What are the uses and dosing guidelines for Nabilone in adults with conditions such as nausea and vomiting from chemotherapy, multiple sclerosis, and chronic pain?

Nabilone Uses and Dosing

Nabilone is FDA-approved specifically for chemotherapy-induced nausea and vomiting (CINV) as a rescue and refractory agent when conventional antiemetics have failed, and emerging evidence supports its use for chronic neuropathic pain and sleep disturbances in cancer patients. 1

Primary FDA-Approved Indication: Chemotherapy-Induced Nausea and Vomiting

When to Use Nabilone for CINV

• Use nabilone as a second-line or rescue agent when first-line antiemetics (5-HT3 antagonists, NK1 antagonists, corticosteroids) have failed to control CINV 2, 1
• ASCO guidelines recommend either dronabinol or nabilone for breakthrough and refractory CINV, with moderate certainty of evidence for nabilone 2, 1
• Nabilone is superior to prochlorperazine and domperidone but does not add benefit when combined with 5-HT3 receptor antagonists 3

Dosing for CINV

• Standard dose: 1-2 mg orally twice daily, starting 1-12 hours before chemotherapy and continuing throughout the chemotherapy cycle and for 48 hours afterward if needed 4, 5
• The typical regimen is 2 mg twice daily (every 12 hours) 4, 5
• Maximum daily dose can reach 6 mg divided in three doses, though side effects increase significantly at higher doses 4

Efficacy Expectations

• Nabilone produces significant reduction in severity and duration of nausea and frequency of vomiting in 50-70% of patients with severe refractory symptoms 4
• More patients prefer nabilone over prochlorperazine despite higher side effect incidence 4, 5

Secondary Uses (Off-Label but Evidence-Supported)

Chronic Pain Management

• Nabilone is considered a third-line agent for neuropathic pain when first-line (gabapentinoids, SNRIs, TCAs) and second-line agents have failed 6
• Nabilone is ineffective for acute pain but shows benefit in neuropathic pain and central hypersensitization 3
• Used as adjunctive therapy, nabilone produces small but significant reductions in chronic noncancer pain, cancer pain, fibromyalgia, and spasticity-associated pain 6

Sleep Disturbances in Cancer Patients

• ASCO guidelines rate nabilone with moderate certainty of evidence for improving sleep in patients with chronic cancer pain 2
• Nabilone may be considered when sleep disturbances are related to chronic pain conditions 2

Dosing for Pain

• Start low: 0.5 mg once or twice daily at bedtime 6
• Titrate gradually by 0.5 mg increments every few days based on response and tolerability 6
• Typical effective dose range: 1-2 mg daily, divided once or twice daily 6
• Maximum dose: 6 mg daily in divided doses, though most patients respond to lower doses 6

Important Contraindications and Precautions

When NOT to Use Nabilone

• Do not use for radiation-induced nausea and vomiting - ASCO and MASCC guidelines explicitly recommend against cannabinoids for this indication 7
• Avoid in patients with psychiatric history due to risk of euphoria, dysphoria, and toxic psychoses 7, 4
• Do not use as first-line therapy for any indication 7, 1

Common Side Effects (Occur in >50% of patients)

• Drowsiness (57-70% of patients) 4, 8
• Dizziness and vertigo (60-70%) 4, 8
• Postural hypotension (35%, though major problem in only 7%) 8
• Euphoria (14%), "high" sensation (7%) 8
• Dysphoria, confusion (18%) 7

Serious Side Effects Requiring Discontinuation

• Toxic psychoses (rare but serious) 4
• Severe postural hypotension with ataxia 4
• Vision disturbances 4
• These serious effects are uncommon but warrant caution, particularly in elderly patients 4

Clinical Pearls and Monitoring

Patient Selection

• Best candidates are those with refractory CINV who have failed conventional antiemetics and can tolerate CNS side effects 1, 4
• Screen for psychiatric history before initiating therapy 7
• Consider lower starting doses in elderly patients and those with cardiovascular disease 8

Monitoring Parameters

• Monitor blood pressure, particularly postural changes, especially on Day 1 of therapy 8
• Assess for CNS effects including drowsiness, dizziness, and mood changes 4
• Evaluate pain scores and sleep quality when used for these indications 6

Drug Interactions

• Use caution with other CNS depressants (benzodiazepines, opioids, alcohol) due to additive sedation 6
• May potentiate effects of anticholinergic medications 6

Abuse Potential

• The likelihood of abuse is considered low despite euphoric effects 6
• Euphoria occurs in only 14% of patients and is generally mild 8

What Nabilone Does NOT Treat

• Not effective for radiation-induced nausea and vomiting - guidelines explicitly advise against this use 7
• Not effective for acute pain 3
• Insufficient evidence to recommend for anxiety, depression, or quality of life as primary outcomes (very low to low certainty evidence) 2
• Not recommended for appetite stimulation or cachexia as primary indication (low certainty evidence) 2