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Overview 

This Guidelines summary covers:

  • the prescribing of cannabis-based medicinal products for people with:
    • intractable nausea and vomiting
    • chronic pain
    • spasticity
    • severe treatment-resistant epilepsy
  • factors to think about when prescribing cannabis-based medicinal products. 

In March 2021, NICE produced a statement clarifying recommendations on unlicensed cannabis-based medicinal products for severe treatment-resistant epilepsy, which should be read alongside the recommendations in this guideline.

Read the related Guidelines in Practice article: Key learning points: NICE cannabis-based medicinal products.

Intractable nausea and vomiting

  • 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.
  • 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.

Chronic pain

  • Do not offer the following to manage chronic pain in adults:
    • nabilone
    • dronabinol
    • THC (delta-9-tetrahydrocannabinol)
    • a combination of cannabidiol (CBD) with THC.
  • Do not offer CBD to manage chronic pain in adults 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 (November 2019) should be able to continue treatment until they and their NHS clinician think it appropriate to stop.

Spasticity

  • 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 (it funds the first 3x10-ml vials if there is agreement for continued funding for people with at least a 20% reduction in spasticity-related symptoms on a 0 to 10 patient-reported numeric rating scale after 4 weeks).
    • 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.
  • 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.

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.

Prescribing

Who should prescribe?

  • Initial prescription of cannabis-based medicinal products (excluding nabilone, THC:CBD spray [Sativex] and medicines not classed as controlled drugs such as cannabidiol) must be made by a specialist medical practitioner (a doctor included in the register of specialist medical practitioners [the Specialist Register], see section 34D of the Medical Act 1983). They should also have a special interest in the condition being treated (see the GMC’s information for doctors on cannabis-based products for medicinal use). 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

  • 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 (breastfeeding is a contraindication for Sativex and nabilone; there is limited evidence on the safety of cannabis-based medicinal products during pregnancy and breastfeeding).
  • 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.

NICE has produced a guideline on babies, children and young people’s experience of healthcare.

  • When prescribing cannabis-based medicinal products, advise people to stop any non-prescribed cannabis, including over-the-counter, online and illicit products.
  • 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.
  • For more information on safe prescribing and use of cannabis-based medicinal products, see the recommendations in the NICE guideline on controlled drugs.

For recommendations on shared care and supporting shared decision-making, refer to the full guideline.

 

Want to learn more about this guideline?

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Read the related Guidelines in Practice article

© NICE 2021. 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: 11 November 2019.

Last updated: October 2021.

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