prescriber is confident to make a fully informed prescribing decision about cannabis-based medicinal products.
When prescribing and monitoring cannabis-based medicinal products, take into account:
current and past use of cannabis (including any over-the-counter and online products)
history of substance misuse including the illicit use of cannabis
potential for dependence, diversion and misuse (in particular with THC)
mental health and medical history, in particular, liver impairment, renal impairment, cardiovascular disease
potential for interaction with other medicines, for example, central nervous system depressants and other centrally active drugs, antiepileptics and hormonal contraceptives
pregnancy and breastfeeding.