Dronabinol for the Treatment of Paraneoplastic Night Sweats in Cancer Patients: A Report of Five Cases Connie Carr, LTC (USAR RET), MSN, FNP-BC, 1 Haley Vertelney, BS, 2 Joshua Fronk, DO, 3 and Sandy Trieu, MD 4 Abstract Background: Night sweats significantly impact the quality of life for cancer patients and are often resistant to treatment. Cannabinoids have been shown to modulate cytokine activity and produce hypothermia in animal models, suggesting that they may be a promising candidate for palliation of night sweats in patients with oncologic disease. Objective: Assess efficacy of the oral cannabinoid, dronabinol, for palliation of night sweats in cancer patients. Design: A retrospective record search identified five cancer patients who had tried oral dronabinol for palliation of their night sweats between 2013 and 2016 and subjectively reported on its efficacy. Setting/Subjects: A convenience sample of five patients from the outpatient consultative palliative medicine program at Stanford Medical Center was chosen from a search of past records. Patients were included if they had a cancer diagnosis and complained of night sweats that subjectively interfered with their quality of life. All agreed to try oral dronabinol for palliation of their night sweats. Measurements: Patients self-reported the effect of oral synthetic dronabinol on their night sweats. Results: Treatment of five patients with advanced cancer with synthetic orally administered dronabinol resulted in the successful management of persistent symptomatic paraneoplastic night sweats. Conclusion: Dronabinol and/or medicinal cannabis are promising therapies for palliation of night sweats in cancer patients. Keywords: cannabis; dronabinol; night sweats Introduction P ersistent sweating secondary to cancer and cancer therapies can substantially impact the quality of life for patients with an oncologic diagnosis. Hot flushes are vaso- motor symptoms that present as periodic episodes of heat sensation. Often worse at night, they disrupt patients’ sleep patterns, and they are frequently accompanied by palpitations and anxiety. These night sweats result in physical and emo- tional fatigue, depression, and reduced function, promoting a vicious cycle associated with the anorexia-cachexia syn- drome that often afflicts cancer patients. 1–4 Hot flashes affect 50–85% of menopausal women, 5 with an incidence of 65–85% in breast cancer patients due to anti- estrogen therapies. 6 An association between night sweats and sleep disruptions, including awakenings for pain, has been reported in male patients. 2 Studies indicate the prevalence of night sweats in the paraneoplastic population ranges from 10% to 48%, 1,7 presenting a major challenge in the symp- tomatic treatment of this group. The exact mechanism for hot flushes is unknown. In gen- eral, sweating is stimulated when a hypothalamic response is triggered by fluctuations in core body temperatures, which can fluctuate nocturnally. 2 An abrupt change in the levels of sex steroids can alter homeostatic regulation by the hypo- thalamus and has been proposed as a contributory mecha- nism. 1–3 This is particularly relevant in patients on hormonal therapies. Up to 80% of breast cancer survivors experi- ence hot flushes, particularly if they are taking or have taken Tamoxifen or similar estrogen receptor antagonists for 1 School of Nursing, San Francisco State University, San Francisco, California. 2 David Geffen School of Medicine at UCLA, Los Angeles, California. 3 Oncology Palliative Care, 4 Palliative Medicine, Stanford University School of Medicine, Stanford, California. Accepted December 23, 2018. JOURNAL OF PALLIATIVE MEDICINE Volume 22, Number 10, 2019 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2018.0551 1221 Downloaded by 27.70.129.20 from www.liebertpub.com at 03/23/23. For personal use only.
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JPM-2018-0551-ver9-Carr_3P 1221..1223Dronabinol for the Treatment of Paraneoplastic Night Sweats in Cancer Patients:
A Report of Five Cases
Connie Carr, LTC (USAR RET), MSN, FNP-BC,1 Haley Vertelney, BS,2
Joshua Fronk, DO,3 and Sandy Trieu, MD4
Abstract
Background: Night sweats significantly impact the quality of life for cancer patients and are often resistant to treatment. Cannabinoids have been shown to modulate cytokine activity and produce hypothermia in animal models, suggesting that they may be a promising candidate for palliation of night sweats in patients with oncologic disease. Objective: Assess efficacy of the oral cannabinoid, dronabinol, for palliation of night sweats in cancer patients. Design: A retrospective record search identified five cancer patients who had tried oral dronabinol for palliation of their night sweats between 2013 and 2016 and subjectively reported on its efficacy. Setting/Subjects: A convenience sample of five patients from the outpatient consultative palliative medicine program at Stanford Medical Center was chosen from a search of past records. Patients were included if they had a cancer diagnosis and complained of night sweats that subjectively interfered with their quality of life. All agreed to try oral dronabinol for palliation of their night sweats. Measurements: Patients self-reported the effect of oral synthetic dronabinol on their night sweats. Results: Treatment of five patients with advanced cancer with synthetic orally administered dronabinol resulted in the successful management of persistent symptomatic paraneoplastic night sweats. Conclusion: Dronabinol and/or medicinal cannabis are promising therapies for palliation of night sweats in cancer patients.
Keywords: cannabis; dronabinol; night sweats
Introduction
Persistent sweating secondary to cancer and cancer therapies can substantially impact the quality of life for
patients with an oncologic diagnosis. Hot flushes are vaso- motor symptoms that present as periodic episodes of heat sensation. Often worse at night, they disrupt patients’ sleep patterns, and they are frequently accompanied by palpitations and anxiety. These night sweats result in physical and emo- tional fatigue, depression, and reduced function, promoting a vicious cycle associated with the anorexia-cachexia syn- drome that often afflicts cancer patients.1–4
Hot flashes affect 50–85% of menopausal women,5 with an incidence of 65–85% in breast cancer patients due to anti- estrogen therapies.6 An association between night sweats and
sleep disruptions, including awakenings for pain, has been reported in male patients.2 Studies indicate the prevalence of night sweats in the paraneoplastic population ranges from 10% to 48%,1,7 presenting a major challenge in the symp- tomatic treatment of this group.
The exact mechanism for hot flushes is unknown. In gen- eral, sweating is stimulated when a hypothalamic response is triggered by fluctuations in core body temperatures, which can fluctuate nocturnally.2 An abrupt change in the levels of sex steroids can alter homeostatic regulation by the hypo- thalamus and has been proposed as a contributory mecha- nism.1–3 This is particularly relevant in patients on hormonal therapies. Up to 80% of breast cancer survivors experi- ence hot flushes, particularly if they are taking or have taken Tamoxifen or similar estrogen receptor antagonists for
1School of Nursing, San Francisco State University, San Francisco, California. 2David Geffen School of Medicine at UCLA, Los Angeles, California. 3Oncology Palliative Care, 4Palliative Medicine, Stanford University School of Medicine, Stanford, California. Accepted December 23, 2018.
JOURNAL OF PALLIATIVE MEDICINE Volume 22, Number 10, 2019 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2018.0551
1221
y.
treatment.8 Similarly, 34–80% of prostate cancer patients on androgen deprivation therapy report experiencing hot flu- shes.9 Cancer cells release pro-inflammatory cytokines such as tumor necrosis factor-a, interleukin (IL)-1, and IL-6, all of which can contribute to flushing and sensation of heat and are associated with the anorexia-cachexia syndrome.1,2 Regard- less of etiology, these symptoms present a key problem in treatment of this population based on both their prevalence and disruption of quality of life.1
Various treatments have been proposed and studied to ad- dress night sweats. Traditional treatment options include both hormonal and non-hormonal pharmacotherapies, as well as integrative therapies such as cognitive-based therapy, yoga, acupuncture, and relaxation techniques.4,10–13 Selective serotonin reuptake inhibitors (SSRIs), a-adrenergic agonists, b-blockers, antidopaminergic agents, aromatase inhibitors, vitamin E, gabapentin, progesterone, thalidomide, black co- hosh, and soy phytoestrogens have all been proposed but are generally not used due to lack of efficacy or side effects.3,7,14–19
Cannabinoids are commonly used for treatment of nausea, neuropathic pain, and anorexia in cancer patients.20 Some studies support the use of nabilone, a synthetic analogue of 9- tetrahydroxycannabinol (9-THC), in the treatment of night sweats in cancer patients as well.1 Nabilone is an agonist at CB1 and CB2 receptors that has been used outside the United States for the treatment of hot flushes in cancer patients. Cannabinoids have been shown to modulate cytokine activity as well as produce hypothermia in mouse models, and it is
possible that nabilone is effective in mitigating night sweats by these methods.1 However, since nabilone is unavailable in the United States, dronabinol should be investigated as a potential candidate for palliation of night sweats because it is available and works by a similar mechanism. The following describes case reports of five patients with metastatic disease who were suffering from paraneoplastic night sweats and whose symp- toms were subjectively palliated with dronabinol.
Method/Case Descriptions
A retrospective search of past medical records identified a convenience sample of five patients with oncologic disease who complained of night sweats that meaningfully interfered with their quality of life and were resistant to traditional therapies. All patients had established care with the outpa- tient consultative palliative medicine program at Stanford Medical Center; they agreed to try ‘‘off label’’ oral drona- binol for palliation of their night sweats between 2013 and 2016 and subjectively reported on its efficacy. Each patient had a comprehensive evaluation by the palliative care team for symptom management and quality of life issues. Patients were excluded if determined to be medically incompetent to make decisions regarding their care.
Patients were asked to describe their symptoms in quali- tative terms at the initial visit and at each subsequent out- patient visit. Edmonton Symptom Assessment System (ESAS) questionnaires are generally obtained from all pa- tients to determine severity of symptoms such as pain, nau- sea, shortness of breath, fatigue, and anxiety. Although ESAS evaluates well-being, it does not specifically address night sweats, and therefore, it was not used to evaluate the specific case reports on these patients with night sweats. The patients’ verbal statements were used as evaluation of the therapy.
Patients ranged in age from 29 to 72 years (Table 1). Two patients were female and three were male. Two were diag- nosed with Acute Myeloblastic Leukemia and the others with colon cancer, rectal cancer, and breast cancer. Patients were at different stages in their disease-modifying therapies. All participants underwent a thorough evaluation by the pallia- tive care team and were medically stable at time of treatment. None of the patients were found to be febrile or have acute symptoms of infection. Medication review did not suggest
Table 1. Patient Characteristics
(years) Diagnosis
1 F 67 Relapsed AML, hemochromatosis 2 M 72 Rectal cancer, metastases to lung
and bone. Likely paraneoplastic syndrome
3 F 50 Ductal carcinoma in situ of breast 4 M 47 Metastatic colon cancer 5 M 29 AML s/p allogenic stem cell
transplant
Description of symptom Dronabinol dose Follow-up Response to Dronabinol
1 Frequent change of clothing, bedding, and disruption of restorative sleep.
5 mg HS One month ‘‘This is the first time I haven’t been waking up all drenched.’’ (phone FU 1 week)
2 ‘‘Cold sweats’’ · 2 months interfering with daytime activity. Awake multiple times a night with wet pajamas.
2.5 mg BID One month ‘‘Cold sweats resolved. No more wet pajamas.’’
3 ‘‘Awake multiple times at night with sweats.’’
5 mg three times daily, increased to 10 mg three times daily
One month ‘‘Able to sleep through the night without sweats.’’
4 ‘‘Wake up 2–3 times nightly drenched.’’ 5 mg HS One month ‘‘No night sweats after 3 nights.’’ 5 Significant night and day sweats, also
associated with ADLs such as getting dressed
5 mg HS One month ‘‘Profuse sweating episodes have improved significantly.’’
ADLs, activities of daily living; FU, follow up; HS, bedtime.
1222 CARR ET AL.
y.
any known cause of night sweats. All patients had reported night sweats as a major cause of distress for several weeks. Patients were re-evaluated in clinic monthly, but phone follow-up was obtained after the first week to evaluate effi- cacy of the medication.
Three patients were given 5 mg at bedtime (HS) and one was started at 5 mg TID and subsequently titrated up to 10 mg TID due to increased symptoms (Table 2). One elderly pa- tient was started at 2.5 mg BID. Patients were evaluated on the next scheduled visit one to four weeks after therapy was initiated. After three days of initiating therapy, one patient reported a change in the severity of night sweats. Two pa- tients reported a complete resolution of night sweats. The other three patients reported a decrease in the severity of their night sweats, resulting in them only having to change clothes once or not at all in the night. One patient decided to stop the dronabinol due to sedation and reported that his night sweats returned when it was discontinued.
Discussion
Although there is limited evidence for use of dronabinol in the treatment of night sweats, it was subjectively successful in palliating this symptom in a limited number of patients with oncologic disease. The five patients we examined originally described their night sweats as greatly interfering with their sleep, which negatively impacted their daytime quality of life as well. Once the patients experienced reso- lution of their night sweats, other symptoms such as anxiety and fatigue improved as well, which lead to an improvement of their overall quality of life. Symptoms resolved in less than one week of initiating the dronabinol for all five patients.
Our study was limited by its retrospective nature and small sample size. Future research could benefit from a double- blinded randomized trial of dronabinol versus placebo treat- ment for the management of night sweats in patients with oncologic disease. The development of standardized forms to better objectify patients’ responses to dronabinol and to evaluate for night flush management would be beneficial as well. Medical cannabis is legal in multiple states and contin- ued research into its potential therapeutic value is necessary.
Author Disclosure Statement
References
1. Maida V: Nabilone for the treatment of paraneoplastic night sweats: A report of four cases. J Palliat Med 2008;6:929–934.
2. Mold JW, Holtzclaw BJ, McCarthy L: Night sweats: A systematic review of the literature. J Am Board Fam Med 2012;6:878–893.
3. Kligman L, Younus J: Management of hot flashes in wo- men with breast cancer. Curr Oncol 2010;17:81–86.
4. Hutton B, Yazdi F, Bordeleau L, et al.: Comparison of physical interventions, behavioral interventions, natural health products, and pharmacologics to manage hot flashes in patients with breast or prostate cancer: Protocol for a systematic review incorporating network meta-analyses. Syst Rev 2015;4:114.
5. Schrock NM, Weikel J, Holland L, et al.: Pilot study to determine the effects of dronabinol on hot flash relief in breast cancer patients. J Clin Oncol 2004;8189–8189.
6. Kontos M, Agbaje OF, Rymer J, Fentiman IS: What can be done about hot flushes after treatment for breast cancer? Climacteric 2010;13:4–21.
7. Hong D, Bi L, Zhou J, et al.: Incidence of menopausal symptoms in postmenopausal breast cancer patients treated with aromatase inhibitors. Oncotarget 2017;8:40558– 40567.
8. Moon Z, Hunter MS, Moss-Morris R, Hughes LD: Factors related to the experience of menopausal symptoms in wo- men prescribed tamoxifen. J Psychosom Obstet Gynaecol 2017;38:226–235.
9. Frisk J: Managing hot flushes in men after prostate can- cer—A systematic review. Maturitas 2010;65:15–22.
10. Arico D, Raggi A, Ferri R: Cognitive behavioral therapy for insomnia in breast cancer survivors: A review of the literature. Front Psychol 2016;7:1162.
11. Lee MS, Kim KH, Choi SM, Emst E: Acupuncture for treating hot flashes in breast cancer patients: A systematic review. Breast Cancer Res Treat 2009;115:497.
12. Brown L, Bryant C, Brown VM, et al.: Self-compassion weakens the association between hot flushes and night sweats and daily life functioning and depression. Maturitas 2014;78:298–303.
13. Ayers B, Smith M, Hellier J, et al.: Effectiveness of group and self-help cognitive behavior therapy in reducing problematic menopausal hot flushes and night sweats (MENOS 2): A randomized controlled trial. Menopause 2012;19:749–59.
14. Loprinzi CL, Kugler JW, Sloan JA, et al.: Venlafaxine in management of hot flashes in survivors of breast cancer: A randomised controlled trial. Lancet 2000;35:2059–2063.
15. Loprinzi CL, Barton DL, Novotny PJ, et al.: Mayo Clinic and North Central Cancer Treatment Group hot flash studies: A 20-year experience. Menopause 2008;15(4 Pt 1):655–660.
16. Prior JC, Hitchcock CL: Progesterone for hot flush and night sweat treatment—Effectiveness for severe vasomotor symptoms and lack of withdrawal rebound. Gynecol En- docrinol 2012;28 Suppl 2:7–11.
17. Mao JJ, Xie, SX, Bowman MA, et al.: Abstract PD4–7: A randomized placebo-controlled trial of acupuncture and gabapentin for hot flashes among breast cancer survivors. In: 37th Annual CTRC-AACR San Antonio Breast Cancer Symposium, December 9–13, 2014.
18. Loibl S, Schwedler S, Stern-Kai T: Venlafaxine is superior to clonidine as treatment of hot flashes in breast cancer patients-a double-blind, randomized study. Ann Oncol 2006; 18:689–693.
19. Krasenska M: Treatment with aromatase inhibitors in postmenopausal women with breast cancer and the possi- bility of influencing side effects. Klin Onkol 2016;29 Suppl 3:S39–49.
20. Lawenda BD: Cannabis and cancer: Prescribe 5 different drugs or simply one botanical.your choice. Integr Oncol Essentials 2012.
Address correspondence to: Connie Carr, LTC (USAR RET), MSN, FNP-BC
School of Nursing San Francisco State University
1600 Holloway Avenue San Francisco, CA 94132
E-mail: [email protected]
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A Report of Five Cases
Connie Carr, LTC (USAR RET), MSN, FNP-BC,1 Haley Vertelney, BS,2
Joshua Fronk, DO,3 and Sandy Trieu, MD4
Abstract
Background: Night sweats significantly impact the quality of life for cancer patients and are often resistant to treatment. Cannabinoids have been shown to modulate cytokine activity and produce hypothermia in animal models, suggesting that they may be a promising candidate for palliation of night sweats in patients with oncologic disease. Objective: Assess efficacy of the oral cannabinoid, dronabinol, for palliation of night sweats in cancer patients. Design: A retrospective record search identified five cancer patients who had tried oral dronabinol for palliation of their night sweats between 2013 and 2016 and subjectively reported on its efficacy. Setting/Subjects: A convenience sample of five patients from the outpatient consultative palliative medicine program at Stanford Medical Center was chosen from a search of past records. Patients were included if they had a cancer diagnosis and complained of night sweats that subjectively interfered with their quality of life. All agreed to try oral dronabinol for palliation of their night sweats. Measurements: Patients self-reported the effect of oral synthetic dronabinol on their night sweats. Results: Treatment of five patients with advanced cancer with synthetic orally administered dronabinol resulted in the successful management of persistent symptomatic paraneoplastic night sweats. Conclusion: Dronabinol and/or medicinal cannabis are promising therapies for palliation of night sweats in cancer patients.
Keywords: cannabis; dronabinol; night sweats
Introduction
Persistent sweating secondary to cancer and cancer therapies can substantially impact the quality of life for
patients with an oncologic diagnosis. Hot flushes are vaso- motor symptoms that present as periodic episodes of heat sensation. Often worse at night, they disrupt patients’ sleep patterns, and they are frequently accompanied by palpitations and anxiety. These night sweats result in physical and emo- tional fatigue, depression, and reduced function, promoting a vicious cycle associated with the anorexia-cachexia syn- drome that often afflicts cancer patients.1–4
Hot flashes affect 50–85% of menopausal women,5 with an incidence of 65–85% in breast cancer patients due to anti- estrogen therapies.6 An association between night sweats and
sleep disruptions, including awakenings for pain, has been reported in male patients.2 Studies indicate the prevalence of night sweats in the paraneoplastic population ranges from 10% to 48%,1,7 presenting a major challenge in the symp- tomatic treatment of this group.
The exact mechanism for hot flushes is unknown. In gen- eral, sweating is stimulated when a hypothalamic response is triggered by fluctuations in core body temperatures, which can fluctuate nocturnally.2 An abrupt change in the levels of sex steroids can alter homeostatic regulation by the hypo- thalamus and has been proposed as a contributory mecha- nism.1–3 This is particularly relevant in patients on hormonal therapies. Up to 80% of breast cancer survivors experi- ence hot flushes, particularly if they are taking or have taken Tamoxifen or similar estrogen receptor antagonists for
1School of Nursing, San Francisco State University, San Francisco, California. 2David Geffen School of Medicine at UCLA, Los Angeles, California. 3Oncology Palliative Care, 4Palliative Medicine, Stanford University School of Medicine, Stanford, California. Accepted December 23, 2018.
JOURNAL OF PALLIATIVE MEDICINE Volume 22, Number 10, 2019 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2018.0551
1221
y.
treatment.8 Similarly, 34–80% of prostate cancer patients on androgen deprivation therapy report experiencing hot flu- shes.9 Cancer cells release pro-inflammatory cytokines such as tumor necrosis factor-a, interleukin (IL)-1, and IL-6, all of which can contribute to flushing and sensation of heat and are associated with the anorexia-cachexia syndrome.1,2 Regard- less of etiology, these symptoms present a key problem in treatment of this population based on both their prevalence and disruption of quality of life.1
Various treatments have been proposed and studied to ad- dress night sweats. Traditional treatment options include both hormonal and non-hormonal pharmacotherapies, as well as integrative therapies such as cognitive-based therapy, yoga, acupuncture, and relaxation techniques.4,10–13 Selective serotonin reuptake inhibitors (SSRIs), a-adrenergic agonists, b-blockers, antidopaminergic agents, aromatase inhibitors, vitamin E, gabapentin, progesterone, thalidomide, black co- hosh, and soy phytoestrogens have all been proposed but are generally not used due to lack of efficacy or side effects.3,7,14–19
Cannabinoids are commonly used for treatment of nausea, neuropathic pain, and anorexia in cancer patients.20 Some studies support the use of nabilone, a synthetic analogue of 9- tetrahydroxycannabinol (9-THC), in the treatment of night sweats in cancer patients as well.1 Nabilone is an agonist at CB1 and CB2 receptors that has been used outside the United States for the treatment of hot flushes in cancer patients. Cannabinoids have been shown to modulate cytokine activity as well as produce hypothermia in mouse models, and it is
possible that nabilone is effective in mitigating night sweats by these methods.1 However, since nabilone is unavailable in the United States, dronabinol should be investigated as a potential candidate for palliation of night sweats because it is available and works by a similar mechanism. The following describes case reports of five patients with metastatic disease who were suffering from paraneoplastic night sweats and whose symp- toms were subjectively palliated with dronabinol.
Method/Case Descriptions
A retrospective search of past medical records identified a convenience sample of five patients with oncologic disease who complained of night sweats that meaningfully interfered with their quality of life and were resistant to traditional therapies. All patients had established care with the outpa- tient consultative palliative medicine program at Stanford Medical Center; they agreed to try ‘‘off label’’ oral drona- binol for palliation of their night sweats between 2013 and 2016 and subjectively reported on its efficacy. Each patient had a comprehensive evaluation by the palliative care team for symptom management and quality of life issues. Patients were excluded if determined to be medically incompetent to make decisions regarding their care.
Patients were asked to describe their symptoms in quali- tative terms at the initial visit and at each subsequent out- patient visit. Edmonton Symptom Assessment System (ESAS) questionnaires are generally obtained from all pa- tients to determine severity of symptoms such as pain, nau- sea, shortness of breath, fatigue, and anxiety. Although ESAS evaluates well-being, it does not specifically address night sweats, and therefore, it was not used to evaluate the specific case reports on these patients with night sweats. The patients’ verbal statements were used as evaluation of the therapy.
Patients ranged in age from 29 to 72 years (Table 1). Two patients were female and three were male. Two were diag- nosed with Acute Myeloblastic Leukemia and the others with colon cancer, rectal cancer, and breast cancer. Patients were at different stages in their disease-modifying therapies. All participants underwent a thorough evaluation by the pallia- tive care team and were medically stable at time of treatment. None of the patients were found to be febrile or have acute symptoms of infection. Medication review did not suggest
Table 1. Patient Characteristics
(years) Diagnosis
1 F 67 Relapsed AML, hemochromatosis 2 M 72 Rectal cancer, metastases to lung
and bone. Likely paraneoplastic syndrome
3 F 50 Ductal carcinoma in situ of breast 4 M 47 Metastatic colon cancer 5 M 29 AML s/p allogenic stem cell
transplant
Description of symptom Dronabinol dose Follow-up Response to Dronabinol
1 Frequent change of clothing, bedding, and disruption of restorative sleep.
5 mg HS One month ‘‘This is the first time I haven’t been waking up all drenched.’’ (phone FU 1 week)
2 ‘‘Cold sweats’’ · 2 months interfering with daytime activity. Awake multiple times a night with wet pajamas.
2.5 mg BID One month ‘‘Cold sweats resolved. No more wet pajamas.’’
3 ‘‘Awake multiple times at night with sweats.’’
5 mg three times daily, increased to 10 mg three times daily
One month ‘‘Able to sleep through the night without sweats.’’
4 ‘‘Wake up 2–3 times nightly drenched.’’ 5 mg HS One month ‘‘No night sweats after 3 nights.’’ 5 Significant night and day sweats, also
associated with ADLs such as getting dressed
5 mg HS One month ‘‘Profuse sweating episodes have improved significantly.’’
ADLs, activities of daily living; FU, follow up; HS, bedtime.
1222 CARR ET AL.
y.
any known cause of night sweats. All patients had reported night sweats as a major cause of distress for several weeks. Patients were re-evaluated in clinic monthly, but phone follow-up was obtained after the first week to evaluate effi- cacy of the medication.
Three patients were given 5 mg at bedtime (HS) and one was started at 5 mg TID and subsequently titrated up to 10 mg TID due to increased symptoms (Table 2). One elderly pa- tient was started at 2.5 mg BID. Patients were evaluated on the next scheduled visit one to four weeks after therapy was initiated. After three days of initiating therapy, one patient reported a change in the severity of night sweats. Two pa- tients reported a complete resolution of night sweats. The other three patients reported a decrease in the severity of their night sweats, resulting in them only having to change clothes once or not at all in the night. One patient decided to stop the dronabinol due to sedation and reported that his night sweats returned when it was discontinued.
Discussion
Although there is limited evidence for use of dronabinol in the treatment of night sweats, it was subjectively successful in palliating this symptom in a limited number of patients with oncologic disease. The five patients we examined originally described their night sweats as greatly interfering with their sleep, which negatively impacted their daytime quality of life as well. Once the patients experienced reso- lution of their night sweats, other symptoms such as anxiety and fatigue improved as well, which lead to an improvement of their overall quality of life. Symptoms resolved in less than one week of initiating the dronabinol for all five patients.
Our study was limited by its retrospective nature and small sample size. Future research could benefit from a double- blinded randomized trial of dronabinol versus placebo treat- ment for the management of night sweats in patients with oncologic disease. The development of standardized forms to better objectify patients’ responses to dronabinol and to evaluate for night flush management would be beneficial as well. Medical cannabis is legal in multiple states and contin- ued research into its potential therapeutic value is necessary.
Author Disclosure Statement
References
1. Maida V: Nabilone for the treatment of paraneoplastic night sweats: A report of four cases. J Palliat Med 2008;6:929–934.
2. Mold JW, Holtzclaw BJ, McCarthy L: Night sweats: A systematic review of the literature. J Am Board Fam Med 2012;6:878–893.
3. Kligman L, Younus J: Management of hot flashes in wo- men with breast cancer. Curr Oncol 2010;17:81–86.
4. Hutton B, Yazdi F, Bordeleau L, et al.: Comparison of physical interventions, behavioral interventions, natural health products, and pharmacologics to manage hot flashes in patients with breast or prostate cancer: Protocol for a systematic review incorporating network meta-analyses. Syst Rev 2015;4:114.
5. Schrock NM, Weikel J, Holland L, et al.: Pilot study to determine the effects of dronabinol on hot flash relief in breast cancer patients. J Clin Oncol 2004;8189–8189.
6. Kontos M, Agbaje OF, Rymer J, Fentiman IS: What can be done about hot flushes after treatment for breast cancer? Climacteric 2010;13:4–21.
7. Hong D, Bi L, Zhou J, et al.: Incidence of menopausal symptoms in postmenopausal breast cancer patients treated with aromatase inhibitors. Oncotarget 2017;8:40558– 40567.
8. Moon Z, Hunter MS, Moss-Morris R, Hughes LD: Factors related to the experience of menopausal symptoms in wo- men prescribed tamoxifen. J Psychosom Obstet Gynaecol 2017;38:226–235.
9. Frisk J: Managing hot flushes in men after prostate can- cer—A systematic review. Maturitas 2010;65:15–22.
10. Arico D, Raggi A, Ferri R: Cognitive behavioral therapy for insomnia in breast cancer survivors: A review of the literature. Front Psychol 2016;7:1162.
11. Lee MS, Kim KH, Choi SM, Emst E: Acupuncture for treating hot flashes in breast cancer patients: A systematic review. Breast Cancer Res Treat 2009;115:497.
12. Brown L, Bryant C, Brown VM, et al.: Self-compassion weakens the association between hot flushes and night sweats and daily life functioning and depression. Maturitas 2014;78:298–303.
13. Ayers B, Smith M, Hellier J, et al.: Effectiveness of group and self-help cognitive behavior therapy in reducing problematic menopausal hot flushes and night sweats (MENOS 2): A randomized controlled trial. Menopause 2012;19:749–59.
14. Loprinzi CL, Kugler JW, Sloan JA, et al.: Venlafaxine in management of hot flashes in survivors of breast cancer: A randomised controlled trial. Lancet 2000;35:2059–2063.
15. Loprinzi CL, Barton DL, Novotny PJ, et al.: Mayo Clinic and North Central Cancer Treatment Group hot flash studies: A 20-year experience. Menopause 2008;15(4 Pt 1):655–660.
16. Prior JC, Hitchcock CL: Progesterone for hot flush and night sweat treatment—Effectiveness for severe vasomotor symptoms and lack of withdrawal rebound. Gynecol En- docrinol 2012;28 Suppl 2:7–11.
17. Mao JJ, Xie, SX, Bowman MA, et al.: Abstract PD4–7: A randomized placebo-controlled trial of acupuncture and gabapentin for hot flashes among breast cancer survivors. In: 37th Annual CTRC-AACR San Antonio Breast Cancer Symposium, December 9–13, 2014.
18. Loibl S, Schwedler S, Stern-Kai T: Venlafaxine is superior to clonidine as treatment of hot flashes in breast cancer patients-a double-blind, randomized study. Ann Oncol 2006; 18:689–693.
19. Krasenska M: Treatment with aromatase inhibitors in postmenopausal women with breast cancer and the possi- bility of influencing side effects. Klin Onkol 2016;29 Suppl 3:S39–49.
20. Lawenda BD: Cannabis and cancer: Prescribe 5 different drugs or simply one botanical.your choice. Integr Oncol Essentials 2012.
Address correspondence to: Connie Carr, LTC (USAR RET), MSN, FNP-BC
School of Nursing San Francisco State University
1600 Holloway Avenue San Francisco, CA 94132
E-mail: [email protected]
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7. 70
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w w
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