NICE Updates Guideline on Prescribing Cannabis-based Medicinal Products

Dawn O'Shea

March 25, 2021

The National Institute for Health and Care Excellence (NICE) has published updated guidance on prescribing cannabis-based medicinal products for people with intractable nausea and vomiting, chronic pain, spasticity and severe treatment-resistant epilepsy.

Intractable nausea and vomiting

  • Consider nabilone as an add-on treatment for adults (≥18 years) with chemotherapy-induced nausea and vomiting which persists despite optimised conventional antiemetics.

  • When considering nabilone, take into account potential adverse drug interactions.

Chronic pain

  • Do not offer the following for chronic pain in adults:

  • Do not offer CBD unless as part of a clinical trial.

  • Adults who started treatment for chronic pain before this guidance was first published (November 2019) should be able to continue until it is appropriate to stop.


  • Offer a four-week trial of THC:CBD spray for moderate-severe spasticity in multiple sclerosis (MS), if other pharmacological treatments are ineffective.

  • After the 4-week trial, continue THC:CBD spray after the trial if there is ≥20 per cent reduction in spasticity-related symptoms on a 0-10 patient-reported numeric rating scale.

Severe treatment-resistant epilepsy


  • Initial prescription of cannabis-based products must be made by a specialist medical practitioner, except for nabilone, THC:CBD spray (Sativex) and medicines not classed as controlled drugs, such as cannabidiol.

  • Subsequent prescriptions may be issued by another prescriber as part of a shared care agreement.

  • Efficacy and safety should be monitored and evaluated, and doses adjusted, if necessary, by the initiating prescriber.

  • A shared care agreement should include agreement on:

    • responsibilities of all parties;

    • nature and frequency of monitoring;

    • when treatment might be stopped;

    • how adverse events will be managed;

    • how communication will be managed between the initiating specialist prescriber, the other prescriber, the patient, family and/or carers;

    • how treatment will be funded; and

    • how care will be maintained when the patient, specialist prescriber or other prescriber moves location, including transition to adult services.

Factors to think about

  • When prescribing and monitoring, take into account:

    • current and past use of cannabis (including over-the-counter and online products);

    • history of substance misuse;

    • potential for dependence, diversion and misuse (in particular with THC);

    • mental health and medical history, in particular, liver impairment, renal impairment and cardiovascular disease; and

    • potential interaction with other medicines, e.g., central nervous system depressant, antiepileptics and hormonal contraceptives

  • Breastfeeding is contraindicated for Sativex and nabilone.

  • When prescribing for babies, children and young people, pay particular attention to the:

    • potential impact on psychological, emotional and cognitive development;

    • potential impact of sedation; and

    • potential impact on structural and functional brain development.

  • Record details of treatment, outcomes and adverse effects using local or national registers if available.

  • For more information on safe prescribing and the use of cannabis-based medicinal products, see the NICE guideline on controlled drugs.

Supporting shared decision-making

  • Discuss:

    • the potential benefits and harms, including any risk of dependence or interaction with other medicines;

    • the licensing status of the medicines;

    • duration of treatment;

    • time to effect;

    • what it has been prescribed for and how to take it;

    • how it may affect their ability to drive;

    • the need to seek advice before travelling abroad; and

    • the importance of not allowing others to use the medicine.

Research recommendations

  • The following were highlighted as areas that require further research:

    • Fibromyalgia or persistent treatment-resistant neuropathic pain in adults.

    • Chronic pain in children and young people.

    • CBD for severe treatment-resistant epilepsy.

    • THC in combination with CBD for severe treatment-resistant epilepsy.

    • Spasticity.

    • Chemotherapy-induced intractable nausea and vomiting in adults.

    • Chemotherapy-induced intractable nausea and vomiting in babies, children and young people.

    • Intractable nausea and vomiting not caused by chemotherapy in adults.

    • Intractable nausea and vomiting not caused by chemotherapy in babies, children and young people.

NICE has also issued a clarification on recommendations for the use of unlicensed cannabis-based products for severe treatment-resistant epilepsy. The clarification should be read alongside this guideline.

This article originally appeared on Univadis, part of the Medscape Professional Network.


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