II. Indications: Synthetic Tetrahydrocannabinol (THC)
- See Cachexia in Cancer
- See Geriatric Failure to Thrive
- See Nausea in Terminally Ill Patients
- Anorexia in Chronic Renal Failure
- Chemotherapy induced Nausea or Vomiting
- Cachexia in AIDS
III. Indications: Purified Cannabidiol (CBD, Epidiolex)
- Lennox–Gastaut Syndrome (rare Seizure Disorder)
- Dravet Syndrome (rare Seizure Disorder)
IV. Indications: Combined THC and CBD
- Chronic Neuropathic pain
- Oral Mucosal spray and oral agents may offer small pain relief (NNT 10)
- May also demonstrate small improvement in sleep quality and physical functioning
- High THC to CBD ratios offer greatest relief, but also are with the greatest adverse effects
- Busse (2021) BMJ 374: n2040 [PubMed]
- Seehusen (2022) Am Fam Physician 106(2): 202-4 [PubMed]
V. Mechanism: Two product types derived from Marijuana and hemp
- Synthetic Tetrahydrocannabinol (THC)
- Will generate a positive Urine Drug Screen
- Purified Cannabidiol (CBD)
- Does not cause the "high" seen with THC
- Typically will not generate a positive Urine Drug Screen (but may if trace THC in product)
VI. Preparations: Cannabidiol (CBD)
- Preparations
- Cannabidiol (Epidiolex) oral solution
- FDA approved in U.S. as of 2018, with a cost of $32,000/year
- DEA Schedule 5
- OTC products (various forms)
- Legal status depends on U.S. State
- Not regulated or studied for efficacy and safety
- Cannabidiol (Epidiolex) oral solution
- Indications: Used to treat rare forms of childhood Epilepsy
- Dravet Syndrome
- Lennox-Gastaut Syndrome
- Tuberous Sclerosis
- Dosing
- Dosed 2.5 mg/kg twice daily (max: 20 mg/kg/day)
VII. Preparations: Synthetic Tetrahydrocannabinol (THC)
- Nabilone (Cesamet)
- THC analogue used to treat intractable Nausea, Vomiting (e.g. Chemotherapy)
- Dosed 1 mg orally twice daily (max: 6 mg/day in divided doses)
- DEA Schedule 2
- Dronabinol (Marinol)
- THC formulation Indicated for intractable Nausea, Vomiting (e.g. Chemotherapy, AIDS-related Anorexia)
- Dosed 2.5 mg orally (or SL, PR) twice daily, increased to 5-10 mg orally twice daily (max: 20 mg/day)
- DEA Schedule 3 (misuse is less likely due to formulation)
VIII. Drug Interactions: Cannabidiol (CBD)
- Cannabidiol inhibits CYP2C19, CYP2C8, CYP2C9
- Increases levels of Citalopram, Phenytoin, Amitriptyline, Valproic Acid, Warfarin
- Cannabidiol levels may be lowered
- Strong CYP3A4 Inducers lower CBD levels (e.g. St. John's Wort, Carbamazepine, Phenytoin, Rifampin)
- Strong CYP3A4 inhibitors raise CBD levels (e.g. Clarithromycin)
IX. Protocol: Chronic Neuropathic Pain
- Start with Cannabidiol (CBD) spray, tablet or sublingual oil drops
- Initial: 5 mg orally twice daily
- Next: Increase total daily dose by 10 mg up to every 2 to 3 days to a maximum of 40 mg/day
- Add Tetrahydrocannabinol (THC)
- Initial: 1 to 2.5 mg/day
- Next: Increase by 1 to 2.5 mg/day every 2 to 7 days to a maximum of 40 mg/day
- References
- (2022) Am Fam Physician 106(2): 208-9
- Busse (2021) BMJ 374:n2040 +PMID: 34497062 [PubMed]
X. Adverse Effects: CBD
- Drowsiness or sedation (esp. in combination with other CNS Depressants)
- Diarrhea
- Liver Function Test abnormalities
XI. Safety
- Avoid THC and CBD in pregnancy, Lactation and those taking multiple medications
- Check CBD product for a certificate of analysis that reports CBD levels, THC levels and contaminants
XII. Resources
- Simplified Guideline for prescribing Medical Cannabinoids in Primary Care
XIII. References
- (2019) Presc Lett 26(6)
- (2018) Presc Lett 25(4)
- (2018) Presc Lett 25(9):51
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dronabinol (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
DRONABINOL 10 MG CAPSULE | Generic | $3.22 each |
DRONABINOL 2.5 MG CAPSULE | Generic | $1.20 each |
DRONABINOL 5 MG CAPSULE | Generic | $2.45 each |