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Cannabinoids in treatment of side
effects from cancer chemotherapy
Overview
The use of
cannabinoids in treating the side effects of cancer chemotherapy
is more widely-studied than other potential therapeutic
applications and a number of clinical studies have taken
place investigating the use of THC and synthetic cannabinoids
as anti-emetic agents. Two preparations have been licensed
for use in clinical treatment either in the UK or elsewhere,
including dronabinol (synthetic THC) and Nabilone (a novel
synthetic cannabinoid).
The powerful
drugs used in cancer chemotherapy effectively kill reproducing
cells, including both the malignant tumour cells and also,
as a side effect, many cells continually reproducing such
as hair follicle cells and those lining the gut, leading
to severe nausea & vomiting. These side effects can
be very severe and many patients find these difficult
or impossible to tolerate, falling into a wasting syndrome
through malnutrition brought on by a combination of reduced
appetite and poor gastrointestinal efficiency, which can
itself shorten life expectancy.
There is variation
between the effects of different anti-cancer drugs. Cisplatin,
one of the most effective chemotherapy agents, induces
vomiting in over 99% of patients not taking an antiemetic,
with around 10 vomiting episodes per dose, although methotrexate
causes emesis in under 10% of patients
There are also
variations in the efficacy and side effects between conventional
drugs used to treat nausea and vomiting. The BMA listed
the side effects of commonly-used anti-emetic drugs as
follows:
Phenothiazines
(prochlorperazine, haloperidol) - severe dystonic reactions,
drowsiness, dry mouth, blurred vision, urinary retention,
hypotension (low blood pressure), allergic reactions,
occasional jaundice.
Metoclopramide
- acute dystonic reactions, facial and muscle spasms,
drowsiness, restlessness, diarrhoea, depression
Domperidone
- acute dystonic reactions
SSRAs
(Ondansetron, gransisetron) - constipation, headache,
altered liver function.
The main beneficial
effects reported from use of cannabinoids are a reduction
in the incidence and severity of nausea and vomiting (emesis),
and stimulation of appetite, together reducing the severity
of cachexia - wasting syndrome - in patients receiving
chemotherapy treatment.
Clinical
Trials involving THC
Sallan et al
(1975) found 10mg THC "significantly more effective"
than placebo at reducing nausea and vomiting in 22 chemotherapy
patients. Chang et al (1979) found 10mg oral or 17mg smoked
THC to decrease methotrexate-induced nausea and vomiting
compared to placebo in 14 of 15 patients. Frytak et al
found 15mg THC better than placebo at inhibiting prochorperazine-induced
emesis, but noted some of the 116 gastrointestinal cancer
patients to find the side effects (sedation, "high"
dysphoria, hypotension & tachycardia) intolerable.
Orr & McKearnan found 7mg THC to be more effective
than prochlorperazine and placebo in 55 patients, of which
82% reported a high. Lucas & Laszlo found 15mg or
2x5mg THC more effective than placebo or standard regimes.
However Chang
et al found 3-hourly oral (10mg) or smoked (17.4mg) THC
ineffective compared with placebo in a small study of
8 patients receiving adriamycin and cyclophosphamide.
Niedhart et al compared THC and Haloperidol in 52 chemotherapy
patients finding no difference in efficacy between the
two drugs. Gralla et al found 10mg THC more effective
than placebo, but less effective than metoclopramide in
controlling cisplatin-induced vomiting in a 27-patient
study. Ungerleider et al in a large study of 214 patients,
found 4-hourly 7.5-12.5mg THC and 10mg prochlorperazine
equally effective in reducing nausea and vomiting, but
noted THC was preferred by more patients. Lane et al found
significant improvement both with THC (10mg dronabinol)
and prochlorperazine, and the combination more effective
than either alone in abolishing nausea and vomiting in
62 patients.
Clinical
Trials involving Nabilone
Nagy et al
studied 47 patients receiving cisplatin, finding nabilone
more effective than prochlorperazine or placebo in reducing
nausea & vomiting caused by cisplatin. Herman et al
found similar results with 113 patients receiving cisplatin,
cyclophosphamide & mustine therapy. Einhorn et al
studied 100 chemotherapy patients, finding nabilone significantly
more effective than prochlorperazine and preferred by
75% of patients, but noted lethargy and hypotension, similar
results found in studies of 114 patients by Wada et al,
in 36 patients by Levitt et al, 18 patients by Johannson
et al, 26 patients by Ahmedzal et al and 24 patients by
Niranan & Mattison.
Jones et al
found "significant reduction in nausea and vomiting
with nabilone compared to placebo" in a study of
54 patients and noted acceptable side effects to include
dizziness (65%) and drowsiness (51%). Niederle et al found
nabilone significantly better than alizapride in reducing
cisplatin-induced nausea & vomiting in 20 patients.
Pomeroy et al found nabilone superior to domperidone in
reducing vomiting episodes among 38 patients, as did Dalzell
et al in a study of 23 children, finding that despite
more side effects it was preferred by two thirds of respondents,
and a study of 30 children by Chan et al found nabilone
superior to prochlorperazine.
Studies
involving natural cannabis
Vinciguerra
et al studied 56 cancer patients unresponsive to conventional
antiemetic agents, who were asked to rate the effectiveness
of marijuana compared to prior chemotherapy cycles. Smoked
marijuana was rated as "moderately effective" or "highly
effective." by 78% of patients. The authors concluded
that marijuana had antiemetic efficacy, but no control
group was used and the patient population varied with
respect to prior marijuana use or THC therapy.
A double-blind,
cross-over, placebo-controlled study by Levitt et al compared
smoked marijuana with oral THC among 20 patients receiving
a variety of chemotherapy drugs. The efficacy was similar,
with 25% of patients achieving complete control over vomiting.
Seven patients (35%) indicated apreference for oral THC
over marijuana; 4 patients (20%) preferred smoked marijuana
and 9 patients (45%) expressed no preference.
Neither study
investigated the time course of antiemetic control, advantages
of self-titration with the smoked marijuana, or ability
of patients to swallow the pills. Patients with severe
vomiting are unlikely to be able to swallow or keep pills
down long enough for them to take effect. The onset of
drug effect is much faster with smoked THC in cannabis
than it is for oral delivery, and the differences in cannabinoid
content of smoked cannabis compared to the oral THC route
can alter the users perceptions and subjective effects.
Haney et al reported smoked cannabis to make users feel
"mellow" whereas oral THC did not. . Although
many cannabis users claim that smoking the drug provides
more effective relief from vomiting than oral THC, no
controlled studies have yet been published which firmly
establish this to be the case.
Conclusions
of Major Recent Inquiries
The British
Medical Association concluded:
"Cannabinoids
are undoubtedly effective as anti-emetic agents in vomiting
induced by anti-cancer drugs" and
that "Systematic trials of the effectiveness of cannabinoids in combatting
vomiting resulting from different chemotherapy agents
should be carried out".
The United
States Institute of Medicine report concluded:
"In
patients already experiencing severe nausea or vomiting,
pills are generally ineffective, because of the difficulty
in swallowing or keeping a pill down, and slow onset
of the drug effect. Thus an inhalation (but, preferably
not smoking) cannabinoid drug delivery system would
be advantageous for treating chemotherapy-induced nausea."
... "It is possible that the harmful
effects of smoking marijuana for a limited period of
time might be outweighed by the antiemetic benefits
of marijuana, at least for, patients for whom standard
antiemetic therapy is ineffective and who suffer from
debilitating emesis. Such patients should be evaluated
on a case by case basis"
The House
of Lords Science & Technology Select Committee made
the following findings and recommendations:
"...cannabis
and cannabinoids are likely to be of benefit as anti-emetics
only to the small proportion of patients who do not
respond to existing treatments, or possibly in the treatment
of the delayed stages of emesis which can occur for
some days following cancer chemotherapy, and which do
not respond well to the serotonin antagonists. Nevertheless,
cannabinoids are undoubtedly effective as anti·emetics
and more research in this field might explore their
use in combination with the serotonin antagonists, help
to determine for which patients they are most appropriate,
and examine the potential of the allegedly less psychoactive
cannabinoid D8·THC, for which there have been encouraging
preliminary clinical results"
"Unlike
cannabis itself, the cannabinoid THC (dronabinol)
and its analogue nabilone are already accepted by
the Government as having medical value -- producing
the anomaly that, while cannabis itself is banned
as a psychoactive drug, THC, the principal substance
which makes it psychoactive, is in legitimate medical
use. Some of our witnesses are prepared to contemplate
wider medical use of the cannabinoids, but not of
cannabis itself. We disagree, since some users of
both find cannabis itself more effective. We do, however,
welcome the inclusion of THC in the trials proposed
by the Asscher group, in like-for-like comparison
with cannabis itself"
"Dronabinol
(THC), though not licensed in this country, has already
been moved to Schedule 2 to the Misuse of Drugs Regulations,
and nabilone is a licensed medicine and not a controlled
drug; so no Government action is required in either
case to permit clinical trials or indeed prescription.
...we recommend that the Government should raise the
matter of rescheduling the remaining cannabinoids
with the WHO in due course, in order to facilitate
research."
"Our
principal reason for recommending that the law be
changed, to make legal the use of cannabis for medical
purposes, is compassionate. Illegal medical use of
cannabis is quite widespread; it is sometimes connived
at and even in some cases encouraged by health professionals;
and yet at present it exposes patients and in some
cases their carers to all the distress of criminal
proceedings, with the possibility of serious penalties.
We acknowledge that, if our recommendation were implemented,
the United Kingdom would be moving out of step with
many other countries; we consider that the Government
should not be afraid to give a lead in this matter
in a responsible way."
Summary
Levitt in an
early review presentation, suggested:"The use of cannabinoids as cancer chemotherapy anti-emetics represents,
in essence, the use of a drug with a relatively undefined
mechanism of action to treat the side effects of other
drugs, also with relatively undefined mechanisms of action,
which are being used to treat cancer, a disease or series
of diseases the precise nature of which remains enigmatic."
Since Levitt's review, there have been major advances
in cannabinoid pharmacology and in understanding of the
cancer disease process. In particular, research by Herkenham
et al demonstrated the presence of numerous cannabinoid
receptors in the nucleus of the solitary tract, a brain
center that is important in the control of vomiting.
Although other
recently developed anti-emetics are as effective or more
effective than oral THC, nabilone or smoked cannabis,
for certain individuals unresponsive to conventional anti-emetic
drugs, the use of smoked cannabis can provide relief more
effectively than oral preparations which may be difficult
to swallow or be expelled in vomit before having a chance
to take effect. The psychoactive/euphoriant effects of
THC or smoked cannabis may provide an improvement in mood,
whereas several conventional preparations e.g. phenothiazines
such as haloperidol (known as "major tranquillisers"
and also used in the treatment of psychoses such as schizophrenia),
may produce unwanted side effects such as excessive sedation,
flattening of mood, and/or distressing physical "extrapyramidal"
symptoms such as uncontrolled or compulsive movements.
In the USA,
synthetic THC (Dronabinol) is available for use as an
adjunct to cancer chemotherapy treatment, and in the UK,
both the British Medical Association and House of Lords
recognised the potential for use of cannabinoids in preventing
nausea and vomiting.
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