Page 44 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 15 of 26 Guideline

TABLE 5: Recommendations for cannabinoid use in symptom management of HIV/palliative care. 72
Symptoms and recommended medication Medication and/or evidence Comment on medication and route of administration
Nausea and vomiting
Dronabinol and the CBMs Antiemetic effects when CB1 receptors activated by THC. THC-rich products: Inhaled.
Dronabinol - Superior anti-emetic activity versus neuroleptics in cancer patients.
Synergistic effect for dronabinol and prochlorperazine.
Non-inferiority for dronabinol versus 5-HT3 antagonists.
CBMs’ - Greater activity of CBMs in suppressing anticipatory nausea in
pre-clinical model.
Pain
Dronabinol Dose: 10 mg better than 20 mg THC-rich products
Efficacy: Mild analgesic effect comparable to 60 mg THC/CBD 1:1
codeine
Adverse reactions (20 mg): dizziness, somnolence, ataxia, Inhaled: Breakthrough pain/ pain crises = immediate benefit.
blurred vision
Nabiximols Low dose (1–4 sprays/day) Oral: Persistent pain (‘long-acting’ effect)
Medium dose (6–10 sprays/day)
High dose (11–16 sprays/day)
- Analgesia with low and medium dose versus placebo, poor drug
tolerability with high dose
Natural cannabinoids - Reduction in pain intensity, opioid-sparing potential, synergism effect
with opioids
- Improvement in pain measures with the use of cannabinoids
compared with placebo.
Benefit from the use of inhaled cannabis treatments for neuropathic
pain.
Prevention of chemotherapy-induced neuropathy in pre-clinical
studies.
Appetite stimulation
Dronabinol Increased appetite and weight stability in HIV/AIDS and THC-rich products: Inhaled or oral
dementia
Natural cannabinoids versus megesterol - Findings favour megesterol
acetate for cancer anorexia
THC efficacy per dose THC 2.5 mg versus THC 2.5 mg + CBD 1 mg versus placebo No significant improvements in survival, weight or other nutritional
variables.
Smoked cannabis - Increased weight with smoked cannabis in experienced HIV+
marijuana smokers
Oral Dronabinol - Improved taste, smell and food enjoyment reported
Insomnia
THC-rich products Inhaled: Sleep induction Association between cannabinoids and improved sleep quality
Oral: Sleep maintenance
THC-rich products Inhaled: Sleep induction Lack of evidence in cancer and palliative care population
Oral: Sleep maintenance
Depression and anxiety
Nabiximols High doses have negative effect in depression, positive Anxiety: CBD-rich
results for anxiety disorders Depression: THC-rich or THC/CBD 1:1
Inhaled: Panic attacks or anxiety
CBD-rich products Recommended for patients with psychiatric disease Oral: For persistent symptoms
THC May exacerbate for example, schizophrenia, psychosis -
and bipolar disorder
Source: Cyr C, Arboleda MF, Kumar S, et al. Cannabis in palliative care: Current challenges and practical recommendations. Ann Palliat Med. 2018;7(4):463–477. https://doi.org/10.21037/
apm.2018.06.04
THC, tetrahydrocannabinol; CBD, cannabinoid-drug.

ß Cervical and anal Pap smears be strengthened. Antiretroviral drugs and regimens are
ß The early introduction of ART. Uncontrolled plasma constantly changing, drug–drug interactions and
(HIV) viral load is associated with the increased risk toxicities are common, and secondary infection with
of malignancy in the HIV-infected cancer patients. 68,69 opportunistic microbes frequently occurs. A team
• Baseline determination of HIV status of every cancer approach is required to improve the survival outcome in
patient. Survival of the HIV and cancer patient requires this group of patients.
access to ART and long-term suppression of HIV. 70,71
• Linkage to care. The ethos of this care is holistic, that is,
oncology, HIV-caregivers and the palliative care team The cannabinoid drugs in
work together in the support of the patient. the palliative management of
• Collaboration is needed between oncology and HIV-infected patients.
radiotherapy and the disciplines of HIV/infectious
diseases and palliative care. Cancer care in SA must be South African courts have recently legalised cannabis for
sensitive to the needs of the HIV-infected people, and medical use. Data on HIV-infected people are sparse and
greater collaboration between HIV, palliative care restricted to observational reports, and although the use of
physicians and oncology and radiotherapy specialists these compounds is widespread both in Africa and globally,
must take place if weak links in healthcare delivery are to the hostility to its use is slowly changing. Nonetheless, data

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