Dronabinol

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# Overview
Dronabinol is a cannabinoid that is FDA approved for the treatment of anorexia associated with weight loss in patients with AIDS, and for the prophylaxis of nausea and vomiting associated with cancer chemotherapy.   Common adverse reactions include asthenia,abdominal pain, nausea, vomiting, palpitations, tachycardia, vasodilation,diarrhea, fecal incontinence.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)

# Indications
Dronabinol Capsules is indicated for the treatment of:
- Anorexia associated with weight loss in patients with AIDS; and
- Nausea and vomiting associated with cancer chemotherapy in patients who have failed to respond adequately to conventional antiemetic treatments.

# Dosage
Appetite Stimulation
- Initially, 2.5 mg dronabinol capsules should be administered orally twice daily (b.i.d.), before lunch and supper. For patients unable to tolerate this 5 mg/day dosage of dronabinol capsules, the dosage can be reduced to 2.5 mg/day, administered as a single dose in the evening or at bedtime. If clinically indicated and in the absence of significant adverse effects, the dosage may be gradually increased to a maximum of 20 mg/day dronabinol capsules, administered in divided oral doses. Caution should be exercised in escalating the dosage of dronabinol capsules because of the increased frequency of dose-related adverse experiences at higher dosages.
Antiemetic
- Dronabinol Capsules are best administered at an initial dose of 5 mg/m2, given 1 to 3 hours prior to the administration of chemotherapy, then every 2 to 4 hours after chemotherapy is given, for a total of 4 to 6 doses/day. Should the 5 mg/m2 dose prove to be ineffective, and in the absence of significant side effects, the dose may be escalated by 2.5 mg/m2 increments to a maximum of 15 mg/m2 per dose. Caution should be exercised in dose escalation, however, as the incidence of disturbing psychiatric symptoms increases significantly at maximum dose.

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Dronabinol in adult patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Dronabinol in adult patients.

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
There is limited information regarding FDA-Labeled Use of Dronabinol in pediatric patients.

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Dronabinol in pediatric patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Dronabinol in pediatric patients.

# Contraindications
- Dronabinol Capsules is contraindicated in any patient who has a known sensitivity to Dronabinol Capsules or any of its ingredients. It contains cannabinoid and sesame oil and should never be used by patients allergic to these substances.

# Warnings
- Patients receiving treatment with Dronabinol Capsules should be specifically warned not to drive, operate machinery, or engage in any hazardous activity until it is established that they are able to tolerate the drug and to perform such tasks safely.

## Precautions
General
- The risk/benefit ratio of Dronabinol Capsules use should be carefully evaluated in patients with the following medical conditions because of individual variation in response and tolerance to the effects of Dronabinol Capsules.
- Seizure and seizure-like activity have been reported in patients receiving dronabinol capsules during marketed use of the drug and in clinical trials. Dronabinol capsules should be used with caution in patients with a history of seizure disorder because dronabinol capsules may lower the seizure threshold. A causal relationship between dronabinol capsules and these events has not been established. Dronabinol capsules should be discontinued immediately in patients who develop seizures and medical attention should be sought immediately.
- Dronabinol Capsules should be used with caution in patients with cardiac disorders because of occasional hypotension, possible hypertension, syncope, or tachycardia.
- Dronabinol capsules should be used with caution in patients with a history of substance abuse, including alcohol abuse or dependence, because they may be more prone to abuse dronabinol capsules as well. Multiple substance abuse is common and marijuana, which contains the same active compound, is a frequently abused substance.
- Dronabinol capsules should be used with caution and careful psychiatric monitoring in patients with mania, depression, or schizophrenia because Dronabinol Capsules may exacerbate these illnesses.
- Dronabinol Capsules should be used with caution in patients receiving concomitant therapy with sedatives, hypnotics or other psychoactive drugs because of the potential for additive or synergistic CNS effects.
- Dronabinol capsules should be used with caution in elderly patients because they may be more sensitive to the neurological, psychoactive, and postural hypotensive effects of the drug.
- Dronabinol capsules should be used with caution in pregnant patients, nursing mothers, or pediatric patients because it has not been studied in these patient populations.

# Adverse Reactions

## Clinical Trials Experience
- Adverse experiences information summarized in the tables below was derived from well-controlled clinical trials conducted in the U.S. and U.S. territories involving 474 patients exposed to Dronabinol Capsules. Studies of AIDS-related weight loss included 157 patients receiving dronabinol at a dose of 2.5 mg twice daily and 67 receiving placebo. Studies of different durations were combined by considering the first occurrence of events during the first 28 days. Studies of nausea and vomiting related to cancer chemotherapy included 317 patients receiving dronabinol and 68 receiving placebo.
- A cannabinoid dose-related "high" (easy laughing, elation and heightened awareness) has been reported by patients receiving dronabinol capsules in the antiemetic (24%) and the lower dose appetite stimulant clinical trials (8%).
- The most frequently reported adverse experiences in patients with AIDS during placebo-controlled clinical trials involved the CNS and were reported by 33% of patients receiving dronabinol capsules. About 25% of patients reported a minor CNS adverse event during the first 2 weeks and about 4% reported such an event each week for the next 6 weeks thereafter.
PROBABLY CAUSALLY RELATED
Incidence greater than 1%
Rates derived from clinical trials in AIDS-related anorexia (N=157) and chemotherapy-related nausea (N=317). Rates were generally higher in the anti-emetic use (given in parentheses).
PROBABLY CAUSALLY RELATED
Incidence greater than 1%
Rates derived from clinical trials in AIDS-related anorexia (N=157) and chemotherapy-related nausea (N=317). Rates were generally higher in the anti-emetic use (given in parentheses).
CAUSAL RELATIONSHIP UNKNOWN
Incidence less than 1%
The clinical significance of the association of these events with dronabinol capsules treatment is unknown, but they are reported as alerting information for the clinician.

## Postmarketing Experience
- Seizure and seizure-like activity have been reported in patients receiving dronabinol capsules during marketed use of the drug and in clinical trials.Reports of fatigue have also been received. A causal relationship between dronabinol capsules and these events has not been established.

# Drug Interactions
- In studies involving patients with AIDS and/or cancer, dronabinol capsules has been co-administered with a variety of medications (e.g., cytotoxic agents, anti-infective agents, sedatives, or opioid analgesics) without resulting in any clinically significant drug/drug interactions. Although no drug/drug interactions were discovered during the clinical trials of dronabinol capsules, cannabinoids may interact with other medications through both metabolic and pharmacodynamic mechanisms. Dronabinol is highly protein bound to plasma proteins, and therefore, might displace other protein-bound drugs. Although this displacement has not been confirmed in vivo, practitioners should monitor patients for a change in dosage requirements when administering dronabinol to patients receiving other highly protein-bound drugs. Published reports of drug/drug interactions involving cannabinoids are summarized in the following table.

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA): 
Pregnancy Category C
- Reproduction studies with dronabinol have been performed in mice at 15 to 450 mg/m2, equivalent to 0.2 to 5 times maximum recommended human dose (MRHD) of 90 mg/m2/day in cancer patients or 1 to 30 times MRHD of 15 mg/m2/day in AIDS patients, and in rats at 74 to 295 mg/m2 (equivalent to 0.8 to 3 times MRHD of 90 mg/m2 in cancer patients or 5 to 20 times MRHD of 15 mg/ m2/day in AIDS patients). These studies have revealed no evidence of teratogenicity due to dronabinol. At these dosages in mice and rats, dronabinol decreased maternal weight gain and number of viable pups and increased fetal mortality and early resorptions. Such effects were dose dependent and less apparent at lower doses which produced less maternal toxicity. There are no adequate and well-controlled studies in pregnant women. Dronabinol should be used only if the potential benefit justifies the potential risk to the fetus.
Pregnancy Category (AUS):
- Australian Drug Evaluation Committee (ADEC) Pregnancy Category
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Dronabinol in women who are pregnant.

### Labor and Delivery
There is no FDA guidance on use of Dronabinol during labor and delivery.

### Nursing Mothers
- Use of dronabinol capsules is not recommended in nursing mothers since, in addition to the secretion of HIV virus in breast milk, dronabinol is concentrated in and secreted in human breast milk and is absorbed by the nursing baby.

### Pediatric Use
There is no FDA guidance on the use of Dronabinol with respect to pediatric patients.

### Geriatic Use
- Clinical studies of dronabinol capsules in AIDS and cancer patients did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious usually starting at the low end of the dosing range, reflecting the greater frequency of falls, decreased hepatic, renal, or cardiac function, increased sensitivity to psychoactive effects and of concomitant disease or other drug therapy.

### Gender
There is no FDA guidance on the use of Dronabinol with respect to specific gender populations.

### Race
There is no FDA guidance on the use of Dronabinol with respect to specific racial populations.

### Renal Impairment
There is no FDA guidance on the use of Dronabinol in patients with renal impairment.

### Hepatic Impairment
There is no FDA guidance on the use of Dronabinol in patients with hepatic impairment.

### Females of Reproductive Potential and Males
There is no FDA guidance on the use of Dronabinol in women of reproductive potentials and males.

### Immunocompromised Patients
There is no FDA guidance one the use of Dronabinol in patients who are immunocompromised.

# Administration and Monitoring

### Administration
- Oral

### Monitoring
There is limited information regarding Monitoring of Dronabinol in the drug label.

# IV Compatibility
There is limited information regarding IV Compatibility of Dronabinol in the drug label.

# Overdosage
- Signs and symptoms following mild dronabinol capsules intoxication include drowsiness, euphoria, heightened sensory awareness, altered time perception, reddened conjunctiva, dry mouth and tachycardia; following moderate intoxication include memory impairment, depersonalization, mood alteration, urinary retention, and reduced bowel motility; and following severe intoxication include decreased motor coordination, lethargy, slurred speech, and postural hypotension. Apprehensive patients may experience panic reactions and seizures may occur in patients with existing seizure disorders.
- The estimated lethal human dose of intravenous dronabinol is 30 mg/kg (2100 mg/ 70 kg). Significant CNS symptoms in antiemetic studies followed oral doses of 0.4 mg/kg (28 mg/70 kg) of dronabinol capsules.
Management
- A potentially serious oral ingestion, if recent, should be managed with gut decontamination. In unconscious patients with a secure airway, instill activated charcoal (30 to 100 g in adults, 1 to 2 g/kg in infants) via a nasogastric tube. A saline cathartic or sorbitol may be added to the first dose of activated charcoal. Patients experiencing depressive, hallucinatory or psychotic reactions should be placed in a quiet area and offered reassurance. Benzodiazepines (5 to 10 mg diazepam po) may be used for treatment of extreme agitation. Hypotension usually responds to Trendelenburg position and IV fluids. Pressors are rarely required.

# Pharmacology
There is limited information regarding Dronabinol Pharmacology in the drug label.

## Mechanism of Action
There is limited information regarding Dronabinol Mechanism of Action in the drug label.

## Structure
- Dronabinol is a cannabinoid designated chemically as (6aR-trans)-6a,7,8,10a-tetrahydro-6,6,9-trimethyl-3-pentyl-6H-dibenzopyran-1-ol. Dronabinol has the following empirical and structural formulas:
- Dronabinol, the active ingredient in dronabinol capsules, is synthetic delta-9-tetrahydrocannabinol (delta-9-THC). Delta-9-tetrahydrocannabinol is also a naturally occurring component of Cannabis sativa L. (Marijuana).
- Dronabinol is a light yellow resinous oil that is sticky at room temperature and hardens upon refrigeration. Dronabinol is insoluble in water and is formulated in sesame oil. It has a pKa of 10.6 and an octanol-water partition coefficient: 6,000:1 at pH 7.
- Capsules for oral administration: Dronabinol Capsules are supplied as oval, soft gelatin capsules containing either 2.5 mg, 5 mg, or 10 mg dronabinol. Each dronabinol capsule strength is formulated with the following inactive ingredients: 2.5 mg capsule contains gelatin, glycerin, sesame oil, titanium dioxide, SDA 35A alcohol, propylene glycol, black iron oxide, polyvinyl acetate phthalate, purified water, isopropyl alcohol, polyethylene glycol, and ammonium hydroxide; 5 mg capsule contains iron oxide red, iron oxide black, gelatin, glycerin, sesame oil, titanium dioxide, SDA 35A alcohol, propylene glycol, polyvinyl acetate phthalate, purified water, isopropyl alcohol, polyethylene glycol, and ammonium hydroxide; 10 mg capsule contains iron oxide red, iron oxide yellow, gelatin, glycerin, sesame oil, titanium dioxide, SDA 35A alcohol, propylene glycol, black iron oxide, polyvinyl acetate phthalate, purified water, isopropyl alcohol, polyethylene glycol, and ammonium hydroxide.

## Pharmacodynamics
- Dronabinol-induced sympathomimetic activity may result in tachycardia and/or conjunctival injection. Its effects on blood pressure are inconsistent, but occasional subjects have experienced orthostatic hypotension and/or syncope upon abrupt standing.
- Dronabinol also demonstrates reversible effects on appetite, mood, cognition, memory, and perception. These phenomena appear to be dose-related, increasing in frequency with higher dosages, and subject to great interpatient variability.
- After oral administration, dronabinol has an onset of action of approximately 0.5 to 1 hours and peak effect at 2 to 4 hours. Duration of action for psychoactive effects is 4 to 6 hours, but the appetite stimulant effect of dronabinol may continue for 24 hours or longer after administration.
- Tachyphylaxis and tolerance develop to some of the pharmacologic effects of dronabinol and other cannabinoids with chronic use, suggesting an indirect effect on sympathetic neurons. In a study of the pharmacodynamics of chronic dronabinol exposure, healthy male volunteers (N = 12) received 210 mg/day dronabinol, administered orally in divided doses, for 16 days. An initial tachycardia induced by dronabinol was replaced successively by normal sinus rhythm and then bradycardia. A decrease in supine blood pressure, made worse by standing, was also observed initially. These volunteers developed tolerance to the cardiovascular and subjective adverse CNS effects of dronabinol within 12 days of treatment initiation.
- Tachyphylaxis and tolerance do not, however, appear to develop to the appetite stimulant effect of dronabinol capsules. In studies involving patients with Acquired Immune Deficiency Syndrome (AIDS), the appetite stimulant effect of Dronabinol capsules has been sustained for up to five months in clinical trials, at dosages ranging from 2.5 mg/day to 20 mg/day.

## Pharmacokinetics
Absorption and Distribution
- Dronabinol capsules is almost completely absorbed (90 to 95%) after single oral doses. Due to the combined effects of first pass hepatic metabolism and high lipid solubility, only 10 to 20% of the administered dose reaches the systemic circulation. Dronabinol has a large apparent volume of distribution, approximately 10 L/kg, because of its lipid solubility. The plasma protein binding of dronabinol and its metabolites is approximately 97%.
- The elimination phase of dronabinol can be described using a two compartment model with an initial (alpha) half-life of about 4 hours and a terminal (beta) half-life of 25 to 36 hours. Because of its large volume of distribution, dronabinol and its metabolites may be excreted at low levels for prolonged periods of time.
- The pharmacokinetics of dronabinol after single doses (2.5, 5, and 10 mg) and multiple doses (2.5, 5, and 10 mg given twice a day; BID) have been studied in healthy women and men.
- A slight increase in dose proportionality on mean Cmax and AUC(0 to 12) of dronabinol was observed with increasing dose over the dose range studied.
Metabolism
- Dronabinol undergoes extensive first-pass hepatic metabolism, primarily by microsomal hydroxylation, yielding both active and inactive metabolites. Dronabinol and its principal active metabolite, 11-OH-delta-9-THC, are present in approximately equal concentrations in plasma. Concentrations of both parent drug and metabolite peak at approximately 0.5 to 4 hours after oral dosing and decline over several days. Values for clearance average about 0.2 L/kg-hr, but are highly variable due to the complexity of cannabinoid distribution.
Elimination
- Dronabinol and its biotransformation products are excreted in both feces and urine. Biliary excretion is the major route of elimination with about half of a radio-labeled oral dose being recovered from the feces within 72 hours as contrasted with 10 to 15% recovered from urine. Less than 5% of an oral dose is recovered unchanged in the feces.
- Following single dose administration, low levels of dronabinol metabolites have been detected for more than 5 weeks in the urine and feces.
- In a study of dronabinol capsules involving AIDS patients, urinary cannabinoid/creatinine concentration ratios were studied bi-weekly over a six week period. The urinary cannabinoid/creatinine ratio was closely correlated with dose. No increase in the cannabinoid/creatinine ratio was observed after the first two weeks of treatment, indicating that steady-state cannabinoid levels had been reached. This conclusion is consistent with predictions based on the observed terminal half-life of dronabinol.
Special Populations
- The pharmacokinetic profile of dronabinol capsules has not been investigated in either pediatric or geriatric patients.

## Nonclinical Toxicology
Carcinogenesis, Mutagenesis, Impairment of Fertility
- Carcinogenicity studies in mice and rats have been conducted under the U.S. National Toxicology Program (NTP). In the 2-year carcinogenicity study in rats, there was no evidence of carcinogenicity at doses up to 50 mg/kg/day, about 20 times the maximum recommended human dose on a body surface area basis. In the 2-year carcinogenicity study in mice, treatment with dronabinol at 125 mg/kg/day, about 25 times the maximum recommended human dose on a body surface area basis, produced thyroid follicular cell adenoma in both male and female mice but not at 250 or 500 mg/kg/day.
- Dronabinol was not genotoxic in the Ames tests, the in vitro chromosomal aberration test in Chinese hamster ovary cells, and the in vivo mouse micronucleus test. It, however, produced a weak positive response in a sister chromatid exchange test in Chinese hamster ovary cells.
- In a long-term study (77 days) in rats, oral administration of dronabinol at doses of 30 to 150 mg/m2, equivalent to 0.3 to 1.5 times maximum recommended human dose (MRHD) of 90 mg/m2/day in cancer patients or 2 to 10 times MRHD of 15 mg/m2/day in AIDS patients, reduced ventral prostate, seminal vesicle and epididymal weights and caused a decrease in seminal fluid volume. Decreases in spermatogenesis, number of developing germ cells, and number of Leydig cells in the testis were also observed. However, sperm count, mating success and testosterone levels were not affected. The significance of these animal findings in humans is not known.

# Clinical Studies
Appetite Stimulation
- The appetite stimulant effect of Dronabinol Capsules in the treatment of AIDS-related anorexia associated with weight loss was studied in a randomized, double-blind, placebo-controlled study involving 139 patients. The initial dosage of dronabinol capsules in all patients was 5 mg/day, administered in doses of 2.5 mg one hour before lunch and one hour before supper. In pilot studies, early morning administration of dronabinol capsules appeared to have been associated with an increased frequency of adverse experiences, as compared to dosing later in the day. The effect of dronabinolc capsules on appetite, weight, mood, and nausea was measured at scheduled intervals during the six-week treatment period. Side effects (feeling high, dizziness, confusion, somnolence) occurred in 13 of 72 patients (18%) at this dosage level and the dosage was reduced to 2.5 mg/day, administered as a single dose at supper or bedtime.
- Of the 112 patients that completed at least 2 visits in the randomized, double-blind, placebo-controlled study, 99 patients had appetite data at 4-weeks (50 received dronabinol capsules and 49 received placebo) and 91 patients had appetite data at 6-weeks (46 received dronabinol capsules and 45 received placebo). A statistically significant difference between dronabinol capsules and placebo was seen in appetite as measured by the visual analog scale at weeks 4 and 6. Trends toward improved body weight and mood, and decreases in nausea were also seen.
- After completing the 6-week study, patients were allowed to continue treatment with dronabinol capsules in an open-label study, in which there was a sustained improvement in appetite.
Antiemetic
- Dronabinol capsules treatment of chemotherapy-induced emesis was evaluated in 454 patients with cancer, who received a total of 750 courses of treatment of various malignancies. The antiemetic efficacy of Dronabinol Capsules was greatest in patients receiving cytotoxic therapy with MOPP for Hodgkin's and non-Hodgkin's lymphomas. Dronabinol Capsule dosages ranged from 2.5 mg/day to 40 mg/day, administered in equally divided doses every four to six hours (four times daily). As indicated in the following table, escalating the Dronabinol Capsules dose above 7 mg/m2 increased the frequency of adverse experiences, with no additional antiemetic benefit.
- Combination antiemetic therapy with Dronabinol Capsules and a phenothiazine (prochlorperazine) may result in synergistic or additive antiemetic effects and attenuate the toxicities associated with each of the agents.

# How Supplied
- Dronabinol Capsules are available containing 2.5 mg, 5 mg or 10 mg of dronabinol.
- The 2.5 mg capsule is an opaque off-white soft gelatin capsule printed with INS in black ink. They are available as follows:
NDC 0378-8170-91
bottles of 60 capsules
- The 5 mg capsule is an opaque maroon or brown soft gelatin capsule printed with INS in white ink. They are available as follows:
NDC 0378-8171-91
bottles of 60 capsules
- The 10 mg capsule is an opaque tan to tan-orange soft gelatin capsule printed with INS in black ink. They are available as follows:
NDC 0378-8172-91
bottles of 60 capsules

## Storage
- Dronabinol Capsules should be packaged in a well-closed container and stored in a refrigerator between 2 and 8C (36 and 46F). Protect from freezing and light.

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information
- Patients receiving treatment with dronabinol capsules should be alerted to the potential for additive central nervous system depression if dronabinol capsules is used concomitantly with alcohol or other CNS depressants such as benzodiazepines and barbiturates.
- Patients receiving treatment with dronabinol capsules should be specifically warned not to drive, operate machinery, or engage in any hazardous activity until it is established that they are able to tolerate the drug and to perform such tasks safely.
- Patients using dronabinol Capsules should be advised of possible changes in mood and other adverse behavioral effects of the drug so as to avoid panic in the event of such manifestations. Patients should remain under the supervision of a responsible adult during initial use of dronabinol capsules and following dosage adjustments.

# Precautions with Alcohol
- Alcohol-Dronabinol interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

# Brand Names
- DRONABINOL

# Look-Alike Drug Names
- A  B

# Drug Shortage Status

# Price