Efficacy of Crude Marijuana and Synthetic Delta-9-Tetrahydrocannabinol as Treatment for Chemotherapy-Induced Nausea and Vomiting: A Systematic Literature Review

with Jayme Cotter RN, MS, OCN®

2010-08-19 10:54:48 ONS Stephanie Hello
2010-08-19 13:58:40 ONS Stephanie We will begin the chat in a few minutes.
2010-08-19 14:04:06 ONS Stephanie Welcome to the ONS Virtual Journal Club. Today we will be discussing Efficacy of Crude Marijuana and Synthetic Delta-9-Tetrahydrocannabinol as Treatment for Chemotherapy-Induced Nausea and Vomiting: A Systematic Literature Review with Jayme Cotter RN, MS, OCN® Please feel free to ask your questions to Jayme. Welcome!!
2010-08-19 14:04:31 Jayme Hi! My name is Jayme Cotter and I am the inpatient oncology CNS at Aurora St Luke's Medical Center in Milwaukee WI. I have worked here for about 2 1/2 years and work primarily with a medical oncology population, although we also have an Autologous Stem Cell Transplant program as well. I received my graduate education at the University of Wisconsin - Madison in 2008. I am currently certified as an OCN. I am excited to be here with you all today and discuss this topic.
2010-08-19 14:04:37 ONS Stephanie Welcome MAE, TD and DBeebe to the ONS Virtual Journal Club
2010-08-19 14:06:53 ONS Stephanie Was everyone able to download and read the article?
2010-08-19 14:07:37 heuerblodgett Jayme- I have not seen Marinol ordered for CNIV in my inpatient setting. Reading the article, I gathered THC was most effective with compazine and zofran when given for moderately emetogenic chemo regimens. Have you seen it ordered in your inpatient setting with pre-chemo meds or have you asked to have it added to the regimen after the other meds have shown not effective?
2010-08-19 14:08:03 ONS Stephanie Welcome to the Virtual Journal Club, baniewicz. Please feel free to ask your questions to Jayme.
2010-08-19 14:08:44 ONS Stephanie Welcome to the Virtual Journal Club, mwelker!
2010-08-19 14:09:56 Jayme I have not seen dronabinol used as a premed for a chemo regimen, but have used it for patients s/p chemo who are refractory to other antiemetics or used in conjunction with other antiemetic classifications when the traditional meds do not completely control a patient's n/v symptoms.
2010-08-19 14:10:43 mwelker I am trying to find the chat on CINV. Where do I go?
2010-08-19 14:11:16 ONS Stephanie You are in the correct location mwelker. Please feel free to ask your questions.
2010-08-19 14:11:44 mwelker Ok thanks, I just wanted to see what others had to say about it.
2010-08-19 14:11:45 Jayme I think dronabinol is a good choice when used in combination for patients having difficulty with n/v, as it interacts with a different receptor/has a different MOA than other antiemetics.
2010-08-19 14:14:11 heuerblodgett Are the side effects of mood alteration, decreased energy and feeling "high" lessened significantly with dronabinol? Do you know if these side effects lessen with use? It looked like these s/e were often the limiting use factor for patients.
2010-08-19 14:14:38 MAE I have seen it used also for refractory patients with some success. It also stimulates appetite in the AIDS population and can be helpful for cancer patients too. I see resistance from providers due to the side effect of sedation. Have you seen it used much in the geriatric population and what is the side effect profile in them?
2010-08-19 14:18:23 Jayme As with all medications, there are side effects to dronabinol and every patient reacts differently. Anecdotally, I believe the side effects to dronabinol are less than that of smoked marijuana. The studies showed that sometimes these side effects were a limiting factor for patients, but often not enough to skew the study significantly. I am not sure if the side effects lessen with use, but I think its all part of the patient perspective and what they are willing to tolerate to achieve the level of n/v they are comfortable with.
2010-08-19 14:19:52 Jayme I have not seen significantly different side effects in the elderly, although if patients have organ dysfunction and difficulty clearing meds, they could possibly be so.
2010-08-19 14:21:55 ONS Stephanie Jayme,
2010-08-19 14:23:12 ONS Stephanie Did you change the practice related to CINV based on this lit review?
2010-08-19 14:26:40 heuerblodgett I have given dronabinol to inpatient onc patients for appetite stimulation and not had anyone tell me there were significant side effects, or undesired side effects. Some, especially the elderly, are often not aware they are taking synthetic THC. I am wondering if you are aware of studies specifically looking into the patient's perceived effects of THC use and whether patients comfort level with using what is usually considered a street drug affects their experience.
2010-08-19 14:26:44 Jayme We did not change any preprinted order sets or protocols in our institution. However, I do advocate for it more and more, and I think our nursing staff would feel the same. I think for a while dronabinol had this stigma about it, and the literature was so scattered, from all different decades, that it was hard to give something to a physician and advocate for trialing the med. Underneath it all, dronabinol is another med useful in treating CINV, having it's own SE profile, and supported in the literature.
2010-08-19 14:29:51 ONS Stephanie What was the reason that you decided to this lit review?
2010-08-19 14:32:50 ONS Stephanie What other questions do you have for Jayme?
2010-08-19 14:34:27 Jayme A secondary aim of this article was to see if patient's had a preference regarding use of this med. I didn't find any articles revealing patients' perceptions of taking the synthetic THC, but did find articles to support that patients preferred oral THC over the smoked marijuana. To be fair though, I was looking for research regarding efficacy for this article, so I think I was really looking for quantitative research instead of qualitative. i think an article focusing on the qualitative piece would be fascinating.
2010-08-19 14:35:54 Jayme I chose to do this lit review because as I was caring for patients as a staff nurse, I felt I got a lot of pushback when I would advocate for dronabinol use in my patients. I felt that I needed to summarize all the data that was out there, especially in light of the newer 5HT3 meds that everyone is using for CINV today.
2010-08-19 14:37:00 Jayme I knew there was data out there, but didn't know what it was. I think I was surprised to find that almost all of the data either supported the use or found no statistically significant difference between dronabinol and the medication it was up against.
2010-08-19 14:39:06 Jayme I feel that our responsibility as nurses is to care for patients in the most comprehensive way possible, trialing different modalities to attenuate as many symptoms as we can. We also need to practice according to evidence based literature, and I wanted to have a resource for other RNs to use when asking MDs for this med.
2010-08-19 14:40:38 cabrini What about cost for the patient? The experience I have found with dronabinol is that it is not covered readily by insurances.
2010-08-19 14:40:46 heuerblodgett I agree a qualitative article would be interesting. Thank you for your article. It will be helpful to me to have information to share with patients and doctors when thinking about adding dronabinol. I may even suggest it for alternative uses with cancer patients who have a history or current use of recreational marijuana use, as smoking the herb has been shown to cause fungal infections, which may be lethal and will certainly delay treatment. Your work is a good step towards helping nurses advocate for patients within a controversial subject.
2010-08-19 14:42:04 heuerblodgett Maybe with more use in the clinical setting insurance companies will cover it more readily. The cost prohibition for effective medications is a barrier that really takes a toll on patients and families.
2010-08-19 14:42:08 ONS Stephanie I will be responding for Jayme as she is having computer problems.
2010-08-19 14:44:30 ONS Stephanie Jayme, We don't want to create more problems for patients than they are already dealing with, so you may want to use it in the hospital but switch to something else when they go home. From a patient perspective, we don't want to put financial strain on top of everything else they are dealing with. The insurance piece was not something that I looked at when doing the review.
2010-08-19 14:45:51 ONS Stephanie Any other questions for Jayme?
2010-08-19 14:47:53 ONS Stephanie If there are no other questions, we will end this session. We will be posting the full transcript on the ONS website in the next few days. Please join us for other Virtual Journal Club chats and Hot Topic Chats.
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