Guidance

Recommendations

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Intractable nausea and vomiting

1.1.1

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.

1.1.2

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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on intractable nausea and vomiting.

Full details of the evidence and the committee's discussion are in evidence review A: intractable nausea and vomiting.

1.2 Chronic pain

1.2.1

Do not offer the following to manage chronic pain in adults:

  • nabilone

  • dronabinol

  • THC (delta-9-tetrahydrocannabinol)

  • a combination of cannabidiol (CBD) with THC.

1.2.2

Do not offer CBD to manage chronic pain in adults unless as part of a clinical trial.

1.2.3

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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on chronic pain.

Full details of the evidence and the committee's discussion are in evidence review B: chronic pain.

1.3 Spasticity

1.3.1

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 3 x10-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.

1.3.2

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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on spasticity.

Full details of the evidence and the committee's discussion are in evidence review C: spasticity.

1.4 Severe treatment-resistant epilepsy

NICE has made recommendations for research 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.

For a short explanation of why the committee made the recommendation for research on CBD, and THC in combination with CBD for severe treatment-resistant epilepsy, see the rationale section on severe treatment-resistant epilepsy.

Full details of the evidence and the committee's discussion are in evidence review D: epilepsy.

1.5 Prescribing

Who should prescribe?

1.5.1

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 in the condition being treated.

Shared care

1.5.2

After the initial prescription, subsequent prescriptions of cannabis-based medicinal products may be issued by another prescriber as part of a shared care agreement under the direction of the initiating specialist prescriber, if:

1.5.3

Efficacy and safety of cannabis-based medicinal products should be monitored and evaluated, and doses should be adjusted by the initiating specialist prescriber as part of the shared care agreement.

1.5.4

A shared care agreement for a person prescribed a cannabis-based medicinal product should include:

  • the responsibilities of all parties [the initiating specialist prescriber, the other prescriber(s), the patient, family and/or carers]

  • the nature and frequency of monitoring and how this will be recorded

  • when treatment might be stopped, for example, if it is not effective

  • how suspected or known adverse reactions will be managed

  • how communication will be managed between the initiating specialist prescriber, the other prescriber, the patient, family and/or carers

  • how the treatment will be funded

  • how care will be maintained when the patient, initiating specialist prescriber or other prescriber moves location (including transition to adult services).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on prescribing: who should prescribe and shared care.

Full details of the evidence and the committee's discussion are in evidence review E: prescribing cannabis-based medicinal products.

Factors to think about when prescribing

1.5.5

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).

1.5.6

When prescribing cannabis-based medicinal products for babies, children and young people, pay particular attention to the:

1.5.7

When prescribing cannabis-based medicinal products, advise people to stop any non-prescribed cannabis, including over-the-counter, online and illicit products.

1.5.8

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 a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on prescribing: factors to think about when prescribing.

Full details of the evidence and the committee's discussion are in evidence review E: prescribing cannabis-based medicinal products.

Supporting shared decision making

1.5.10

Before prescribing cannabis-based medicinal products, discuss with people:

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on prescribing: supporting shared decision making.

Full details of the evidence and the committee's discussion are in evidence review E: prescribing cannabis-based medicinal products.

Terms used in this guideline

Cannabis-based medicinal products

In this guideline cannabis-based medicinal products include:

Optimised conventional antiemetics

These are treatments that are commonly used in practice at an optimum tolerated dose to manage nausea and vomiting.