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.

Spasticity

  • 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

Prescribing

  • 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.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....