Sativex (nabiximols) - factsheet
Date of issue: August 2013
Updated with funding for Sativex in England - October 2014
This factsheet will be reviewed within three years
Sativex was the first cannabis-based medicine to be licensed in the UK. It is licensed for use in MS-related spasticity (muscle stiffness) when people have found that other medicines have not worked well or found their side effects intolerable.
What is Sativex?
Sativex is a mouth (oromucosal) spray formulated from two chemical extracts derived from the cannabis plant and contains delta-9 tetrahydrocannabinol (THC) and cannabidiol (CBD).
How does Sativex work?
The way that cannabis derivatives, like Sativex, work is not fully understood but discovery of the cannabinoid receptors, a natural system of receptors in the human body, has provided some insight. Receptors are protein molecules in or on the surface of cells to which a substance (such as a drug) can bind, causing a change in cell behaviour or activity. The active ingredients of Sativex exert their effects upon the CB1 receptor in the brain and the CB2 receptor in the immune system.
Who can be prescribed Sativex?
The established anti-spasticity drugs, such as baclofen, tizanidine, gabapentin, pregabalin and clonazepam, remain the first line treatments for MS spasticity. If these treatments are not working well or have intolerable side effects, Sativex may be considered. The addition of Sativex means that it may be possible to decrease the dose of other anti-spasticity medication and so decrease any troublesome side effects.
Clinical trials investigating the effects of Sativex on MS spasticity demonstrated that those people who experienced improvement (48%) did so within four weeks of receiving the medicine1-4. Consequently, Sativex is prescribed for a trial period, usually four weeks, in the first instance. If there is no clear improvement in spasticity-related symptoms, Sativex will be stopped.
Treatment with Sativex must be started and supervised by a specialist doctor with experience of treating people with MS spasticity such as a neurologist, consultant rehabilitation specialist or consultant pain specialist. In some areas, GPs can write prescriptions for Sativex but only under instruction from a specialist.
The specialist doctor will conduct a full assessment of the severity of the spasticity and an evaluation of the response to standard spasticity treatments before considering if the person might benefit from Sativex.
How effective is Sativex in treating MS spasticity?A phase III clinical trial4 investigating the effects of Sativex in over 500 people showed that 48% of participants had 20% or more improvement in their spasticity. Amongst those who responded, about three quarters had an improvement of greater than 30% in their spasticity score within four weeks when compared with those taking a placebo. Combined analysis of three clinical trials confirmed the effectiveness of Sativex5.
How often is Sativex taken?
Sativex is sprayed into the mouth either on the inside of the cheek or under the tongue. The severity of spasticity symptoms varies from one person to another so the number of sprays needed depends on the individual. At the start of treatment, the prescribing doctor will advise on frequency and timing of mouth sprays and may suggest a gradual increase until the most effective dose is found.
The maximum dose of Sativex is 12 sprays per day. A gap of at least 15 minutes should be left between sprays. The doses can be spread over the day in a way that suits the individual. The effectiveness of treatment should be assessed from time to time to see if it should be continued.
What are the side effects?
You must not drive or use machinery when you first start Sativex and until you are on a regular daily dose.
The most common side effects are fatigue or dizziness. These tend to occur in the first four weeks of treatment and wear off over time. Side effects can also be reduced by taking fewer sprays or waiting longer between sprays. Some people report pain in their mouths at the sites where the spray is administered. To minimise this, sites should be alternated as much as possible. Sativex has occasionally caused a brief loss of consciousness. People who experience any significant side effects should not drive, operate machinery or take part in any activity that could prove hazardous.
As Sativex is derived from cannabis, there were initial concerns that it might cause drug dependence, be psychoactive or cause withdrawal symptoms. However, studies into long-term use of Sativex in people with MS showed that sudden discontinuation of treatment did not result in any significant withdrawal-like symptoms although some people reported temporary changes in their sleeping patterns, mood or appetite following discontinuation. The lack of withdrawal symptoms suggests that dependence on the treatment is highly unlikely6,7. In addition, Sativex did not affect cognition (thinking or memory) or induce any mental health problems at the doses used8.
Does Sativex interact with other medicines?
The prescribing doctor should be made aware of all other medications that the person is taking including over the counter and herbal medicines. Particular care should be taken if this includes any sleeping pills, sedatives or other drugs with sedative effects as combining these medicines with Sativex may cause increased sleepiness.
Also, Sativex is often given in addition to other anti-spasticity medication. The addition of Sativex needs careful monitoring as there may be an increased risk of falls until the best dose has been established.
Sativex may interact with alcohol and can affect coordination, concentration and the ability to respond quickly. Alcohol should be avoided especially at the beginning of treatment or when changing dose.
Who should not be prescribed Sativex?
People should not be prescribed Sativex if they:
- Have an allergy to cannabinoids or the other ingredients of Sativex propylene glycol, ethanol and peppermint oil
- Have a known or suspected personal history, or family history, of schizophrenia, psychosis or other significant psychiatric disorder. This does not include depression which is part of the person's MS symptoms
- Are breastfeeding.
Specialists may be cautious in prescribing Sativex to people who:
- Are under 18 years of age due to lack of safety and efficacy data
- Have epilepsy or regular fits (seizures)
- Have liver, kidney or heart problems
- Are elderly, due to the increased risk of falls
- Have previously abused any drug or substance
- Are pregnant or plan to become pregnant. Sativex should not be used unless the doctor believes the benefits of treatment outweigh the potential risks posed to the baby
Both men and women receiving Sativex should use effective contraception during treatment and for three months after stopping Sativex.
Funding of Sativex
In October 2014, NICE (the National Institute for Health and Care Excellence) published Clinical Guideline 186 Multiple sclerosis: management of multiple sclerosis in primary and secondary care. In this, they made the recommendation "Do not offer Sativex to treat spasticity in people with MS because it is not a cost effective treatment". NICE Guidelines apply to NHS care in England.
Despite this recommendation, specialists may submit an individual funding request (IFR) if they can make the case that the individual will benefit. IFRs are not always granted, meaning that some people opt to pay for Sativex themselves. The cost of fulfilling a private prescription varies widely depending on the pharmacy so it is worth calling around for the best price.
In April 2011, the Scottish Medicines Consortium (SMC), which plays the equivalent role to NICE for the NHS in Scotland, announced that it was unable to recommend Sativex within the NHS in Scotland as it had not received a submission from the holder of the marketing authorisation. However, an individual patient treatment request (IPTR) can be made.
In August 2014, Sativex was approved for use within NHS Wales. It can be used as a treatment for symptom improvement in adult patients with moderate to severe spasticity due to MS who have not responded adequately to other anti-spasticity medication and who demonstrate clinically significant improvement in spasticity related symptoms during an initial trial of therapy.
Travelling abroad with Sativex
Sativex is a controlled drug and its legal status varies between countries. People taking Sativex should check its legal status in the countries to which they are travelling by contacting the Embassy, Consulate or High Commission of each country for information about the rules on carrying controlled drugs.
Driving while taking Sativex may be illegal in some countries.
People leaving the UK with Sativex will need a letter from their prescribing doctor that includes:
- name, address, date of birth
- outward and return dates of travel
- the countries being visited
- the name, total amount and strength of the medicine being carried.
They will not need a Home Office license if they are travelling for less than three months or carrying less than three months supply of medicine. Information on travelling abroad with Sativex is available at www.gov.uk/travelling-controlled-drugs
When travelling through airport security, the current rules on carrying medicines and carrying liquids will both apply.
Sativex for other symptoms and conditions
Sativex has also been studied for its effects on a number of other MS-related symptoms including spasticity and spasms, pain, bladder symptoms9, tremor and sleep disturbance. Sativex is still in development as a possible treatment for cancer pain and neuropathic pain, including in MS. It is not licensed for these uses as they are still experimental.
Legal position of Sativex and cannabis
Sativex was the first cannabis-based medicine to be licensed in the UK. It is a class B drug and can only be lawfully possessed under a prescription issued by a qualified health professional. Passing Sativex to someone else, unless that person is lawfully entitled to possess the drug, amounts to unlawful supply of a controlled substance.
In contrast, 'street' cannabis is an illegal drug and is not currently recognised in law as having any medicinal value. The penalties for possessing or using cannabis are significant. Recent legal cases have indicated that the law makes no exception for people using or supplying cannabis to help relieve medical symptoms.
Cannabis and its derivatives are being tested in ongoing clinical trials. More information is available in the 'cannabis' entry of our A to Z of MS .
For further information on spasticity see the MS Trust's Spasticity and spasms factsheet. The Spasticity triggers resource is an aid to identifying factors that can make spasticity worse. Both can be ordered on the MS Trust website or by calling 0800 032 3839
Collin C, Ambler Z, Kent R, et al.
A randomised controlled study of Sativex in patients with symptoms of spasticity due to multiple sclerosis.
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