Learn from the expert: compounding pharmacist Lombardi about cannabis dosing

She still remembers her first cannabis order ten years ago, receiving three 5-gram pharmacy containers of Bedrocan® flos. “I was nervous. Now, I have dispensed over 20,000 cannabis-based medicine preparations, most as oil extracts for oromucosal administration.” The number continues to grow annually. The speaker is Italian pharmacist Annunziata Lombardi. She is one of the healthcare professionals who have been interviewed for ‘The clinical primer’, a publication especially intended for doctors and pharmacists who want to learn more about the administration of cannabis as a form of therapy. Below you will find a summary in which Lombardi focuses primarily on the dosage and application of medicinal cannabis in patients.

Can you describe a typical patient to whom you would dispense cannabis-based medicines?

There is no typical patient because cannabis-based medicines can be used for all age groups and for multiple pathologies. The Italian National Health Insurance reimburses cannabis-based medicines, as magistral prescription preparations, for a limited number of medical indications: anorexia/cachexia, glaucoma, Tourette syndrome, spasms and pain induced by chemotherapy, vomiting and lack of appetite in chemotherapy patients. In my experience, the most recurrent diseases are chronic pain, fibromyalgia, and neurological problems. There is also a growing demand from patients suffering from autism, anxiety, and sleep disorders.

Oral dose forms (oil extracts) are an increasingly popular mode of administration, what advice do you give patients on safe use?

In Italy, cannabis extracts, for oromucosal dosing, account for 80% of prescriptions. I train my patients on the proper dosage to convert the mg of active substance (THC and CBD) prescribed by the physician into mL and/or drops of extract. This conversion is different for every extract, and it is based on the post-extraction HPLC analytical results. In Italy, pharmacists must analyse the extract for cannabinoid content after production and state this on the label before dispensing. This helps the patient know the amount of active substance taken.

What advice do you give patients on vaporization?

I recommend the use of a medical device because it guarantees the quality and reproducibility of the therapy. However, some patients cannot afford a medical device and opt for another type of vaporizer. In any case, I ask the patient to pay attention to two aspects: (1) the vaporizer temperature, because naïve patients may experience major side effects if the temperature is set too high, (2) the timing of the onset of action, which can be extremely rapid with this administration route.

What do patients say about the administration of cannabis-based medicines by vaporization?

Patients who need an immediate effect to control tremors, intense pain, and seizures appreciate the rapid onset of action provided by inhalation. The main disadvantages of this route are: it is not discrete and often cannot be used in public spaces; the cost of the vaporizer is high; some patients do not have the pulmonary power to actively inhale.

What special considerations should pharmacists be aware of for patients taking oral dose forms?

Pharmacists must inform the patient that the onset of the oral dose form is slow and can take up to three hours. The patient must be aware of that and wait for the effect and not take additional medicine.

Do you have any good advice for pharmacists starting out?

Be passionate about what you do. This is an exciting professional opportunity and it is nothing like dispensing finished drugs.

• Be convinced that you are part of the cannabis- based medicines revolution and this is just the beginning.
• Go to cannabis conferences and trainings in your country and abroad if you have the chance.
• Read scientific literature. There is a lot of academic and clinical research going on.
• Collect patient’s feedback and data.
• Look for other professionals who share your interest. Do not stop at pharmacists but look for physicians, scientists, patients, and anybody who can help you enrich your knowledge.
• Build up strong and solid relationships with physicians and patients.