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This summary only covers key recommendations in primary care. Please refer to the full guideline for a complete set of recommendations.

1.1 Intractable nausea and vomiting

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

1.1.2 When considering nabilone for adults with chemotherapy-induced nausea and vomiting, take into account potential adverse drug interactions, for example, with central nervous system depressants and other centrally active drugs.

1.2 Chronic pain

1.2.1 Do not offer the following to manage chronic pain in adults:

  • nabilone

  • dronabinol

  • THC (delta-9-tetrahydrocannabinol)

  • a combination of cannabidiol (CBD) with THC.

1.2.2 Do not offer CBD to manage chronic pain in adults unless as part of a clinical trial.

1.2.3 Adults who started cannabis-based medicinal products to manage chronic pain in the NHS before this guidance was published[1] should be able to continue treatment until they and their NHS clinician think it appropriate to stop.

1.3 Spasticity

1.3.1 Offer a 4-week trial of THC:CBD spray to treat moderate to severe spasticity in adults with multiple sclerosis, if:

  • other pharmacological treatments for spasticity are not effective (see the recommendations on spasticity in NICE’s guideline on multiple sclerosis in adults)

  • the company provides THC:CBD spray according to its pay-for-responders scheme[2].

    After the 4-week trial, continue THC:CBD spray if the person has had at least a 20% reduction in spasticity-related symptoms on a 0 to 10 patient-reported numeric rating scale.

1.3.2 Treatment with THC:CBD spray should be initiated and supervised by a physician with specialist expertise in treating spasticity due to multiple sclerosis, in line with its marketing authorisation.

1.4 Severe treatment-resistant epilepsy

NICE has made research recommendations on the use of cannabis-based medicinal products for severe treatment-resistant epilepsy.

NICE has published technology appraisal guidance on cannabidiol with clobazam for treating seizures associated with Lennox-Gastaut syndrome and Dravet syndrome.

1.5 Prescribing

Who should prescribe?

1.5.1 Initial prescription of cannabis-based medicinal products[3] must be made by a specialist medical practitioner (a doctor included in the register of specialist medical practitioners [the Specialist Register][4]). They should also have a special interest in the condition being treated[5]. For children and young people under the care of paediatric services, the initiating prescriber should also be a tertiary paediatric specialist.

Factors to think about when prescribing

1.5.5 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[6].

1.5.6 When prescribing cannabis-based medicinal products for babies, children and young people, pay particular attention to the:

  • potential impact on psychological, emotional and cognitive development

  • potential impact of sedation

  • potential impact on structural and functional brain development.

1.5.7 When prescribing cannabis-based medicinal products, advise people to stop any non-prescribed cannabis, including over-the-counter, online and illicit products.

1.5.8 Prescribers should record details of treatment, clinical outcomes and adverse effects for people prescribed cannabis-based medicinal products, using local or national registers if available.

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

Footnotes

[1] November 2019.

[2] According to the terms of the pay-for-responders scheme, the company will fund the first 3 x10-ml vials of THC:CBD spray if there is an agreement for continued funding for people who experience at least a 20% reduction in spasticity-related symptoms on a 0 to 10 patient-reported numeric rating scale after 4 weeks of treatment.

[3] This excludes nabilone, THC:CBD spray (Sativex) and cannabis-based medicines that are not classed as controlled drugs such as cannabidiol. See the relevant summaries of product characteristics for further information on prescribing. See recommendation 1.3.2 for information on prescribing of THC:CBD spray.

[4] See section 34D of the Medical Act 1983.

[5] See the GMC’s information for doctors on cannabis-based products for medicinal use.

[6] Breastfeeding is a contraindication for Sativex and nabilone. There is limited evidence on the safety of cannabis-based medicinal products during pregnancy and breastfeeding.

© NICE 2019. Cannabis-based medicinal products. Available from: www.nice.org.uk/guidance/ng144. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. 

Published November 2019.

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