Is chronic use of nabilone (cannabinnoid) recommended?

Nabilone Should Not Be Used Chronically Except in Specific Clinical Scenarios

Nabilone should not be used chronically in most clinical scenarios due to significant risks of adverse effects, potential for dependence, and limited evidence for long-term efficacy. 1

Appropriate Clinical Scenarios for Nabilone Use

• Nabilone is primarily indicated for short-term management of chemotherapy-induced nausea and vomiting refractory to conventional therapy 1
• It may be considered as a temporary substitution for patients experiencing Cannabis Withdrawal Syndrome (CWS) in specific circumstances, particularly in the perioperative period 2
• Nabilone substitution is appropriate for patients with CWS symptoms who were previously consuming significant amounts of cannabis (>1.5g/day of high-THC smoked cannabis or >20mg/day of THC oil) 2
• Patients with suspected CWS should be referred to psychiatry or addiction medicine specialists who can guide appropriate nabilone use 2

Risks of Chronic Use

• Chronic use of nabilone may be associated with untoward effects on motivation, cognition, judgment, and other mental status changes 1
• Nabilone has a high potential for psychological dependence and abuse 1
• Common adverse effects include drowsiness (60-70% of patients), dizziness, vertigo, dry mouth, and hypotension 1, 3
• More serious adverse effects can include postural hypotension, ataxia, vision disturbance, and toxic psychoses 3
• Elderly patients are particularly vulnerable to nabilone-induced dizziness and postural hypotension 4

Monitoring Requirements for Chronic Use

• If chronic use is absolutely necessary, patients should:
  • Be monitored for orthostatic vital signs before and after initiating therapy 4
  • Have regular blood pressure monitoring, especially those with cardiovascular conditions 4
  • Be assessed for development of tolerance and dependence 5
  • Receive dose reduction when moderate to severe dizziness affects daily activities 4

Dosing Considerations

• For necessary short-term use, start with the lowest available dose to reduce adverse effects 2
• In older adults, consider starting with lower doses (0.5mg daily) and monitor closely for dizziness 4
• If discontinuation is needed, taper the dose gradually rather than stopping abruptly 4
• Doses higher than 1mg twice daily have not shown additional benefit but increase side effects 6

Alternative Approaches

• Consider regional anesthesia when planning perioperative pain management for patients using cannabis products 2
• For chronic pain management, consider other adjuvant analgesics with better safety profiles 2
• The National Comprehensive Cancer Network suggests considering alternative pain management strategies if dizziness is problematic 4

Special Populations

• Nabilone is particularly concerning in older adults due to significant anticholinergic effects, orthostatic hypotension, sedation, and potential cardiac effects 2
• Patients with cardiovascular issues should be closely monitored as THC can affect heart rate and blood pressure 7
• Patients with hepatic impairment may be at higher risk for adverse effects due to reduced drug clearance 7

Drug Interactions

• Nabilone can inhibit several cytochrome P450 enzymes (CYP3A4, CYP2C9, CYP2C19) 1
• The simultaneous use of nabilone and alcohol or barbiturates may produce additive depressive effects on central nervous system function 1
• Both nabilone and many medications can cause central nervous system effects that may be additive 7

In conclusion, while nabilone has legitimate short-term therapeutic uses, chronic administration is generally not recommended due to significant risks of adverse effects, potential for dependence, and limited evidence supporting long-term efficacy.