When is nabilone indicated as a treatment for chemotherapy-induced nausea and vomiting?

Nabilone Indications for Treatment

Nabilone is primarily indicated for the treatment of nausea and vomiting associated with cancer chemotherapy in patients who have failed to respond adequately to conventional antiemetic treatments. 1

Primary Indication

• Nabilone is FDA-approved specifically for chemotherapy-induced nausea and vomiting (CINV) that is refractory to conventional antiemetic therapy 1, 2
• It is not intended to be used as a first-line antiemetic or on an as-needed basis 1
• Prescriptions should be limited to the amount necessary for a single cycle of chemotherapy (typically a few days) 1

Clinical Considerations for Use

• When a cannabinoid is chosen for rescue and refractory CINV, the American Society of Clinical Oncology (ASCO) recommends either dronabinol or nabilone 2
• Nabilone has shown superior efficacy compared to older antiemetics like prochlorperazine in controlling severe CINV, with 80% of patients responding to nabilone compared to only 32% for prochlorperazine in clinical trials 3
• Nabilone should be administered under close supervision, particularly during initial use and dose adjustments, due to its potential to alter mental state 1

Dosing and Administration

• Typical dosing is 2mg twice daily, starting 12 hours prior to chemotherapy and continuing for the duration of the chemotherapy cycle 4
• Oral administration is the only available route 5
• A newer oral dronabinol solution has decreased intraindividual variability compared to older capsule formulations, which may improve predictability of response 5

Contraindications and Precautions

• Nabilone is a Schedule II controlled substance with high potential for abuse 1
• Patients should be monitored for signs of excessive use, abuse, and misuse 1
• Patients with personal or family history of substance abuse or mental illness may be at increased risk for substance abuse 1
• Psychotomimetic reactions are possible and should be anticipated 1

Side Effects

• Common side effects include drowsiness (57%), postural dizziness (35%), and lightheadedness (18%) 6
• More serious but less common effects include euphoria (14-16%), hallucinations (3%), and hypotension 6, 3
• Despite higher incidence of side effects compared to conventional antiemetics, patients often prefer nabilone for continued use due to its superior antiemetic efficacy 3

Secondary Uses

• While not FDA-approved for these indications, nabilone has been studied for:
  • Neuropathic pain management (may be beneficial as a second to fourth-line option) 7
  • Refractory cases of non-chemotherapy related nausea and vomiting 8

Clinical Algorithm for Use

1. First, ensure patient has failed conventional antiemetics (5-HT3 antagonists, NK1 receptor antagonists, dexamethasone, olanzapine) 2
2. Assess for risk factors for substance abuse or mental illness 1
3. Begin with 2mg twice daily, starting 12 hours before chemotherapy 4
4. Monitor closely for psychotomimetic reactions and other side effects 1
5. Limit prescription to the amount needed for a single chemotherapy cycle 1

Common Pitfalls

• Using nabilone as a first-line antiemetic rather than after failure of conventional therapies 1
• Prescribing for extended periods beyond a single chemotherapy cycle 1
• Inadequate monitoring for psychotomimetic reactions or signs of abuse 1
• Failing to recognize that while medical marijuana contains similar active components, it lacks the precise dosing and scheduling available with FDA-approved cannabinoids like nabilone 2