BMJ 2001;323:16 ( 7 July )

Papers

Cannabinoids for control of chemotherapy induced nausea and vomiting: quantitative systematic review

Martin R Tramèr, staff anaesthetist, ^a Dawn Carroll, senior research nurse, ^b Fiona A Campbell, consultant in anaesthetics and pain management, ^c D John M Reynolds, consultant clinical pharmacologist, ^d R Andrew Moore, consultant biochemist, ^b Henry J McQuay, professor of pain relief. ^b

^a Division d'Anesthésiologie, Département Anesthésiologie, Pharmacologie Clinique et Soins Intensif de Chirurgie, Hôpitaux Universitaires, CH-1211 Genève 14, Switzerland, ^b Pain Research, Nuffield Department of Anaesthetics, Churchill, Oxford Radcliffe Hospital, Oxford OX3 7LJ, ^c Pain Management Centre, Undercroft, South Block, Queen's Medical Centre, Nottingham NG7 2UH, ^d Department of Clinical Pharmacology, Radcliffe Infirmary, Oxford OX2 6HE

Correspondence to: M R Tramèr, martin.tramer{at}hcuge.ch

Objective: To quantify the antiemetic efficacy and adverse effects of cannabis used for sickness induced by chemotherapy.
Design: Systematic review.
Data sources: Systematic search (Medline, Embase, Cochrane library, bibliographies), any language, to August 2000.
Studies: 30 randomised comparisons of cannabis with placebo or antiemetics from which dichotomous data on efficacy and harm were available (1366 patients). Oral nabilone, oral dronabinol (tetrahydrocannabinol), and intramuscular levonantradol were tested. No cannabis was smoked. Follow up lasted 24 hours.
Results: Cannabinoids were more effective antiemetics than prochlorperazine, metoclopramide, chlorpromazine, thiethylperazine, haloperidol, domperidone, or alizapride: relative risk 1.38 (95% confidence interval 1.18 to 1.62), number needed to treat 6 for complete control of nausea; 1.28 (1.08 to 1.51), NNT 8 for complete control of vomiting. Cannabinoids were not more effective in patients receiving very low or very high emetogenic chemotherapy. In crossover trials, patients preferred cannabinoids for future chemotherapy cycles: 2.39 (2.05 to 2.78), NNT 3. Some potentially beneficial side effects occurred more often with cannabinoids: "high" 10.6 (6.86 to 16.5), NNT 3; sedation or drowsiness 1.66 (1.46 to 1.89), NNT 5; euphoria 12.5 (3.00 to 52.1), NNT 7. Harmful side effects also occurred more often with cannabinoids: dizziness 2.97 (2.31 to 3.83), NNT 3; dysphoria or depression 8.06 (3.38 to 19.2), NNT 8; hallucinations 6.10 (2.41 to 15.4), NNT 17; paranoia 8.58 (6.38 to 11.5), NNT 20; and arterial hypotension 2.23 (1.75 to 2.83), NNT 7. Patients given cannabinoids were more likely to withdraw due to side effects 4.67 (3.07 to 7.09), NNT 11.
Conclusions: In selected patients, the cannabinoids tested in these trials may be useful as mood enhancing adjuvants for controlling chemotherapy related sickness. Potentially serious adverse effects, even when taken short term orally or intramuscularly, are likely to limit their widespread use.

What is already known on this topic Requests have been made for legalisation of cannabis (marijuana) for medical use Long term smoking of cannabis can have physical and neuropsychiatric adverse effects Cannabis may be useful in the control of chemotherapy related sickness What this study adds Oral nabilone and dronabinol and intramuscular levonantradol are superior to conventional antiemetics (such as prochlorperazine or metoclopramide) in chemotherapy Side effects are common with cannabinoids, and although some may be potentially beneficial (euphoria, "high," sedation), others are harmful (dysphoria, depression, hallucinations) Many patients have a strong preference for cannabinoids

---

© BMJ 2001
CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Relevant Articles

Canada legalises the medical use of cannabis

David Spurgeon
BMJ 2001 323: 68. [Extract] [Full Text]

Cannaboids are effective as analgesics and antiemetics but have side effects
BMJ 2001 323: 0. [Full Text]

Cannabinoids for pain and nausea

Eija Kalso
BMJ 2001 323: 2-3. [Extract] [Full Text] [PDF]

This article has been cited by other articles:

• Izzo, A A, Camilleri, M (2008). Emerging role of cannabinoids in gastrointestinal and liver diseases: basic and clinical aspects. Gut 57: 1140-1155 [Abstract] [Full text]  
• Wang, T. MSc, Collet, J.-P. PhD MD, Shapiro, S. PhD, Ware, M. A. MBBS MSc (2008). Adverse effects of medical cannabinoids: a systematic review. CMAJ 178: 1669-1678 [Abstract] [Full text]  
• Hesketh, P. J. (2008). Chemotherapy-Induced Nausea and Vomiting. NEJM 358: 2482-2494 [Full text]  
• Gan, T. J., Meyer, T. A., Apfel, C. C., Chung, F., Davis, P. J., Habib, A. S., Hooper, V. D., Kovac, A. L., Kranke, P., Myles, P., Philip, B. K., Samsa, G., Sessler, D. I., Temo, J., Tramer, M. R., Vander Kolk, C., Watcha, M. (2007). Society for Ambulatory Anesthesia Guidelines for the Management of Postoperative Nausea and Vomiting. Anesth. Analg. 105: 1615-1628 [Abstract] [Full text]  
• Engels, F. K., de Jong, F. A., Sparreboom, A., Mathot, R. A. A., Loos, W. J., Kitzen, J. J. E. M., de Bruijn, P., Verweij, J., Mathijssen, R. H. J. (2007). Medicinal Cannabis Does Not Influence the Clinical Pharmacokinetics of Irinotecan and Docetaxel. The Oncologist 12: 291-300 [Abstract] [Full text]  
• Blazquez, C., Carracedo, A., Barrado, L., Real, P. J., Fernandez-Luna, J. L., Velasco, G., Malumbres, M., Guzman, M. (2006). Cannabinoid receptors as novel targets for the treatment of melanoma. FASEB J. 20: 2633-2635 [Abstract] [Full text]  
• Beaulieu, P. (2006). Effects of nabilone, a synthetic cannabinoid, on postoperative pain: [Les effets de la nabilone, un cannabinoide synthetique, sur la douleur postoperatoire].. Canadian J. Anesthesia 53: 769-775 [Abstract] [Full text]  
• Strasser, F., Luftner, D., Possinger, K., Ernst, G., Ruhstaller, T., Meissner, W., Ko, Y.-D., Schnelle, M., Reif, M., Cerny, T. (2006). Comparison of Orally Administered Cannabis Extract and Delta-9-Tetrahydrocannabinol in Treating Patients With Cancer-Related Anorexia-Cachexia Syndrome: A Multicenter, Phase III, Randomized, Double-Blind, Placebo-Controlled Clinical Trial From the Cannabis-In-Cachexia-Study-Group. JCO 24: 3394-3400 [Abstract] [Full text]  
• Zhu, H.-J., Wang, J.-S., Markowitz, J. S., Donovan, J. L., Gibson, B. B., Gefroh, H. A., DeVane, C. L. (2006). Characterization of P-glycoprotein Inhibition by Major Cannabinoids from Marijuana. J. Pharmacol. Exp. Ther. 317: 850-857 [Abstract] [Full text]  
• de Jong, F. A., Engels, F. K., Mathijssen, R. H.J., van Zuylen, L., Verweij, J., Peters, R. P.H., Sparreboom, A. (2005). Medicinal Cannabis in Oncology Practice: Still a Bridge Too Far?. JCO 23: 2886-2891 [Full text]  
• Derbenev, A. V., Stuart, T. C., Smith, B. N. (2004). Cannabinoids suppress synaptic input to neurones of the rat dorsal motor nucleus of the vagus nerve. J. Physiol. 559: 923-938 [Abstract] [Full text]  
• Blazquez, C., Gonzalez-Feria, L., Alvarez, L., Haro, A., Casanova, M. L., Guzman, M. (2004). Cannabinoids Inhibit the Vascular Endothelial Growth Factor Pathway in Gliomas. Cancer Res. 64: 5617-5623 [Abstract] [Full text]  
• Hayry, M (2004). Prescribing cannabis: freedom, autonomy, and values. J. Med. Ethics 30: 333-336 [Abstract] [Full text]  
• Karst, M., Salim, K., Burstein, S., Conrad, I., Hoy, L., Schneider, U. (2003). Analgesic Effect of the Synthetic Cannabinoid CT-3 on Chronic Neuropathic Pain: A Randomized Controlled Trial. JAMA 290: 1757-1762 [Abstract] [Full text]  
• Van Sickle, M. D., Oland, L. D., Mackie, K., Davison, J. S., Sharkey, K. A. (2003). {Delta}9-Tetrahydrocannabinol selectively acts on CB1 receptors in specific regions of dorsal vagal complex to inhibit emesis in ferrets. Am. J. Physiol. Gastrointest. Liver Physiol. 285: G566-G576 [Abstract] [Full text]  
• Gan, T. J., Meyer, T., Apfel, C. C., Chung, F., Davis, P. J., Eubanks, S., Kovac, A., Philip, B. K., Sessler, D. I., Temo, J., Tramer, M. R., Watcha, M. (2003). Consensus Guidelines for Managing Postoperative Nausea and Vomiting. Anesth. Analg. 97: 62-71 [Abstract] [Full text]  
• Iversen, L. (2003). Cannabis and the brain. Brain 126: 1252-1270 [Abstract] [Full text]  
• (2003). OTHER ARTICLES NOTED (Nov 01 to 18 Oct 02). Evid. Based Nurs. 6: e1-1 [Full text]  
• Kinzbrunner, B. M (2002). Review: cannabinoids control chemotherapy-induced nausea and vomiting but increase the risk of side effects. Evid. Based Med. 7: 25-25 [Full text]  
• Russo, E., Iversen, L., Petro, D. J, Grotenhermen, F., Campbell, F. A, Moore, A., McQuay, H. J, Carroll, D., Tramer, M. R, Reynolds, D J. M (2001). Cannabinoids in pain management. BMJ 323: 1249-1249 [Full text]  
• Altman, D. G, Cates, C. (2001). Authors should make their data available. BMJ 323: 1069-1069 [Full text]  
• (2001). Medical Marijuana: Should We Recommend It for Pain and Nausea?. JWatch Emergency Med. 2001: 14-14 [Full text]  
• (2001). Cannabinoids for Pain and Nausea: They Work, but There's a Price. JWatch General 2001: 7-7 [Full text]  
• Kalso, E. (2001). Cannabinoids for pain and nausea. BMJ 323: 2-3 [Full text]  
• Campbell, F. A, Tramer, M. R, Carroll, D., Reynolds, D J. M, Moore, R A., McQuay, H. J (2001). Are cannabinoids an effective and safe treatment option in the management of pain? A qualitative systematic review. BMJ 323: 13-13 [Abstract] [Full text]  

Rapid Responses:

Read all Rapid Responses

Psychosocial factors in research on cannabinoids

Brenda Coldwell
bmj.com, 14 Jul 2001 [Full text]

Cannabis exacerbating pain

Sian Koppel
bmj.com, 31 Jul 2001 [Full text]

Endpoints need to be clinically relevant

Jean Potter
bmj.com, 7 Aug 2001 [Full text]