What is the role of medical marijuana in managing cancer-related cough?

Medical Marijuana for Cancer-Related Cough

Medical marijuana is not recommended for managing cancer-related cough as there is insufficient evidence supporting its efficacy, and current guidelines do not include cannabis as part of the treatment algorithm for cancer-related cough. 1

Evidence-Based Management of Cancer-Related Cough

First-Line Approaches

• Begin with non-pharmacological interventions including cough suppression exercises where available 1
• For localized endobronchial disease, consider endobronchial brachytherapy if surgery, chemotherapy, or external beam radiation are not indicated 1

Pharmacological Management Algorithm

1. Initial treatment: Start with demulcents such as butamirate linctus, simple linctus, or glycerin-based linctus where available 1
2. Second-line: For cough that doesn't respond to demulcents, use an opiate-derivative titrated to an acceptable side-effect profile 1
3. Third-line: For opioid-resistant cough, try peripherally-acting antitussives where available (levodropropizine, moguisteine, levocloperastine, or sodium cromoglycate) 1
4. Fourth-line: For cough resistant to peripheral antitussives, consider local anesthetics including nebulized lidocaine/bupivacaine or benzonatate 1
5. For intractable cough: Consider N-of-1 trials with diazepam, gabapentin, carbamazepine, baclofen, amitriptyline, or thalidomide when all other approaches fail 1

Cannabis and Cancer Symptom Management

Current Evidence

• The 2024 ASCO guidelines state there is insufficient evidence to recommend for or against cannabis for managing cancer treatment-related symptoms, including cough 1
• While cannabis is commonly used by cancer patients for symptom management (20-40% of patients), its use is primarily reported for:
  • Sleep difficulties (48%) 2
  • Stress, anxiety, or depression (46%) 2
  • Pain (42%) 2
  • Appetite stimulation (40% of THC users) 3
  • Nausea (28% of THC users) 3

Important Considerations and Cautions

• Cannabis may potentially interfere with cancer immunotherapy, with studies showing:
  • Reduced response rates to nivolumab 1
  • Decreased time to tumor progression 1
  • Decreased overall survival in patients using cannabis while on immunotherapy 1
• Long-term cannabis use carries risks including:
  • Cannabinoid hyperemesis syndrome after prolonged heavy use 1
  • Possible psychiatric effects including increased risk of depressive disorders 1
  • Risk of developing cannabis use disorder (10% of chronic users) 1
  • Increased risk of motor vehicle accidents 1

Communication Gap

• Only 25% of cancer patients discuss cannabis use with their healthcare providers 2
• Many patients receive little clinical guidance from oncology teams regarding safety and optimal use 1

Conclusion for Clinical Practice

• Follow the established stepwise approach for cancer-related cough management starting with demulcents and progressing through opioids, peripheral antitussives, and local anesthetics as needed 1
• Cannabis should not be recommended specifically for cancer-related cough due to lack of evidence for this indication 1
• If patients are using or considering cannabis for other symptoms, counsel them about potential risks, especially if they are receiving immunotherapy 1