Medical Cannabis for Chemotherapy Side Effects

Short answer

Two cannabinoid medicines carry FDA approval for chemotherapy-induced nausea and vomiting (CINV): dronabinol and nabilone. Both are synthetic. The cannabis plant has no FDA approval. A medical cannabis card is not a prescription.

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What the FDA approved

• Dronabinol (Marinol, Syndros). Synthetic delta-9-THC. Capsules and oral solution. Approved for CINV in patients who did not respond to other antiemetics.
• Nabilone (Cesamet). Synthetic THC analog. Capsule. Same indication.

Marinol sits in Schedule III under federal law. Syndros and Cesamet sit in Schedule II.

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Evidence base

A 2017 National Academies report found conclusive evidence that oral cannabinoids reduce CINV. Most trials compared dronabinol and nabilone with older antiemetics such as prochlorperazine and metoclopramide. Those drugs predate ondansetron and aprepitant. Few trials compare cannabinoids against current standard regimens.

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Evidence for smoked and vaporized cannabis is weaker. Trials are small. THC content in flower varies by batch, so doses are hard to repeat.

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The 2024 ASCO guideline advises against cannabis and cannabinoids for CINV outside clinical trials. NCCN lists dronabinol and nabilone as add-on options to a standard antiemetic regimen.

Dosing and onset

Marinol label: 5 mg per square meter of body surface area, taken 1 to 3 hours before chemotherapy, then every 2 to 4 hours after, for 4 to 6 doses a day. Nabilone: 1 mg to 2 mg twice a day.

Oral cannabinoids take 30 to 90 minutes to act. Inhaled THC reaches peak blood levels in minutes and wears off in 2 to 3 hours.

Side effects

• Drowsiness, dizziness, dry mouth
• Euphoria, impaired memory, trouble with balance
• Fast heart rate, low blood pressure, red eyes
• Increased appetite

Rare events include paranoia, psychosis, and heavy sedation in older adults.

Interactions

THC is broken down by CYP3A4 and CYP2C9. Adding opioids, benzodiazepines, antihistamines, or alcohol raises sedation risk. CBD blocks some CYP enzymes and can raise blood levels of other drugs.

State programs

38 states and DC run medical cannabis programs. Testing for pesticides, mold, and potency differs by state. Federal law still lists cannabis in Schedule I.

Questions for an oncologist

1. Are standard antiemetics enough, or is an add-on needed?
2. Does dronabinol or nabilone fit my other medications?
3. What dose, and how close to infusion?
4. Which side effects should trigger a call?