PRECEPTOR: RONALD HERMAN A REVIEW OF THE EVIDENCE FOR MEDICAL CANNABIS BASED ON APPROVED CONDITIONS IN IOWA AUTHORS: RYAN MOLANDER, SARAH KADURA, SPENCER SMYTHE, AND NICKOLAS SCOTT PRECEPTOR: RONALD HERMAN BACKGROUND On May 12, 2017, Governor Branstad signed a new Medical Cannabidiol Act, House File 524 from the Iowa legislature.  The current Act will approve medical cannabis for patients with this list of conditions: cancer, if the underlying condition or treatment produces one or more of the following; severe or chronic pain, nausea/severe vomiting, or cachexia/severe wasting, multiple sclerosis with severe and persistent muscle spasms, seizures- including those characteristic of epilepsy, AIDS or HIV, Crohn’s disease, amyotrophic lateral sclerosis, any terminal illness with a probable life expectancy of under one year, if the illness or its treatment produces one or more of the following; severe/chronic pain, nausea/severe vomiting, cachexia/severe wasting, Parkinson's disease, and untreatable pain. NAUSEA/VOMITING According to NASEM: There is conclusive evidence that oral cannabinoids are effective antiemetics in the treatment of chemotherapy-induced nausea and vomiting 51 additional studies not included in the NASEM showing evidence for medical marijuana as an antiemetic  MUSCULAR AND NEUROLOGICAL DISORDERS NASEM Recommendation for muscular and neurologic disorders: Epilepsy - insufficient evidence MS - substantial evidence that oral cannabinoids are an effective treatment for improving patient-reported multiple sclerosis spasticity symptoms, but limited evidence for an effect on clinician-measured spasticity.     Paralysis due to spinal cord injury - insufficient evidence ALS - insufficient evidence  Parkinson's Disease - insufficient evidence CONCLUSIONS Nausea/Vomiting: There is conclusive evidence for oral cannabinoids as effective anti-emetics in treatment of chemotherapy induced nausea and vomiting. Analgesia: There is consistent evidence that suggests that cannabinoids demonstrate a modest effect on chronic pain Muscular & Neurologic Disorders: With the exception of MS, there was insufficient evidence to support or refute use of cannabinoids for treatment of muscular and neurologic disorders. Cachexia & Wasting: There is some evidence for oral cannabinoids being able to increase weight in patients with HIV-associated wasting syndrome and anorexia nervosa. No benefit has been demonstrated in cancer-associated anorexia-cachexia syndrome OBJECTIVE The purpose of this project is to review studies that determine the safety and efficacy of medical marijuana use for the different disease states as specified by Iowa's state law.  Many prescribers are still hesitant of prescribing marijuana to their patients due to the lack of education on the subject. We thoroughly evaluated current and past studies of medical marijuana is various dosage forms and strengths from multiple databases to help guide physician decision-making when prescribing medical cannabis for the specified conditions. ANALGESIA According to NASEM: there is consistent evidence that suggests that cannabinoids demonstrate a modest effect on pain.  Majority of the studies were from a systematic review, Whiting et al 2015 which examined 28 RCTs treating chronic pain. There was also 48 other studies after narrowing down the original abstracts included that demonstrated a modest effect on pain not mentioned in NASEM. Studies performed mainly used inhaled cannabis in the flower form or an oral mucosal spray called Sativex. Due to time constraints we were not fully able to do a traditional systematic review.  Currently, there is one RCT in the recruiting phase that will compare THC vs CBD vs placebo with different dosages.  CACHEXIA AND WASTING The NASEM report identified 2 good systematic reviews that examined use for cachexia in HIV/AIDS.​ Whiting et al. (2015) assessed four randomized controlled trials involving 255 patients​. All four studies included dronabinol, with one investigating inhaled cannabis as well. Three trials were placebo-controlled, and one used the progestational agent megestrol acetate as the comparator.​ A second systematic review (Lutge et al., 2013) focused on morbidity and mortality in HIV/AIDS as the primary outcomes, with changes in appetite and weight as secondary endpoints. Seven RCTs conducted between 1993 and 2009 were included in the qualitative analysis. The trials compared dronabinol or inhaled cannabis with a placebo or with each other.​ There were no good or fair systematic reviews that reported on cannabis or cannabinoids as effective treatments for cancer-associated anorexia-cachexia syndrome or for anorexia nervosa.  ​ There were no studies identified in the database search for evidence of the treatment of cachexia and wasting outside of those that were included in the NASEM report. REFERENCES National Academies of Sciences, Engineering, and Medicine. 2017. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, DC: The National Academies Press. Whiting PF, Wolff RF, Deshpande S, Di Nisio M, Duffy S, Hernandez AV, Keurentjes JC, Lang S, Misso K, Ryder S, Schmidlkofer S, Westwood M, Kleijnen J. Cannabinoids for Medical Use: A Systematic Review and Meta-analysis. JAMA. 2015 METHODS We used the databases PubMed, Embase, CINAHL, and IPA to find articles demonstrating high quality evidence for the use of cannabidiol in each of the approved indications from the new Medical Cannabidiol Act.  Our search strategy includes splitting the conditions into “cachexia/wasting”, “nausea/vomiting”, “pain”, and “neurological” and reviewing literature that addresses CBD’s ability to treat these symptoms. While carrying out the search on the databases, we decided to limit the criteria to English-only publications and human trials, and only use information from randomized control trials, systematic reviews, or controlled clinical trials.