PRESCRIBING MEDICINAL CANNABIS

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Sarah Miles
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1 PRESCRIBING MEDICINAL CANNABIS Dr. Judith Lacey Head of Supportive Care Chris O Brien Lifehouse Comprehensive Cancer Centre 21 st November 2017

2 Overview When could cannabis be indicated for your patients TGA indications recognised State variation Identifying refractory symptoms and approach to refractory symptoms Choosing a product Prescribing Monitoring the patient, dose adjustment, ongoing care

3 The medicalization model for cannabis has physicians feeling Angst. Why? Clinical care Cannabis R&D Tech/Plant/medical Agriculture (Medicinal grade product)

4 Good symptom management requires knowledge of how to apply evidence based interventions But what if the evidence isn t available? We fall back onto. reduce suffering + do no harm + prescribe using model of best practice guidelines + start developing strategies to obtain the evidence then adapt your prescribing accordingly

5 Indications today in Australia for prescribing cannabis outside of clinical trials Refractory CINV Refractory cancer related nausea Refractory cancer related anorexia Complex refractory cancer related pain palliative care Refractory non cancer pain MS Childhood epilepsy

impact on their life and wellbeing Managing symptom types with the

6 Approach to the patient to improve wellbeing Measures to modify disease Measures to relieve reversible factors Addressing the whole person and impact on their life and wellbeing Managing symptom types with the correct regimen Look for other therapies that may help Combination of all of the above

7 Approach to Prescribing Medicinal Cannabis History Treatment plan Choose a product & make application Start product, by chosen route, titrate dose Monitor the patient, adjust treatment

8 Case 58 year old man with local pancreatic Ca, LN+ Chemo and RT CINV (chemotherapy induced Nausea and vomiting) Jean Frederic Bazille's portrait of Pierre-Auguste Renoir.

Step 1 : Take a history Presenting Symptom and

(xeloda) and Gemcitabine Medication review Mental health

drug dependency Social History Appropriate

Metformin, Glicazide, Atorvostatin, Pantoprazole.

9 Step 1 : Take a history Presenting Symptom and underlying diagnosis Past medical History Capcitabine (xeloda) and Gemcitabine Medication review Mental health history Family History Risk behaviours associated with drug dependency Social History Appropriate investigations Norspan 10mcg, Endone PRN, Amitriptyline, Metformin, Glicazide, Atorvostatin, Pantoprazole. During chemotherapy: palonasetron and ondansetron 4mgbd Expectation of care, prognosis

$Before calling nausea refractory: Common medications used : Haloperidol, Metoclopramide, Ondansetron,Palonosetron Cyclizine, Levomepromazine, Steroids, benzodiazapines,$

10 Scoring nausea 7/10 using the ESAS Nausea description: Central nausea at sight and smell of food, on waking in morning, and in the afternoons. Post prandial nausea and vomiting after food managed by reducing intake to small frequent meals. Noted mild nausea since surgery but significant exacerbation with chemotherapy. Prescribed first consultation: add on Metoclopramide 10mg tds ½ hr before meals Cyclizine 50mg tds and Ondansetron 4-8mg bd prn. Review bloods. Before calling nausea refractory: Common medications used : Haloperidol, Metoclopramide, Ondansetron,Palonosetron Cyclizine, Levomepromazine, Steroids, benzodiazapines, Stemetil, Largactyl, Olanzapine Referred to dietitian and exercise physiologist

11 Step 2 : Develop a Treatment Plan 1. Clear treatment goals for cannabinoid starting and stopping 2. Specialist support if eg prescribed by GP 3. Risk management processes 4. Monitoring arrangements 5. Exit strategy 6. Informed consent

12 Step 3: Choose a product Choosing a product based on evidence that exists Development of guidance documents Start low, go slow

13 Step 4:Route of administration Route Time to onset Lasts for benefit vapourised 15min -30min 2-4 hrs Quick onset, short duration smoked 15 min-30min 2-4 hrs Rapid onset, no smoke Oro mucosal 60-90min 6-8 hrs up to 24hrs Gradual, easy to titrate Ingested orally min 6-8 hrs up to 24h Gradual, first pass metabolism liver tea?? Rectal/supps/topic al??

14 Step 4: Start low go slow: dosing CBD: THC rich whole plant sativa oil. CBD: THC 9.8mg: 9.9mg 1ml= 10mg of THC equivalent Start 0.25mls at night ( equivalent to 2.5mg THC and CBD) Increase if tolerated to tds and then by 0.25ml increments If this dose is adequate, you do not need to increase it. If you have symptoms, particularly nausea, try taking the same dose every 8 hours. Please record details of how you feel, what it does to your symptom of concern, how long it lasts and side effects. Increase by increments of 0.25mls every 8-24hrs until on the right dose during chemo: 1 day before, 3-5 days after. N/A for oral daily chemo. Daily during RT, reduce on breaks

Step 5: Monitor the patient 15 Effective Surveillance, Recognition, and Intervention Minimizes the Potential Impact of AEs 1,2 Proactive monitoring Early recognition and

15 Step 5: Monitor the patient 15 Effective Surveillance, Recognition, and Intervention Minimizes the Potential Impact of AEs 1,2 Proactive monitoring Early recognition and reporting Appropriate management Vigilant follow-up 1. Teply BA et al. Oncology (Williston Park). 2014;28 Suppl 3: Kannan R et al. Clin J Onc Nurs. 2015;18(3): , 326.

later increased 6 6 5 4 4 4 3 3 3 3 2 2 2 2 2 2 2 2 1 1 1 1 0 0 0 0 0 0 nausea

16 Initial consult Symptoms over me using ESAS (0-best - 10-worst) Cannabis started - 19/5 11-Apr 9-May 25-May 14-Jul 14-Aug 21-Sep 7 6 RT /chemo, dose later increased nausea appe te distress fa gue dry mouth Cannabis commenced During and immediately after treatment

17 Thank you..questions?

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