Sativex® and Gentamicin for Optimized Pharmagological Treatment in Older Patients (CanPan)

Malnutrition and inappropriate prescribing of renally excreted drugs are common among older persons and are associated with severe consequences such as complicated courses of treatment, mortality, and reduced quality of life. The overall purpose of CanPan is to optimize treatment of older persons with malnutrition with a focus on appetite stimulation and optimized prescribing of renal risk drugs.

The CanPan trial consists of two sub-studies. Substudy 1 will provide knowledge on appetite and appetite stimulation and together, sub study 1 and 2 will offer unique knowledge on how body composition, renal function and biomarkers of organ function influence pharmacokinetics for a highly lipophilic (Sativex®) and hydrophilic (Hexamycin®) drug in older medical patients with malnutrition.

The CanPan trial consists of sub study 1 and sub study 2. Subjects who meet all the inclusion criteria and none of the exclusion criteria are invited to participate in both sub studies. Sub study 1 consist of trial days 1 and 2 and sub study 2 consists of trial day 3.

Sub study 1:

Sub study 1 is a double-blinded, randomized, placebo-controlled, multidose, crossover trial that evaluates the appetite stimulating effect as well as the pharmacokinetics of Sativex®. The primary purpose of sub study 1 is to 1) uncover whether Sativex® has appetite stimulating properties defined as increased energy intake compared to placebo, 2) to develop a pharmacokinetic-pharmacodynamic model, and gain knowledge about the effect of Sativex® on other markers of appetite, the intraocular pressure of the eye and safety parameters.

In sub study 1, subjects receive both Sativex® and placebo. Both Sativex® and placebo are administered as an oromucosal spray. Sativex consists of 2.7 mg tetrahydrocannabinol (THC) and 2.5 mg cannabidiol (CBD) per dose of spray (Cannabis sativa L. extract, cannabis leaf and flower). Subjects receive three dose of spray two times during a trial day. Trial day 1 is planned \<14 days after inclusion and there is a 2-week break between trial days 1 and 2 due to a wash-out period. Follow-up visits/phonecalls are made on days 1, 2 and 7 after trial days 1 and 2.

Sub study 2:

Sub-study 2 is a single-dose pharmacokinetic study using gentamicin (Hexamycin®) as a renally excreted model drug. The purpose of sub study 2 is to compare the prediction accuracy of clearance estimates between eGFRpanel (creatinine-cystatinC-beta-2_microglobulin-beta_trace_protein, eGFRcomb (creatinine-cystatinC), eGFRcreatinine (creatinine), uCrCl (24-hour urine creatinine clearance) and mGFR (measured GFR) as covariates in population based pharmacokinetic modeling of gentamicin.

On trial day 3, gentamicin is used as the model substance for a drug that is excreted \> 90% renally. Gentamicin is administered as a single dose of 5 mg/kg as an intravenous injection (bolus). The marketed drug, Hexamycin® (40 mg / mL), is used for this purpose. Trial day 3 is held within 4 weeks after trial day 2. Follow-up visits are made on day 1 and 2 after trial day 3.

Eligibility Criteria:
Inclusion Criteria:

* ≥65 years of age
* Admitted to the acute medical department, Hvidovre Hospital
* Can cooperate cognitively and physically (patient reported)
* Low appetite/anorexia of ageing measures by SNAQ score ≤14
* BMI ≤30 (screening)
* Able to read and understand Danish
* Postmenopausal defined as missed periods for at least 12 months before the start of the trial

Exclusion Criteria:

* Regular use of medical cannabis (patient reported)
* Use of medical cannabis within 14 days at baseline (patient reported)
* Recognized or suspected psychotic illness in the subject or the subjects family (medical record and patient report)
* Severe personality disorders (journal)
* Significant psychiatric disorder in addition to mild to moderate depression (medical record)
* Allergy to the ingredients of Sativex®, placebo and Hexamycin® (patient reported)
* Terminal diagnosis (journal)
* Liver transplant (journal)
* Chronic eGFR ≤15 mL / min2 or dialysis treatment (medical record)
* High risk of nephrotoxicity due to existing drug treatment (medical assessment)
* Pacemaker (journal)
* Epilepsy (journal)
* Recurrent seizures (journal)
* Uncontrolled hypertension (journal)
* Food intolerance to the ingredients in the test meals (patient-reported)
* Vegetarian and vegan (patient-reported)
* Unwilling to avoid driving for up to 72 hours after administration of Sativex® (patient-reported)
* Unwilling to avoid alcohol 24 hours up to test days (patient-reported)
* Patients with ascites ( journal)
* Patients with significant edema on the days of the trial (journal / visual inspection)
* In active treatment of cancer or have disseminated cancer (journal)
* Known with brain - or kidney tumor (journal)
* Known with angina pectoris or intermittent claudication
* Known with stroke, AMI, or heart failure (NYHA III-IV) within the past 5 years (journal)
* In isolation
* Obs. Covid-19