451
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Bar-Lev Schleider L, Abuhasira R, Novack V. Medical cannabis: aligning use to evidence-based medicine approach. Br J Clin Pharmacol 2018; 84:2458-2462. [PMID: 29859014 DOI: 10.1111/bcp.13657] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 05/21/2018] [Accepted: 05/29/2018] [Indexed: 12/22/2022] Open
Abstract
During the past decade we have been witnessing a rise in medical cannabis use, yet the evidence for the safety and efficacy of the various cannabinoid compounds is scarce. The State of Israel has always been at the forefront of clinical and translational research in support of Evidence Based Medicine. With respect to cannabis Israel has created a medical and regulatory environment that enables clinical studies with cannabis which may lead to improved Evidence Based use of these compounds. This opinion paper discusses selected studies into the safety and effects of cannabis derived products.
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Affiliation(s)
- Lihi Bar-Lev Schleider
- Cannabis Clinical Research Institute, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Israel
| | - Ran Abuhasira
- Cannabis Clinical Research Institute, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Israel
| | - Victor Novack
- Cannabis Clinical Research Institute, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Israel
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452
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Di Marzo V. New approaches and challenges to targeting the endocannabinoid system. Nat Rev Drug Discov 2018; 17:623-639. [DOI: 10.1038/nrd.2018.115] [Citation(s) in RCA: 256] [Impact Index Per Article: 42.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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453
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Chen K, Farrar M, Cardamone M, Gill D, Smith R, Cowell CT, Truong L, Lawson JA. Cannabidiol for treating drug‐resistant epilepsy in children: the New South Wales experience. Med J Aust 2018; 209:217-221. [DOI: 10.5694/mja18.00023] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 05/04/2018] [Indexed: 01/02/2023]
Affiliation(s)
| | - Michelle Farrar
- Sydney Childrenˈs Hospital Randwick, Sydney, NSW
- UNSW Sydney, Sydney, NSW
| | - Michael Cardamone
- Sydney Childrenˈs Hospital Randwick, Sydney, NSW
- UNSW Sydney, Sydney, NSW
| | - Deepak Gill
- Childrenˈs Hospital at Westmead, Sydney, NSW
| | - Robert Smith
- John Hunter Childrenˈs Hospital, Newcastle, NSW
- University of Newcastle, Newcastle, NSW
| | | | - Linda Truong
- Clinical Trials Unit, Sydney Childrenˈs Hospitals Network, Sydney, NSW
| | - John A Lawson
- Sydney Childrenˈs Hospital Randwick, Sydney, NSW
- UNSW Sydney, Sydney, NSW
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454
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Lawson JA, Scheffer IE. Therapeutic use of medicinal cannabis in difficult to manage epilepsy. Br J Clin Pharmacol 2018; 84:2488-2490. [PMID: 30088286 DOI: 10.1111/bcp.13711] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 07/04/2018] [Accepted: 07/05/2018] [Indexed: 01/12/2023] Open
Affiliation(s)
| | - Ingrid E Scheffer
- University of Melbourne, Austin Health and Royal Children's Hospital, Florey Institute, Melbourne, Australia
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455
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Papaseit E, Pérez-Mañá C, Pérez-Acevedo AP, Hladun O, Torres-Moreno MC, Muga R, Torrens M, Farré M. Cannabinoids: from pot to lab. Int J Med Sci 2018; 15:1286-1295. [PMID: 30275754 PMCID: PMC6158663 DOI: 10.7150/ijms.27087] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 06/30/2018] [Indexed: 01/12/2023] Open
Abstract
Cannabis is becoming increasingly present in our society. In recent years, the line between the natural (cannabis) and the synthetic (synthetic cannabinoids), the recreational (cannabis) and the medical (pharmaceutical cannabinoids and medical cannabis) has been crossed. In this paper we review some of the novel aspects of cannabis and cannabinoids in relation to their legal situation, changes in their composition and forms of cannabis use, the concept of medical cannabis, and synthetic cannabinoids as new psychoactive substances (NPS). We have also analyzed serious adverse reactions and intoxications associated with the use of synthetic cannabinoids, as well as the latest developments in the research of pharmaceutical cannabinoids.
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Affiliation(s)
- Esther Papaseit
- Clinical Pharmacology Unit, Hospital Universitari Germans Trias i Pujol (HUGTP-IGTP), Badalona (Spain)
- Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, Barcelona (Spain)
| | - Clara Pérez-Mañá
- Clinical Pharmacology Unit, Hospital Universitari Germans Trias i Pujol (HUGTP-IGTP), Badalona (Spain)
- Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, Barcelona (Spain)
| | - Ana Pilar Pérez-Acevedo
- Clinical Pharmacology Unit, Hospital Universitari Germans Trias i Pujol (HUGTP-IGTP), Badalona (Spain)
- Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, Barcelona (Spain)
| | - Olga Hladun
- Clinical Pharmacology Unit, Hospital Universitari Germans Trias i Pujol (HUGTP-IGTP), Badalona (Spain)
- Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, Barcelona (Spain)
| | - M. Carmen Torres-Moreno
- Clinical Pharmacology Unit, Hospital Universitari Germans Trias i Pujol (HUGTP-IGTP), Badalona (Spain)
- Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, Barcelona (Spain)
| | - Robert Muga
- Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, Barcelona (Spain)
- Internal Medicine Department, Universitari Germans Trias i Pujol (HUGTP-IGTP), Badalona (Spain)
| | - Marta Torrens
- Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, Barcelona (Spain)
- Drug Addiction Program, Institut de Neuropsiquiatria i Adiccions (INAD), Parc de Salut Mar, Barcelona (Spain)
| | - Magí Farré
- Clinical Pharmacology Unit, Hospital Universitari Germans Trias i Pujol (HUGTP-IGTP), Badalona (Spain)
- Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, Barcelona (Spain)
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456
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Freeman JL. Safety of cannabidiol prescribed for children with refractory epilepsy. Med J Aust 2018; 209:228-229. [PMID: 30092751 DOI: 10.5694/mja17.01193] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 03/08/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Jeremy L Freeman
- Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, VIC
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457
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Huizenga MN, Fureman BE, Soltesz I, Stella N. Proceedings of the Epilepsy Foundation's 2017 Cannabinoids in Epilepsy Therapy Workshop. Epilepsy Behav 2018; 85:237-242. [PMID: 29908905 PMCID: PMC6372237 DOI: 10.1016/j.yebeh.2018.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 05/09/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Megan N Huizenga
- Department of Pharmacology and Physiology, Georgetown University, Washington, DC, United States.
| | - Brandy E Fureman
- Research and New Therapies, Epilepsy Foundation of America, Landover, MD, United States
| | - Ivan Soltesz
- Department of Neurosurgery, Stanford Neurosciences Institute, Stanford University, Stanford, CA, United States
| | - Nephi Stella
- Department of Pharmacology, University of Washington, Seattle, WA, United States; Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States
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458
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Klinger N, Mittal S. Deep brain stimulation for seizure control in drug-resistant epilepsy. Neurosurg Focus 2018; 45:E4. [DOI: 10.3171/2018.4.focus1872] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Antiepileptic drugs prevent morbidity and death in a large number of patients suffering from epilepsy. However, it is estimated that approximately 30% of epileptic patients will not have adequate seizure control with medication alone. Resection of epileptogenic cortex may be indicated in medically refractory cases with a discrete seizure focus in noneloquent cortex. For patients in whom resection is not an option, deep brain stimulation (DBS) may be an effective means of seizure control. Deep brain stimulation targets for treating seizures primarily include the thalamic nuclei, hippocampus, subthalamic nucleus, and cerebellum. A variety of stimulation parameters have been studied, and more recent advances in electrical stimulation to treat epilepsy include responsive neurostimulation. Data suggest that DBS is effective for treating drug-resistant epilepsy.
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Affiliation(s)
- Neil Klinger
- 1Department of Neurosurgery, Wayne State University; and
- 2Comprehensive Epilepsy Program, Detroit Medical Center, Wayne State University, Detroit, Michigan
| | - Sandeep Mittal
- 1Department of Neurosurgery, Wayne State University; and
- 2Comprehensive Epilepsy Program, Detroit Medical Center, Wayne State University, Detroit, Michigan
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459
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Cannabidiol did not induce teratogenicity or neurotoxicity in exposed zebrafish embryos. Chem Biol Interact 2018; 291:81-86. [DOI: 10.1016/j.cbi.2018.06.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/22/2018] [Accepted: 06/09/2018] [Indexed: 12/25/2022]
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460
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Hausman-Kedem M, Menascu S, Kramer U. Efficacy of CBD-enriched medical cannabis for treatment of refractory epilepsy in children and adolescents - An observational, longitudinal study. Brain Dev 2018; 40:544-551. [PMID: 29674131 DOI: 10.1016/j.braindev.2018.03.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 03/15/2018] [Accepted: 03/28/2018] [Indexed: 01/08/2023]
Abstract
The objective of this observational study was to evaluate the efficacy of medical cannabis for the treatment of refractory epilepsy. Fifty-seven patients (age 1-20 years) with epilepsy of various etiologies were treated with Cannabis oil extract (CBD/THC ratio of 20:1) for at least 3 months (Median follow up time-18 months). Forty-Six Patients were included in the efficacy analysis. Average CBD dose was11.4 mg/kg/d. Twenty-six patients (56%) had ≤50% reduction in mean monthly seizure frequency. There was no statistically significant difference in response rate among various epilepsy etiologies, and cannabis strain used. Younger age at treatment onset (<10 years) and higher CBD dose (>11 mg/kg/d) were associated with better response to treatment. Adverse reactions were reported in 46% of patients and were the main reason for treatment cessation. Our results suggest that adding CBD-enriched cannabis extract to the treatment regimen of patients with refractory epilepsy may result in a significant reduction in seizure frequency according to parental reports. Randomized controlled trials are necessary to assess its true efficacy.
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Affiliation(s)
- Moran Hausman-Kedem
- Pediatric Neurology Unit, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel.
| | - Shay Menascu
- Pediatric Neurology Unit, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Uri Kramer
- Pediatric Neurology Unit, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
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461
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Schonhofen P, Bristot IJ, Crippa JA, Hallak JEC, Zuardi AW, Parsons RB, Klamt F. Cannabinoid-Based Therapies and Brain Development: Potential Harmful Effect of Early Modulation of the Endocannabinoid System. CNS Drugs 2018; 32:697-712. [PMID: 30109642 DOI: 10.1007/s40263-018-0550-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The endocannabinoid retrograde signaling pathway is widely expressed in the central nervous system, where it plays major roles in regulating synaptic plasticity (excitatory and inhibitory) through long-term potentiation and long-term depression. The endocannabinoid system (ECS) components-cannabinoid receptors, endocannabinoids and synthesis/degradation enzymes-are expressed and are functional from early developmental stages and throughout adolescent cortical development, regulating progenitor cell fate, neural differentiation, migration and survival. This may potentially confer increased vulnerability to adverse outcomes from early cannabinoid exposure. Cannabidiol (CBD) is one of the most studied exogenous cannabinoids, and CBD-enriched Cannabis extracts have been widely (and successfully) used as adjuvants to treat children with refractory epilepsy, and there is even a Food and Drug Administration (FDA)-approved drug with purified CBD derived from Cannabis. However, there is insufficient information on possible long-term changes in the central nervous system caused by cannabinoid treatments during early childhood. Like the majority of cannabinoids, CBD is able to exert its effects directly and indirectly through the ECS, which can perturb the regulatory processes mediated by this system. In addition, CBD has a large number of non-endocannabinoid targets, which can explain CBD's effects. Here, we review the current knowledge about CBD-based therapies-pure and CBD-enriched Cannabis extracts-in studies with pediatric patients, their side effects, and their mechanisms of action regarding the central nervous system and neurodevelopment aspects. Since Cannabis extracts contain Δ9-tetrahydrocannabinol (Δ9-THC), we consider that pure CBD is possibly safer for young patients. Nevertheless, CBD, as well as other natural and/or synthetic cannabinoids, should be studied in more detail as a therapeutic alternative to CBD-enriched Cannabis extracts for young patients.
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Affiliation(s)
- Patrícia Schonhofen
- Laboratory of Cellular Biochemistry, Department of Biochemistry, ICBS/UFRGS, 2600 Ramiro Barcelos St, Porto Alegre, RS, 90035-003, Brazil
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, ICBS/UFRGS, Porto Alegre, RS, 90035-003, Brazil
- National Institutes of Science and Technology-Translational Medicine (INCT-TM), Porto Alegre, Brazil
| | - Ivi Juliana Bristot
- Laboratory of Cellular Biochemistry, Department of Biochemistry, ICBS/UFRGS, 2600 Ramiro Barcelos St, Porto Alegre, RS, 90035-003, Brazil
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, ICBS/UFRGS, Porto Alegre, RS, 90035-003, Brazil
- National Institutes of Science and Technology-Translational Medicine (INCT-TM), Porto Alegre, Brazil
| | - José Alexandre Crippa
- National Institutes of Science and Technology-Translational Medicine (INCT-TM), Porto Alegre, Brazil
- Neuroscience and Behavior Department, Faculty of Medicine of Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Jaime Eduardo Cecílio Hallak
- National Institutes of Science and Technology-Translational Medicine (INCT-TM), Porto Alegre, Brazil
- Neuroscience and Behavior Department, Faculty of Medicine of Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Antônio Waldo Zuardi
- National Institutes of Science and Technology-Translational Medicine (INCT-TM), Porto Alegre, Brazil
- Neuroscience and Behavior Department, Faculty of Medicine of Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Richard B Parsons
- Institute of Pharmaceutical Science, King's College London (KCL), London, SE1 9NH, UK
| | - Fábio Klamt
- Laboratory of Cellular Biochemistry, Department of Biochemistry, ICBS/UFRGS, 2600 Ramiro Barcelos St, Porto Alegre, RS, 90035-003, Brazil.
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, ICBS/UFRGS, Porto Alegre, RS, 90035-003, Brazil.
- National Institutes of Science and Technology-Translational Medicine (INCT-TM), Porto Alegre, Brazil.
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462
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McCoy B, Wang L, Zak M, Al-Mehmadi S, Kabir N, Alhadid K, McDonald K, Zhang G, Sharma R, Whitney R, Sinopoli K, Snead OC. A prospective open-label trial of a CBD/THC cannabis oil in dravet syndrome. Ann Clin Transl Neurol 2018; 5:1077-1088. [PMID: 30250864 PMCID: PMC6144444 DOI: 10.1002/acn3.621] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 06/26/2018] [Indexed: 11/11/2022] Open
Abstract
Introduction Both Δ9 Tetrahydrocannabidiol (THC) and cannabidiol (CBD) components of cannabis, have been shown to have anticonvulsant effects. Cannabis oils are used to treat seizures in drug‐resistant epilepsy (DRE). Recent trials provide data on dosing, side effects, and efficacy of CBD, yet there is a paucity of information on THC in epilepsy. Primary objective was to establish dosing and tolerability of TIL‐TC150 ‐ a cannabis plant extract produced by Tilray®, containing 100 mg/mL CBD and 2 mg/mL THC‐ in children with Dravet syndrome. Secondary objectives were to assess impact of therapy on seizures, electroencephalogram (EEG) and quality of life. Methods Twenty children received add‐on therapy with TIL‐TC150. The dose ranged from 2 to 16 mg/kg/day of CBD and 0.04 to 0.32 mg/kg/day of THC. Patients were monitored for tolerability and adverse events, and secondary objectives. Results Nineteen participants completed the 20‐week intervention. Mean dose achieved was 13.3 mg/kg/day of CBD (range 7–16 mg/kg/day) and 0.27 mg/kg/day of THC (range 0.14–0.32 mg/kg/day). Adverse events, common during titration included somnolence, anorexia, and diarrhea. Abnormalities of liver transaminases and platelets were observed with concomitant valproic acid therapy. There was a statistically significant improvement in quality of life, reduction in EEG spike activity, and median motor seizure reduction of 70.6%, with 50% responder rate of 63%. Conclusions TIL‐TC150 was safe and well tolerated in our subjects. TIL‐TC150 treatment resulted in a reduction in seizure counts, spike index on EEG, and improved quality of life measures. This study provides safety and dosing information for THC‐containing cannabinoid preparations.
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Affiliation(s)
- Bláthnaid McCoy
- Division of Neurology the Hospital for Sick Children Toronto Canada.,Department of Pediatrics University of Toronto Toronto Canada
| | - Laura Wang
- Department of Pharmacy Hospital for Sick Children Toronto Canada
| | - Maria Zak
- Division of Neurology the Hospital for Sick Children Toronto Canada
| | | | - Nadia Kabir
- Division of Neurology the Hospital for Sick Children Toronto Canada
| | - Kenda Alhadid
- Division of Neurology the Hospital for Sick Children Toronto Canada
| | - Kyla McDonald
- Department of Psychology the Hospital for Sick Children Toronto Ontario Canada
| | - Grace Zhang
- Department of Psychology the Hospital for Sick Children Toronto Ontario Canada
| | - Rohit Sharma
- Division of Neurology the Hospital for Sick Children Toronto Canada
| | - Robyn Whitney
- Division of Neurology the Hospital for Sick Children Toronto Canada.,Department of Pediatrics University of Toronto Toronto Canada
| | - Katia Sinopoli
- Department of Psychology the Hospital for Sick Children Toronto Ontario Canada
| | - O Carter Snead
- Division of Neurology the Hospital for Sick Children Toronto Canada
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463
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Investigating owner use of dietary supplements in dogs with idiopathic epilepsy. Res Vet Sci 2018; 119:276-284. [PMID: 30064067 DOI: 10.1016/j.rvsc.2018.07.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 06/01/2018] [Accepted: 07/21/2018] [Indexed: 12/29/2022]
Abstract
Epilepsy is the most common chronic neurological disorder in dogs. Some diets have been shown to have a positive impact upon the seizure activity in dogs with idiopathic epilepsy (IE), while other diets and dietary supplements (DS), although marketed as providing health benefits, lack conclusive scientific evidence on their actual beneficial effects. A web-based owner questionnaire was designed to assess how and why owners of dogs with IE use different dietary regimes and DS. The study cohort, with 297 valid responses, consisted mainly of pure-breed (82.5%) male neutered (52.9%) dogs. Over two-thirds of owners (67.7%) changed their dog's diet after their dog received a diagnosis of IE. Nearly half of the owners (45.8%) reported giving DS, the most common being coconut oil or derived medium-chain triglyceride oil (71.3%). Some owner justifications of DS use included improvement of seizure frequency (88.2%), seizure severity (61.8%) and protection from potential drug side effects (62.5%). Many owners give DS to their dog with IE. The pharmacokinetic properties of anti-epileptic drugs, such as efficacy, absorption and clearance can be influenced by other medications, diets and possibly by DS. We propose that use of DS should be considered and monitored by veterinary surgeons in epilepsy management.
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464
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Willems LM, Bertsche A, Bösebeck F, Hornemann F, Immisch I, Klein KM, Knake S, Kunz R, Kurlemann G, Langenbruch L, Möddel G, Müller-Schlüter K, von Podewils F, Reif PS, Steinhoff BJ, Steinig I, Rosenow F, Schubert-Bast S, Strzelczyk A. Efficacy, Retention, and Tolerability of Brivaracetam in Patients With Epileptic Encephalopathies: A Multicenter Cohort Study From Germany. Front Neurol 2018; 9:569. [PMID: 30083127 PMCID: PMC6064736 DOI: 10.3389/fneur.2018.00569] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 06/25/2018] [Indexed: 01/10/2023] Open
Abstract
Objective: To evaluate the efficacy and tolerability of brivaracetam (BRV) in a severely drug refractory cohort of patients with epileptic encephalopathies (EE). Method: A multicenter, retrospective cohort study recruiting all patients treated with EE who began treatment with BRV in an enrolling epilepsy center between 2016 and 2017. Results: Forty-four patients (27 male [61%], mean age 29 years, range 6 to 62) were treated with BRV. The retention rate was 65% at 3 months, 52% at 6 months and 41% at 12 months. A mean retention time of 5 months resulted in a cumulative exposure to BRV of 310 months. Three patients were seizure free during the baseline. At 3 months, 20 (45%, 20/44 as per intention-to-treat analysis considering all patients that started BRV including three who were seizure free during baseline) were either seizure free (n = 4; 9%, three of them already seizure-free at baseline) or reported at least 25% (n = 4; 9%) or 50% (n = 12; 27%) reduction in seizures. An increase in seizure frequency was reported in two (5%) patients, while there was no change in the seizure frequency of the other patients. A 50% long-term responder rate was apparent in 19 patients (43%), with two (5%) free from seizures for more than six months and in nine patients (20%, with one [2 %] free from seizures) for more than 12 months. Treatment-emergent adverse events were predominantly of psychobehavioural nature and were observed in 16%. Significance: In this retrospective analysis the rate of patients with a 50% seizure reduction under BRV proofed to be similar to those seen in regulatory trials for focal epilepsies. BRV appears to be safe and relatively well tolerated in EE and might be considered in patients with psychobehavioral adverse events while on levetiracetam.
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Affiliation(s)
- Laurent M Willems
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe University Frankfurt, Frankfurt, Germany
| | - Astrid Bertsche
- Department of Neuropediatrics, University of Rostock, Rostock, Germany.,Centre of Pediatric Research, Hospital for Children and Adolescents, Leipzig, Germany
| | - Frank Bösebeck
- Epilepsy Center Rotenburg, Agaplesion Diakonieklinikum Rotenburg, Rotenburg, Germany
| | - Frauke Hornemann
- Centre of Pediatric Research, Hospital for Children and Adolescents, Leipzig, Germany
| | - Ilka Immisch
- Epilepsy Center Hessen and Department of Neurology, Philipps-University, Marburg, Germany
| | - Karl M Klein
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe University Frankfurt, Frankfurt, Germany
| | - Susanne Knake
- Epilepsy Center Hessen and Department of Neurology, Philipps-University, Marburg, Germany
| | - Rhina Kunz
- Epilepsy Center Greifswald and Department of Neurology, Ernst-Moritz-Arndt-University, Greifswald, Germany
| | - Gerhard Kurlemann
- Department of Neuropediatrics, Westfälische Wilhelms-University, Münster, Germany
| | - Lisa Langenbruch
- Epilepsy Center Münster-Osnabrück, Department of Neurology with Institute of Translational Neurology - Epileptology, Westfälische Wilhelms-University, Münster, Germany
| | - Gabriel Möddel
- Epilepsy Center Münster-Osnabrück, Department of Neurology with Institute of Translational Neurology - Epileptology, Westfälische Wilhelms-University, Münster, Germany
| | - Karen Müller-Schlüter
- Epilepsy Center for Children, University Hospital Neuruppin, Brandenburg Medical School, Neuruppin, Germany
| | - Felix von Podewils
- Epilepsy Center Greifswald and Department of Neurology, Ernst-Moritz-Arndt-University, Greifswald, Germany
| | - Philipp S Reif
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe University Frankfurt, Frankfurt, Germany
| | | | - Isabel Steinig
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe University Frankfurt, Frankfurt, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe University Frankfurt, Frankfurt, Germany.,Epilepsy Center Hessen and Department of Neurology, Philipps-University, Marburg, Germany
| | - Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe University Frankfurt, Frankfurt, Germany.,Department of Neuropediatrics, Goethe University Frankfurt, Frankfurt, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe University Frankfurt, Frankfurt, Germany.,Epilepsy Center Hessen and Department of Neurology, Philipps-University, Marburg, Germany
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465
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Szaflarski JP, Bebin EM, Comi AM, Patel AD, Joshi C, Checketts D, Beal JC, Laux LC, De Boer LM, Wong MH, Lopez M, Devinsky O, Lyons PD, Zentil PP, Wechsler R. Long-term safety and treatment effects of cannabidiol in children and adults with treatment-resistant epilepsies: Expanded access program results. Epilepsia 2018; 59:1540-1548. [PMID: 29998598 PMCID: PMC6175436 DOI: 10.1111/epi.14477] [Citation(s) in RCA: 138] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2018] [Indexed: 01/12/2023]
Abstract
Objective Since 2014, cannabidiol (CBD) has been administered to patients with treatment‐resistant epilepsies (TREs) in an ongoing expanded‐access program (EAP). We report interim results on the safety and efficacy of CBD in EAP patients treated through December 2016. Methods Twenty‐five US‐based EAP sites enrolling patients with TRE taking stable doses of antiepileptic drugs (AEDs) at baseline were included. During the 4‐week baseline period, parents/caregivers kept diaries of all countable seizure types. Patients received oral CBD starting at 2‐10 mg/kg/d, titrated to a maximum dose of 25‐50 mg/kg/d. Patient visits were every 2‐4 weeks through 16 weeks and every 2‐12 weeks thereafter. Efficacy endpoints included the percentage change from baseline in median monthly convulsive and total seizure frequency, and percentage of patients with ≥50%, ≥75%, and 100% reductions in seizures vs baseline. Data were analyzed descriptively for the efficacy analysis set and using the last‐observation‐carried‐forward method to account for missing data. Adverse events (AEs) were documented at each visit. Results Of 607 patients in the safety dataset, 146 (24%) withdrew; the most common reasons were lack of efficacy (89 [15%]) and AEs (32 [5%]). Mean age was 13 years (range, 0.4‐62). Median number of concomitant AEDs was 3 (range, 0‐10). Median CBD dose was 25 mg/kg/d; median treatment duration was 48 weeks. Add‐on CBD reduced median monthly convulsive seizures by 51% and total seizures by 48% at 12 weeks; reductions were similar through 96 weeks. Proportion of patients with ≥50%, ≥75%, and 100% reductions in convulsive seizures were 52%, 31%, and 11%, respectively, at 12 weeks, with similar rates through 96 weeks. CBD was generally well tolerated; most common AEs were diarrhea (29%) and somnolence (22%). Significance Results from this ongoing EAP support previous observational and clinical trial data showing that add‐on CBD may be an efficacious long‐term treatment option for TRE.
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Affiliation(s)
| | | | - Anne M Comi
- Kennedy Krieger Institute, Baltimore, MD, USA
| | - Anup D Patel
- Nationwide Children's Hospital, Columbus, OH, USA
| | - Charuta Joshi
- University of Iowa Children's Hospital, Iowa City, IA, USA
| | | | - Jules C Beal
- Montefiore Medical Center and Albert Einstein College in Medicine, Bronx, NY, USA
| | - Linda C Laux
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | | | - Matthew H Wong
- Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Merrick Lopez
- Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Orrin Devinsky
- NYU Langone's Comprehensive Epilepsy Center, New York, NY, USA
| | - Paul D Lyons
- Virginia Comprehensive Epilepsy Program, Winchester, VA, USA
| | | | - Robert Wechsler
- Consultants in Epilepsy & Neurology, PLLC and Idaho Comprehensive Epilepsy Center, Boise, ID, USA
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466
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Reithmeier D, Tang-Wai R, Seifert B, Lyon AW, Alcorn J, Acton B, Corley S, Prosser-Loose E, Mousseau DD, Lim HJ, Tellez-Zenteno J, Huh L, Leung E, Carmant L, Huntsman RJ. The protocol for the Cannabidiol in children with refractory epileptic encephalopathy (CARE-E) study: a phase 1 dosage escalation study. BMC Pediatr 2018; 18:221. [PMID: 29981580 PMCID: PMC6035794 DOI: 10.1186/s12887-018-1191-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 06/24/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Initial studies suggest pharmaceutical grade cannabidiol (CBD) can reduce the frequency of convulsive seizures and lead to improvements in quality of life in children affected by epileptic encephalopathies. With limited access to pharmaceutical CBD, Cannabis extracts in oil are becoming increasingly available. Physicians show reluctance to recommend Cannabis extracts given the lack of high quality safety data especially regarding the potential for harm caused by other cannabinoids, such as Δ9-tetrahydrocannabinol (Δ9-THC). The primary aims of the study presented in this protocol are (i) To determine whether CBD enriched Cannabis extract is safe and well-tolerated for pediatric patients with refractory epilepsy, (ii) To monitor the effects of CBD-enriched Cannabis extract on the frequency and duration of seizure types and on quality of life. METHODS Twenty-eight children with treatment resistant epileptic encephalopathy ranging in age from 1 to 10 years will be recruited in four Canadian cities into an open-label, dose-escalation phase 1 trial. The primary objectives for the study are (i) To determine if the CBD-enriched Cannabis herbal extract is safe and well-tolerated for pediatric patients with treatment resistant epileptic encephalopathy and (ii) To determine the effect of CBD-enriched Cannabis herbal extract on the frequency and duration of seizures. Secondary objectives include (i) To determine if CBD-enriched Cannabis herbal extracts alter steady-state levels of co-administered anticonvulsant medications. (ii) To assess the relation between dose escalation and quality of life measures, (iii) To determine the relation between dose escalation and steady state trough levels of bioactive cannabinoids. (iv) To determine the relation between dose escalation and incidence of adverse effects. DISCUSSION This paper describes the study design of a phase 1 trial of CBD-enriched Cannabis herbal extract in children with treatment-resistant epileptic encephalopathy. This study will provide the first high quality analysis of safety of CBD-enriched Cannabis herbal extract in pediatric patients in relation to dosage and pharmacokinetics of the active cannabinoids. TRIAL REGISTRATION http://clinicaltrials.gov [Internet]. Bethesda (MD): National Library of Medicine (US). 2016 Dec 16. Identifier NCT03024827, Cannabidiol in Children with Refractory Epileptic Encephalopathy: CARE-E; 2017 Jan 19 [cited 2017 Oct]; Available from: http://clinicaltrials.gov/ct2/show/NCT03024827.
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Affiliation(s)
- Darren Reithmeier
- Cannabinoid Research Initiative of Saskatchewan (CRIS), University of Saskatchewan, Saskatoon, Saskatchewan Canada
- College of Pharmacy and Nutrition, University of Saskatchewan, Room E3210 Health Sciences 104 Clinic Place, Saskatoon, SK S7N-2Z4 Canada
| | - Richard Tang-Wai
- Cannabinoid Research Initiative of Saskatchewan (CRIS), University of Saskatchewan, Saskatoon, Saskatchewan Canada
- Department of Pediatrics, Division of Child Neurology, Loma Linda University, Loma Linda, California, USA
- Division of Pediatric Neurology, Department of Pediatrics, University of Alberta, 11405-87 Avenue, 4th Floor, Edmonton, AB T6G-1C9 Canada
| | - Blair Seifert
- Cannabinoid Research Initiative of Saskatchewan (CRIS), University of Saskatchewan, Saskatoon, Saskatchewan Canada
- Department of Pharmaceutical Services, Saskatchewan Health Authority, Saskatoon Health Region, Royal University Hospital, 103 Hospital Drive, Saskatoon, SK S7N-0W8 Canada
| | - Andrew W. Lyon
- Cannabinoid Research Initiative of Saskatchewan (CRIS), University of Saskatchewan, Saskatoon, Saskatchewan Canada
- Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority, St. Paul’s Hospital, 1702 20th Street West, Saskatoon, SK S7M-0Z9 Canada
| | - Jane Alcorn
- Cannabinoid Research Initiative of Saskatchewan (CRIS), University of Saskatchewan, Saskatoon, Saskatchewan Canada
- College of Pharmacy and Nutrition, University of Saskatchewan, Room E3210 Health Sciences 104 Clinic Place, Saskatoon, SK S7N-2Z4 Canada
| | - Bryan Acton
- Cannabinoid Research Initiative of Saskatchewan (CRIS), University of Saskatchewan, Saskatoon, Saskatchewan Canada
- Saskatchewan Health Authority and Department of Psychology, University of Saskatchewan, Saskatoon, Saskatchewan Canada
- Department of Clinical Health Psychology, Royal University Hospital, 103 Hospital Drive, Saskatoon, SK S7N 0W8 Canada
| | - Scott Corley
- Cannabinoid Research Initiative of Saskatchewan (CRIS), University of Saskatchewan, Saskatoon, Saskatchewan Canada
- Clinical Trial Support Unit, University of Saskatchewan, Royal University Hospital, Room 5676, 103 Hospital Drive, Saskatoon, SK S7N 0W8 Canada
| | - Erin Prosser-Loose
- Cannabinoid Research Initiative of Saskatchewan (CRIS), University of Saskatchewan, Saskatoon, Saskatchewan Canada
- Department of Pediatrics, University of Saskatchewan, Royal University Hospital, Room 2665, 103 Hospital Drive, Saskatoon, SK S7N 0W8 Canada
| | - Darrell D. Mousseau
- Cannabinoid Research Initiative of Saskatchewan (CRIS), University of Saskatchewan, Saskatoon, Saskatchewan Canada
- Cell Signalling Laboratory, Departments of Psychiatry and Physiology, University of Saskatchewan, GB41, HSB 107 Wiggins Ave, Saskatoon, SK S7N 5E5 Canada
| | - Hyun J. Lim
- Cannabinoid Research Initiative of Saskatchewan (CRIS), University of Saskatchewan, Saskatoon, Saskatchewan Canada
- Department of Community Health and Epidemiology, University of Saskatchewan, Room E3222 Health Sciences, 104 Clinic Place, Saskatoon, SK S7N-2Z4 Canada
| | - Jose Tellez-Zenteno
- Cannabinoid Research Initiative of Saskatchewan (CRIS), University of Saskatchewan, Saskatoon, Saskatchewan Canada
- Department of Medicine, Division of Neurology, University of Saskatchewan, Royal University Hospital, Room 1622, 103 Hospital Drive, Saskatoon, SK S7N 0W8 Canada
| | - Linda Huh
- Division of Pediatric Neurology, Department of Pediatrics, University of British Columbia, BC Children’s Hospital, Room 2D19, 4480 Oak Street, Vancouver, BC V6H-3V4 Canada
| | - Edward Leung
- Division of Pediatric Neurology, Room CE208, Department of Pediatrics 5, University of Manitoba, Children’s Hospital, 840 Sherbrooke Street, Winnipeg, MB R3A-1S1 Canada
| | - Lionel Carmant
- Division of Pediatric Neurology, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Universite de Montreal, Room 5-4, 3175 Chemin de la Cote Ste-Catherine, Montreal, QC H3T-1C5 Canada
| | - Richard J. Huntsman
- Cannabinoid Research Initiative of Saskatchewan (CRIS), University of Saskatchewan, Saskatoon, Saskatchewan Canada
- Department of Pediatrics, Royal University Hospital, Rm 2744, 103 Hospital Drive, Saskatoon, SK S7N 0W8 Canada
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467
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Suraev A, Lintzeris N, Stuart J, Kevin RC, Blackburn R, Richards E, Arnold JC, Ireland C, Todd L, Allsop DJ, McGregor IS. Composition and Use of Cannabis Extracts for Childhood Epilepsy in the Australian Community. Sci Rep 2018; 8:10154. [PMID: 29977078 PMCID: PMC6033872 DOI: 10.1038/s41598-018-28127-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 06/04/2018] [Indexed: 12/20/2022] Open
Abstract
Recent surveys suggest that many parents are using illicit cannabis extracts in the hope of managing seizures in their children with epilepsy. In the current Australian study we conducted semi-structured interviews with families of children with diverse forms of epilepsy to explore their attitudes towards and experiences with using cannabis extracts. This included current or previous users of cannabis extracts to treat their child's seizures (n = 41 families), and families who had never used (n = 24 families). For those using cannabis, extracts were analysed for cannabinoid content, with specific comparison of samples rated by families as "effective" versus those rated "ineffective". Results showed that children given cannabis extracts tended to have more severe epilepsy historically and had trialled more anticonvulsants than those who had never received cannabis extracts. There was high variability in the cannabinoid content and profile of cannabis extracts rated as "effective", with no clear differences between extracts perceived as "effective" and "ineffective". Contrary to family's expectations, most samples contained low concentrations of cannabidiol, while Δ9-tetrahydrocannabinol was present in nearly every sample. These findings highlight profound variation in the illicit cannabis extracts being currently used in Australia and warrant further investigations into the therapeutic value of cannabinoids in epilepsy.
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Affiliation(s)
- A Suraev
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - N Lintzeris
- Addiction Medicine, Central Clinical School, Faculty of Medicine, The University of Sydney, Sydney, 2006, Australia
- The Langton Centre, Drug and Alcohol Services, South East Sydney Local Health District, NSW Health, Surry Hills, 2010, Australia
| | - J Stuart
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - R C Kevin
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - R Blackburn
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - E Richards
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - J C Arnold
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
- Department of Pharmacology, Faculty of Medicine, University of Sydney, Sydney, NSW, 2006, Australia
| | - C Ireland
- Epilepsy Action Australia, Sydney, Australia
| | - L Todd
- Epilepsy Action Australia, Sydney, Australia
| | - D J Allsop
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - I S McGregor
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia.
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468
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Abstract
Introduction: Preclinical and clinical studies suggest that cannabidiol (CBD) found in Cannabis spp. has broad therapeutic value. CBD products can currently be purchased online, over the counter and at Cannabis-specific dispensaries throughout most of the country, despite the fact that CBD is generally deemed a Schedule I controlled substance by the U.S. Drug Enforcement Administration and renounced as a dietary supplement ingredient by the U.S. Food and Drug Administration. Consumer demand for CBD is high and growing, but few studies have examined the reasons for increasing CBD use. Materials and Methods: A self-selected convenience sample (n = 2409) was recruited via an online survey designed to characterize whom, how, and why individuals are currently using CBD. The anonymous questionnaire was accessed from October 25, 2017 to January 25, 2018. Participants were recruited through social media. Results: Almost 62% of CBD users reported using CBD to treat a medical condition. The top three medical conditions were pain, anxiety, and depression. Almost 36% of respondents reported that CBD treats their medical condition(s) “very well by itself,” while only 4.3% reported “not very well.” One out of every three users reported a nonserious adverse effect. The odds of using CBD to treat a medical condition were 1.44 (95% confidence interval, 1.16–1.79) times greater among nonregular users of Cannabis than among regular users. Conclusion: Consumers are using CBD as a specific therapy for multiple diverse medical conditions—particularly pain, anxiety, depression, and sleep disorders. These data provide a compelling rationale for further research to better understand the therapeutic potential of CBD.
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Affiliation(s)
- Jamie Corroon
- The Center for Medical Cannabis Education, Del Mar, California.,Helfgott Research Institute, National University of Natural Medicine (NUNM), Portland, Oregon
| | - Joy A Phillips
- Donald P. Shiley BioScience Center, San Diego State University, San Diego, California
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469
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Efron D, Freeman J. Medical cannabis for paediatric developmental-behavioural and psychiatric disorders. J Paediatr Child Health 2018; 54:715-717. [PMID: 29614206 DOI: 10.1111/jpc.13902] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 01/26/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Daryl Efron
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Jeremy Freeman
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Neurology, Royal Children's Hospital, Melbourne, Victoria, Australia
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470
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Stockings E, Zagic D, Campbell G, Weier M, Hall WD, Nielsen S, Herkes GK, Farrell M, Degenhardt L. Evidence for cannabis and cannabinoids for epilepsy: a systematic review of controlled and observational evidence. J Neurol Neurosurg Psychiatry 2018; 89:741-753. [PMID: 29511052 DOI: 10.1136/jnnp-2017-317168] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 12/12/2017] [Accepted: 12/16/2017] [Indexed: 01/08/2023]
Abstract
UNLABELLED Review evidence for cannabinoids as adjunctive treatments for treatment-resistant epilepsy. Systematic search of Medline, Embase and PsycINFO was conducted in October 2017. Outcomes were: 50%+ seizure reduction, complete seizure freedom; improved quality of life (QoL). Tolerability/safety were assessed by study withdrawals, adverse events (AEs) and serious adverse events (SAEs). Analyses were conducted in Stata V.15.0. 36 studies were identified: 6 randomised controlled trials (RCTs), 30 observational studies. Mean age of participants was 16.1 years (range 0.5-55 years). Cannabidiol (CBD) 20 mg/kg/day was more effective than placebo at reducing seizure frequency by 50%+(relative risk (RR) 1.74, 95% CI 1.24 to 2.43, 2 RCTs, 291 patients, low Grades of Recommendation, Assessment, Development and Evaluation (GRADE) rating). The number needed to treat for one person using CBD to experience 50%+ seizure reduction was 8 (95% CI 6 to 17). CBD was more effective than placebo at achieving complete seizure freedom (RR 6.17, 95% CI 1.50 to 25.32, 3 RCTs, 306 patients, low GRADE rating), and improving QoL (RR 1.73, 95% CI 1.33 to 2.26), however increased risk of AEs (RR 1.24, 95% CI 1.13 to 1.36) and SAEs (RR 2.55, 95% CI 1.48 to 4.38). Pooled across 17 observational studies, 48.5% (95% CI 39.0% to 58.1%) of patients reported 50%+ reductions in seizures; in 14 observational studies 8.5% (95% CI 3.8% to 14.5%) were seizure-free. Twelve observational studies reported improved QoL (55.8%, 95% CI 40.5 to 70.6); 50.6% (95% CI 31.7 to 69.4) AEs and 2.2% (95% CI 0 to 7.9) SAEs. Pharmaceutical-grade CBD as adjuvant treatment in paediatric-onset drug-resistant epilepsy may reduce seizure frequency. Existing RCT evidence is mostly in paediatric samples with rare and severe epilepsy syndromes; RCTs examining other syndromes and cannabinoids are needed. PROSPERO REGISTRATION NUMBER CRD42017055412.
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Affiliation(s)
- Emily Stockings
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, New South Wales, Australia
| | - Dino Zagic
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, New South Wales, Australia
| | - Gabrielle Campbell
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, New South Wales, Australia
| | - Megan Weier
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, New South Wales, Australia
| | - Wayne D Hall
- Centre for Youth Substance Abuse Research, University of Queensland, Brisbane, Queensland, Australia.,National Addiction Centre, Kings College London, London, England
| | - Suzanne Nielsen
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, New South Wales, Australia
| | - Geoffrey K Herkes
- Department of Neurology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Michael Farrell
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, New South Wales, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, New South Wales, Australia
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471
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Freedman DA, Patel AD. Inadequate Regulation Contributes to Mislabeled Online Cannabidiol Products. Pediatr Neurol Briefs 2018; 32:3. [PMID: 30008541 PMCID: PMC6024459 DOI: 10.15844/pedneurbriefs-32-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Researchers from the University of Pennsylvania, Veterans Affairs San Diego, RTI
international, Americans for Safe Access, Palo Alto University and Johns Hopkins
University analyzed the content of 84 cannabidiol (CBD) products purchased on the
internet and compared the results to their advertised concentrations.
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Affiliation(s)
- Daniel A Freedman
- Departments of Pediatrics and Neurology, Nationwide Children's Hospital, Columbus, OH
| | - Anup D Patel
- Departments of Pediatrics and Neurology, Nationwide Children's Hospital, Columbus, OH
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472
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Ostrovsky DA, Ehrlich A. Addition of Cannabidiol to Current Antiepileptic Therapy Reduces Drop Seizures in Children and Adults With Treatment-Resistant Lennox-Gastaut Syndrome. Explore (NY) 2018; 14:311-313. [PMID: 29887290 DOI: 10.1016/j.explore.2018.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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473
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Mouhamed Y, Vishnyakov A, Qorri B, Sambi M, Frank SMS, Nowierski C, Lamba A, Bhatti U, Szewczuk MR. Therapeutic potential of medicinal marijuana: an educational primer for health care professionals. Drug Healthc Patient Saf 2018; 10:45-66. [PMID: 29928146 PMCID: PMC6001746 DOI: 10.2147/dhps.s158592] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
With the proposed Canadian July 2018 legalization of marijuana through the Cannabis Act, a thorough critical analysis of the current trials on the efficacy of medicinal marijuana (MM) as a treatment option is necessary. This review is particularly important for primary care physicians whose patients may be interested in using MM as an alternative therapy. In response to increased interest in MM, Health Canada released a document in 2013 for general practitioners (GPs) as an educational tool on the efficacy of MM in treating some chronic and acute conditions. Although additional studies have filled in some of the gaps since the release of the Health Canada document, conflicting and inconclusive results continue to pose a challenge for physicians. This review aims to supplement the Health Canada document by providing physicians with a critical yet concise update on the recent advancements made regarding the efficacy of MM as a potential therapeutic option. An update to the literature of 2013 is important given the upcoming changes in legislation on the use of marijuana. Also, we briefly highlight the current recommendations provided by Canadian medical colleges on the parameters that need to be considered prior to authorizing MM use, routes of administration as well as a general overview of the endocannabinoid system as it pertains to cannabis. Lastly, we outline the appropriate medical conditions for which the authorization of MM may present as a practical alternative option in improving patient outcomes as well as individual considerations of which GPs should be mindful. The purpose of this paper is to offer physicians an educational tool that provides a necessary, evidence-based analysis of the therapeutic potential of MM and to ensure physicians are making decisions on the therapeutic use of MM in good faith.
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Affiliation(s)
- Yara Mouhamed
- Graduate Diploma & Professional Master in Medical Sciences, School of Medicine, Queen’s University, Kingston, ON, Canada
| | - Andrey Vishnyakov
- Graduate Diploma & Professional Master in Medical Sciences, School of Medicine, Queen’s University, Kingston, ON, Canada
| | - Bessi Qorri
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, ON, Canada
| | - Manpreet Sambi
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, ON, Canada
| | - SM Signy Frank
- Graduate Diploma & Professional Master in Medical Sciences, School of Medicine, Queen’s University, Kingston, ON, Canada
| | - Catherine Nowierski
- Graduate Diploma & Professional Master in Medical Sciences, School of Medicine, Queen’s University, Kingston, ON, Canada
| | - Anmol Lamba
- Graduate Diploma & Professional Master in Medical Sciences, School of Medicine, Queen’s University, Kingston, ON, Canada
| | - Umrao Bhatti
- Graduate Diploma & Professional Master in Medical Sciences, School of Medicine, Queen’s University, Kingston, ON, Canada
| | - Myron R Szewczuk
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, ON, Canada
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474
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Ružić Zečević D, Folić M, Tantoush Z, Radovanović M, Babić G, Janković SM. Investigational cannabinoids in seizure disorders, what have we learned thus far? Expert Opin Investig Drugs 2018; 27:535-541. [DOI: 10.1080/13543784.2018.1482275] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
| | - Marko Folić
- Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Ziyad Tantoush
- Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Milan Radovanović
- Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Goran Babić
- Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
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475
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Sagar KA, Gruber SA. Marijuana matters: reviewing the impact of marijuana on cognition, brain structure and function, & exploring policy implications and barriers to research. Int Rev Psychiatry 2018; 30:251-267. [PMID: 29966459 PMCID: PMC6455965 DOI: 10.1080/09540261.2018.1460334] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The neurobiologic effects of cannabis, commonly referred to as 'marijuana' (MJ), have been studied for decades. The impact of recreational MJ use on cognition and measures of brain function and structure is outlined, and variables influencing study results are discussed, including age of the consumer, patterns of MJ use, variations in MJ potency, and the presence of additional cannabinoids. Although evidence suggests that chronic, heavy recreational MJ use is related to cognitive decrements and neural changes, particularly when use begins in adolescence, findings from studies of recreational MJ users may not be applicable to medical marijuana (MMJ) patients given differences in demographic variables, product selection, and reasons for use. Although additional research is needed to fully understand the impact of MJ and individual cannabinoids on the brain, current findings are beginning to inform public policy, including considerations for age limits, potential limits for some cannabinoids, and guidelines for use. However, barriers continue to impede researchers' ability to conduct studies that will guide policy change and provide vital information to consumers and patients regarding best practices and safest methods for use. The need for information is critical, as legalization of MJ for medical and recreational use is increasingly widespread.
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Affiliation(s)
- Kelly A. Sagar
- McLean Hospital, Cognitive and Clinical Neuroimaging Core, McLean Imaging Center, 115 Mill St, Belmont, MA, 02478,Department of Psychiatry, Harvard Medical School, 401 Park Drive, Boston, MA, 02115,Boston University School of Medicine, 72 E Concord St Boston, MA, 02118
| | - Staci A. Gruber
- McLean Hospital, Cognitive and Clinical Neuroimaging Core, McLean Imaging Center, 115 Mill St, Belmont, MA, 02478,Department of Psychiatry, Harvard Medical School, 401 Park Drive, Boston, MA, 02115,Corresponding Author Information Address: McLean Hospital, 115 Mill Street, Belmont, MA 02478, Telephone: 617-855-2762, Fax: 617-855-3713,
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476
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Bonn-Miller MO, ElSohly M, Loflin MJE, Chandra S, Vandrey R. Cannabis and cannabinoid drug development: evaluating botanical versus single molecule approaches. Int Rev Psychiatry 2018; 30:277-284. [PMID: 30179534 PMCID: PMC6242809 DOI: 10.1080/09540261.2018.1474730] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Accumulating evidence suggests that the endocannabinoid system is a promising target for the treatment of a variety of health conditions. Two paths of cannabinoid drug development have emerged. One approach is focused on developing medications that are directly derived from the cannabis plant. The other utilizes a single molecule approach whereby individual phytocannabinoids or novel cannabinoids with therapeutic potential are identified and synthesized for pharmaceutical development. This commentary discusses the unique challenges and merits of botanical vs single molecule cannabinoid drug development strategies, highlights how both can be impacted by legalization of cannabis via legislative processes, and also addresses regulatory and public health considerations that are important to consider as cannabinoid medicine advances as a discipline.
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Affiliation(s)
- Marcel O. Bonn-Miller
- University of Pennsylvania Perelman School of Medicine, Department of Psychiatry, Philadelphia, PA 19104, USA
| | - Mahmoud ElSohly
- National Center for Natural Product Research, Research Institute of Pharmaceutical Sciences, School of Pharmacy, University of Mississippi, MS 38677, USA,Department of Pharmaceutics and Drug Delivery, School of Pharmacy, University of Mississippi, University, MS 38677, USA,ElSohly Laboratory Inc., 5 Industrial Park Drive, Oxford, MS 38655, USA
| | - Mallory J. E. Loflin
- San Diego Healthcare System, Center of Excellence for Stress and Mental Health, San Diego, CA 92161, USA
| | - Suman Chandra
- National Center for Natural Product Research, Research Institute of Pharmaceutical Sciences, School of Pharmacy, University of Mississippi, MS 38677, USA
| | - Ryan Vandrey
- Johns Hopkins University School of Medicine, Baltimore MD, 21224, USA
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Devinsky O, Patel AD, Cross JH, Villanueva V, Wirrell EC, Privitera M, Greenwood SM, Roberts C, Checketts D, VanLandingham KE, Zuberi SM. Effect of Cannabidiol on Drop Seizures in the Lennox-Gastaut Syndrome. N Engl J Med 2018; 378:1888-1897. [PMID: 29768152 DOI: 10.1056/nejmoa1714631] [Citation(s) in RCA: 577] [Impact Index Per Article: 96.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cannabidiol has been used for treatment-resistant seizures in patients with severe early-onset epilepsy. We investigated the efficacy and safety of cannabidiol added to a regimen of conventional antiepileptic medication to treat drop seizures in patients with the Lennox-Gastaut syndrome, a severe developmental epileptic encephalopathy. METHODS In this double-blind, placebo-controlled trial conducted at 30 clinical centers, we randomly assigned patients with the Lennox-Gastaut syndrome (age range, 2 to 55 years) who had had two or more drop seizures per week during a 28-day baseline period to receive cannabidiol oral solution at a dose of either 20 mg per kilogram of body weight (20-mg cannabidiol group) or 10 mg per kilogram (10-mg cannabidiol group) or matching placebo, administered in two equally divided doses daily for 14 weeks. The primary outcome was the percentage change from baseline in the frequency of drop seizures (average per 28 days) during the treatment period. RESULTS A total of 225 patients were enrolled; 76 patients were assigned to the 20-mg cannabidiol group, 73 to the 10-mg cannabidiol group, and 76 to the placebo group. During the 28-day baseline period, the median number of drop seizures was 85 in all trial groups combined. The median percent reduction from baseline in drop-seizure frequency during the treatment period was 41.9% in the 20-mg cannabidiol group, 37.2% in the 10-mg cannabidiol group, and 17.2% in the placebo group (P=0.005 for the 20-mg cannabidiol group vs. placebo group, and P=0.002 for the 10-mg cannabidiol group vs. placebo group). The most common adverse events among the patients in the cannabidiol groups were somnolence, decreased appetite, and diarrhea; these events occurred more frequently in the higher-dose group. Six patients in the 20-mg cannabidiol group and 1 patient in the 10-mg cannabidiol group discontinued the trial medication because of adverse events and were withdrawn from the trial. Fourteen patients who received cannabidiol (9%) had elevated liver aminotransferase concentrations. CONCLUSIONS Among children and adults with the Lennox-Gastaut syndrome, the addition of cannabidiol at a dose of 10 mg or 20 mg per kilogram per day to a conventional antiepileptic regimen resulted in greater reductions in the frequency of drop seizures than placebo. Adverse events with cannabidiol included elevated liver aminotransferase concentrations. (Funded by GW Pharmaceuticals; GWPCARE3 ClinicalTrials.gov number, NCT02224560 .).
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Affiliation(s)
- Orrin Devinsky
- From New York University Langone Comprehensive Epilepsy Center, New York (O.D.); Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus (A.D.P.), and the University of Cincinnati Medical Center, Department of Neurology, Cincinnati (M.P.) - all in Ohio; UCL Great Ormond Street Institute of Child Health, London (J.H.C.), GW Research Ltd., Cambridge (S.M.G., C.R., D.C.), and the Royal Hospital for Children and School of Medicine, University of Glasgow, Glasgow (S.M.Z.) - all in the United Kingdom; Refractory Epilepsy Unit, Neurology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain (V.V.); the Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN (E.C.W.); and Greenwich Biosciences, Carlsbad, CA (K.E.V.)
| | - Anup D Patel
- From New York University Langone Comprehensive Epilepsy Center, New York (O.D.); Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus (A.D.P.), and the University of Cincinnati Medical Center, Department of Neurology, Cincinnati (M.P.) - all in Ohio; UCL Great Ormond Street Institute of Child Health, London (J.H.C.), GW Research Ltd., Cambridge (S.M.G., C.R., D.C.), and the Royal Hospital for Children and School of Medicine, University of Glasgow, Glasgow (S.M.Z.) - all in the United Kingdom; Refractory Epilepsy Unit, Neurology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain (V.V.); the Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN (E.C.W.); and Greenwich Biosciences, Carlsbad, CA (K.E.V.)
| | - J Helen Cross
- From New York University Langone Comprehensive Epilepsy Center, New York (O.D.); Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus (A.D.P.), and the University of Cincinnati Medical Center, Department of Neurology, Cincinnati (M.P.) - all in Ohio; UCL Great Ormond Street Institute of Child Health, London (J.H.C.), GW Research Ltd., Cambridge (S.M.G., C.R., D.C.), and the Royal Hospital for Children and School of Medicine, University of Glasgow, Glasgow (S.M.Z.) - all in the United Kingdom; Refractory Epilepsy Unit, Neurology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain (V.V.); the Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN (E.C.W.); and Greenwich Biosciences, Carlsbad, CA (K.E.V.)
| | - Vicente Villanueva
- From New York University Langone Comprehensive Epilepsy Center, New York (O.D.); Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus (A.D.P.), and the University of Cincinnati Medical Center, Department of Neurology, Cincinnati (M.P.) - all in Ohio; UCL Great Ormond Street Institute of Child Health, London (J.H.C.), GW Research Ltd., Cambridge (S.M.G., C.R., D.C.), and the Royal Hospital for Children and School of Medicine, University of Glasgow, Glasgow (S.M.Z.) - all in the United Kingdom; Refractory Epilepsy Unit, Neurology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain (V.V.); the Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN (E.C.W.); and Greenwich Biosciences, Carlsbad, CA (K.E.V.)
| | - Elaine C Wirrell
- From New York University Langone Comprehensive Epilepsy Center, New York (O.D.); Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus (A.D.P.), and the University of Cincinnati Medical Center, Department of Neurology, Cincinnati (M.P.) - all in Ohio; UCL Great Ormond Street Institute of Child Health, London (J.H.C.), GW Research Ltd., Cambridge (S.M.G., C.R., D.C.), and the Royal Hospital for Children and School of Medicine, University of Glasgow, Glasgow (S.M.Z.) - all in the United Kingdom; Refractory Epilepsy Unit, Neurology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain (V.V.); the Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN (E.C.W.); and Greenwich Biosciences, Carlsbad, CA (K.E.V.)
| | - Michael Privitera
- From New York University Langone Comprehensive Epilepsy Center, New York (O.D.); Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus (A.D.P.), and the University of Cincinnati Medical Center, Department of Neurology, Cincinnati (M.P.) - all in Ohio; UCL Great Ormond Street Institute of Child Health, London (J.H.C.), GW Research Ltd., Cambridge (S.M.G., C.R., D.C.), and the Royal Hospital for Children and School of Medicine, University of Glasgow, Glasgow (S.M.Z.) - all in the United Kingdom; Refractory Epilepsy Unit, Neurology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain (V.V.); the Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN (E.C.W.); and Greenwich Biosciences, Carlsbad, CA (K.E.V.)
| | - Sam M Greenwood
- From New York University Langone Comprehensive Epilepsy Center, New York (O.D.); Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus (A.D.P.), and the University of Cincinnati Medical Center, Department of Neurology, Cincinnati (M.P.) - all in Ohio; UCL Great Ormond Street Institute of Child Health, London (J.H.C.), GW Research Ltd., Cambridge (S.M.G., C.R., D.C.), and the Royal Hospital for Children and School of Medicine, University of Glasgow, Glasgow (S.M.Z.) - all in the United Kingdom; Refractory Epilepsy Unit, Neurology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain (V.V.); the Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN (E.C.W.); and Greenwich Biosciences, Carlsbad, CA (K.E.V.)
| | - Claire Roberts
- From New York University Langone Comprehensive Epilepsy Center, New York (O.D.); Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus (A.D.P.), and the University of Cincinnati Medical Center, Department of Neurology, Cincinnati (M.P.) - all in Ohio; UCL Great Ormond Street Institute of Child Health, London (J.H.C.), GW Research Ltd., Cambridge (S.M.G., C.R., D.C.), and the Royal Hospital for Children and School of Medicine, University of Glasgow, Glasgow (S.M.Z.) - all in the United Kingdom; Refractory Epilepsy Unit, Neurology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain (V.V.); the Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN (E.C.W.); and Greenwich Biosciences, Carlsbad, CA (K.E.V.)
| | - Daniel Checketts
- From New York University Langone Comprehensive Epilepsy Center, New York (O.D.); Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus (A.D.P.), and the University of Cincinnati Medical Center, Department of Neurology, Cincinnati (M.P.) - all in Ohio; UCL Great Ormond Street Institute of Child Health, London (J.H.C.), GW Research Ltd., Cambridge (S.M.G., C.R., D.C.), and the Royal Hospital for Children and School of Medicine, University of Glasgow, Glasgow (S.M.Z.) - all in the United Kingdom; Refractory Epilepsy Unit, Neurology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain (V.V.); the Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN (E.C.W.); and Greenwich Biosciences, Carlsbad, CA (K.E.V.)
| | - Kevan E VanLandingham
- From New York University Langone Comprehensive Epilepsy Center, New York (O.D.); Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus (A.D.P.), and the University of Cincinnati Medical Center, Department of Neurology, Cincinnati (M.P.) - all in Ohio; UCL Great Ormond Street Institute of Child Health, London (J.H.C.), GW Research Ltd., Cambridge (S.M.G., C.R., D.C.), and the Royal Hospital for Children and School of Medicine, University of Glasgow, Glasgow (S.M.Z.) - all in the United Kingdom; Refractory Epilepsy Unit, Neurology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain (V.V.); the Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN (E.C.W.); and Greenwich Biosciences, Carlsbad, CA (K.E.V.)
| | - Sameer M Zuberi
- From New York University Langone Comprehensive Epilepsy Center, New York (O.D.); Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus (A.D.P.), and the University of Cincinnati Medical Center, Department of Neurology, Cincinnati (M.P.) - all in Ohio; UCL Great Ormond Street Institute of Child Health, London (J.H.C.), GW Research Ltd., Cambridge (S.M.G., C.R., D.C.), and the Royal Hospital for Children and School of Medicine, University of Glasgow, Glasgow (S.M.Z.) - all in the United Kingdom; Refractory Epilepsy Unit, Neurology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain (V.V.); the Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN (E.C.W.); and Greenwich Biosciences, Carlsbad, CA (K.E.V.)
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478
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Meng Q, Buchanan B, Zuccolo J, Poulin MM, Gabriele J, Baranowski DC. A reliable and validated LC-MS/MS method for the simultaneous quantification of 4 cannabinoids in 40 consumer products. PLoS One 2018; 13:e0196396. [PMID: 29718956 PMCID: PMC5931681 DOI: 10.1371/journal.pone.0196396] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 04/12/2018] [Indexed: 01/02/2023] Open
Abstract
In the past 50 years, Cannabis sativa (C. sativa) has gone from a substance essentially prohibited worldwide to one that is gaining acceptance both culturally and legally in many countries for medicinal and recreational use. As additional jurisdictions legalize Cannabis products and the variety and complexity of these products surpass the classical dried plant material, appropriate methods for measuring the biologically active constituents is paramount to ensure safety and regulatory compliance. While there are numerous active compounds in C. sativa the primary cannabinoids of regulatory and safety concern are (-)-Δ⁹-tetrahydrocannabinol (THC), cannabidiol (CBD), and their respective acidic forms THCA-A and CBDA. Using the US Food and Drug Administration (FDA) bioanalytical method validation guidelines we developed a sensitive, selective, and accurate method for the simultaneous analysis CBD, CBDA, THC, and THCA-A in oils and THC & CBD in more complex matrices. This HPLC-MS/MS method was simple and reliable using standard sample dilution and homogenization, an isocratic chromatographic separation, and a triple quadrupole mass spectrometer. The lower limit of quantification (LLOQ) for analytes was 0.195 ng/mL over a 0.195-50.0 ng/mL range of quantification with a coefficient of correlation of >0.99. Average intra-day and inter-day accuracies were 94.2-112.7% and 97.2-110.9%, respectively. This method was used to quantify CBD, CBDA, THC, and THCA-A in 40 commercial hemp products representing a variety of matrices including oils, plant materials, and creams/cosmetics. All products tested met the federal regulatory restrictions on THC content in Canada (<10 μg/g) except two, with concentrations of 337 and 10.01 μg/g. With respect to CBD, the majority of analyzed products contained low CBD levels and a CBD: CBDA ratio of <1.0. In contrast, one product contained 8,410 μg/g CBD and a CBD: CBDA ratio of >1,000 (an oil-based product). Overall, the method proved amenable to the analysis of various commercial products including oils, creams, and plant material and may be diagnostically indicative of adulteration with non-hemp C. sativa, specialized hemp cultivars, or unique manufacturing methods.
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Affiliation(s)
- Qingfang Meng
- Research and Development, Delivra Corp., Charlottetown, PE, Canada
| | - Beth Buchanan
- Research and Development, Delivra Corp., Charlottetown, PE, Canada
| | - Jonathan Zuccolo
- Research and Development, Delivra Corp., Charlottetown, PE, Canada
| | | | - Joseph Gabriele
- Research and Development, Delivra Corp., Charlottetown, PE, Canada
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479
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Maroon J, Bost J. Review of the neurological benefits of phytocannabinoids. Surg Neurol Int 2018; 9:91. [PMID: 29770251 PMCID: PMC5938896 DOI: 10.4103/sni.sni_45_18] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 02/19/2018] [Indexed: 12/31/2022] Open
Abstract
Background: Numerous physical, psychological, and emotional benefits have been attributed to marijuana since its first reported use in 2,600 BC in a Chinese pharmacopoeia. The phytocannabinoids, cannabidiol (CBD), and delta-9-tetrahydrocannabinol (Δ9-THC) are the most studied extracts from cannabis sativa subspecies hemp and marijuana. CBD and Δ9-THC interact uniquely with the endocannabinoid system (ECS). Through direct and indirect actions, intrinsic endocannabinoids and plant-based phytocannabinoids modulate and influence a variety of physiological systems influenced by the ECS. Methods: In 1980, Cunha et al. reported anticonvulsant benefits in 7/8 subjects with medically uncontrolled epilepsy using marijuana extracts in a phase I clinical trial. Since then neurological applications have been the major focus of renewed research using medical marijuana and phytocannabinoid extracts. Results: Recent neurological uses include adjunctive treatment for malignant brain tumors, Parkinson's disease, Alzheimer's disease, multiple sclerosis, neuropathic pain, and the childhood seizure disorders Lennox-Gastaut and Dravet syndromes. In addition, psychiatric and mood disorders, such as schizophrenia, anxiety, depression, addiction, postconcussion syndrome, and posttraumatic stress disorders are being studied using phytocannabinoids. Conclusions: In this review we will provide animal and human research data on the current clinical neurological uses for CBD individually and in combination with Δ9-THC. We will emphasize the neuroprotective, antiinflammatory, and immunomodulatory benefits of phytocannabinoids and their applications in various clinical syndromes.
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Affiliation(s)
- Joseph Maroon
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jeff Bost
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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480
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Tatum WO, Hasan TF, Coonan EE, Smelick CP. Recurrent seizures from chronic kratom use, an atypical herbal opioid. EPILEPSY & BEHAVIOR CASE REPORTS 2018; 10:18-20. [PMID: 30062086 PMCID: PMC6063981 DOI: 10.1016/j.ebcr.2018.04.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 03/28/2018] [Accepted: 04/04/2018] [Indexed: 12/17/2022]
Abstract
Kratom is an herbal compound that has been used as a recreational drug though is not regulated by the Food and Drug Administration. We report a 19-year-old male with recurrent seizures that developed during daily Kratom abuse as a self-treatment for anxiety. Following recurrent focal impaired awareness seizures in addition to generalized tonic-clonic seizures, he was begun on anti-seizure drugs. Seizures subsided after completing rehabilitation. Brain MRI at 29 months revealed bilaterally symmetric T1-hyperintensity in globus pallidus, subthalamic nuclei, and cerebral peduncles. Our case suggests Kratom abuse may be associated with structural brain lesions on MRI and symptomatic focal epilepsy.
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Affiliation(s)
| | - Tasneem F. Hasan
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, United States
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481
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Linares IMP, Guimaraes FS, Eckeli A, Crippa ACS, Zuardi AW, Souza JDS, Hallak JE, Crippa JAS. No Acute Effects of Cannabidiol on the Sleep-Wake Cycle of Healthy Subjects: A Randomized, Double-Blind, Placebo-Controlled, Crossover Study. Front Pharmacol 2018; 9:315. [PMID: 29674967 PMCID: PMC5895650 DOI: 10.3389/fphar.2018.00315] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 03/19/2018] [Indexed: 12/17/2022] Open
Abstract
Cannabidiol (CBD) is a component of Cannabis sativa that has a broad spectrum of potential therapeutic effects in neuropsychiatric and other disorders. However, few studies have investigated the possible interference of CBD on the sleep-wake cycle. The aim of the present study was to evaluate the effect of a clinically anxiolytic dose of CBD on the sleep-wake cycle of healthy subjects in a crossover, double-blind design. Twenty-seven healthy volunteers that fulfilled the eligibility criteria were selected and allocated to receive either CBD (300 mg) or placebo in the first night in a double-blind randomized design (one volunteer withdrew from the study). In the second night, the same procedure was performed using the substance that had not been administered in the previous occasion. CBD or placebo were administered 30 min before the start of polysomnography recordings that lasted 8 h. Cognitive and subjective measures were performed immediately after polysomnography to assess possible residual effects of CBD. The drug did not induce any significant effect (p > 0.05). Different from anxiolytic and antidepressant drugs such as benzodiazepines and selective serotonin reuptake inhibitors, acute administration of an anxiolytic dose of CBD does not seem to interfere with the sleep cycle of healthy volunteers. The present findings support the proposal that CBD do not alter normal sleep architecture. Future studies should address the effects of CBD on the sleep-wake cycle of patient populations as well as in clinical trials with larger samples and chronic use of different doses of CBD. Such studies are desirable and opportune.
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Affiliation(s)
- Ila M. P. Linares
- Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
- Instituto Nacional de Ciência e Tecnologia Translacional em Medicina, Conselho Nacional de Desenvolvimento Científico e Tecnológico, Brasília, Brazil
| | - Francisco S. Guimaraes
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Alan Eckeli
- Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
- Instituto Nacional de Ciência e Tecnologia Translacional em Medicina, Conselho Nacional de Desenvolvimento Científico e Tecnológico, Brasília, Brazil
| | - Ana C. S. Crippa
- Department of Pediatrics, Neuropediatrics, Federal University of Paraná, Curitiba, Brazil
| | - Antonio W. Zuardi
- Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
- Instituto Nacional de Ciência e Tecnologia Translacional em Medicina, Conselho Nacional de Desenvolvimento Científico e Tecnológico, Brasília, Brazil
| | - Jose D. S. Souza
- Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
- Instituto Nacional de Ciência e Tecnologia Translacional em Medicina, Conselho Nacional de Desenvolvimento Científico e Tecnológico, Brasília, Brazil
| | - Jaime E. Hallak
- Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
- Instituto Nacional de Ciência e Tecnologia Translacional em Medicina, Conselho Nacional de Desenvolvimento Científico e Tecnológico, Brasília, Brazil
| | - José A. S. Crippa
- Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
- Instituto Nacional de Ciência e Tecnologia Translacional em Medicina, Conselho Nacional de Desenvolvimento Científico e Tecnológico, Brasília, Brazil
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482
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Abstract
Dravet syndrome (DS) is a medically refractory epilepsy that onsets in the first year of life with prolonged seizures, often triggered by fever. Over time, patients develop other seizure types (myoclonic, atypical absences, drops), intellectual disability, crouch gait and other co-morbidities (sleep problems, autonomic dysfunction). Complete seizure control is generally not achievable with current therapies, and the goals of treatment are to balance reduction of seizure burden with adverse effects of therapies. Treatment of co-morbidities must also be addressed, as they have a significant impact on the quality of life of patients with DS. Seizures are typically worsened with sodium-channel agents. Accepted first-line agents include clobazam and valproic acid, although these rarely provide adequate seizure control. Benefit has also been noted with stiripentol, topiramate, levetiracetam, the ketogenic diet and vagal nerve stimulation. Several agents presently in development, specifically fenfluramine and cannabidiol, have shown efficacy in clinical trials. Status epilepticus is a recurring problem for patients with DS, particularly in their early childhood years. All patients should be prescribed a home rescue therapy (usually a benzodiazepine) but should also have a written seizure action plan that outlines when rescue should be given and further steps to take in the local hospital if the seizure persists despite home rescue therapy.
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483
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Neubauer D, Perković Benedik M, Osredkar D. Cannabidiol for treatment of refractory childhood epilepsies: Experience from a single tertiary epilepsy center in Slovenia. Epilepsy Behav 2018. [PMID: 29526578 DOI: 10.1016/j.yebeh.2018.02.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE Refractory epilepsies in children present a major burden for patients and their families. Cannabidiol (CBD) has been suggested as a potential treatment for refractory epilepsies. The aim of this study was to evaluate the effectiveness of add-on therapy with CBD for the treatment of refractory childhood epilepsies. METHOD Patients with childhood-onset refractory epilepsy, treated at the tertiary epilepsy center of the University Children's Hospital Ljubljana, Slovenia, were included in the study. Add-on therapy with CBD was initiated once the child's epilepsy was categorized as pharmacoresistant to other antiepileptic drugs/therapies. The dosage of CBD was gradually increased to at least 8mg/kg/day. The effect of CBD treatment was evaluated by the reduction in seizure burden and presence of side effects (positive and negative). Serial electroencephalography was performed in some children. RESULTS Sixty-six patients were included in the analysis. Thirty-two (48.5%) patients had a more than 50% improvement regarding seizure burden, 14 of whom (21.2%) became seizure-free. None of the patients reported worsening of seizure frequency, but CBD had no effect in 15 (22.7%) patients. Some patients reported less vigorous seizures, shorter duration of seizures, shorter time to recovery, and other positive side effects of CBD treatment. Adverse effects were reported in 5/66 children. CONCLUSIONS In our cohort of patients, CBD was found to have potential benefits as add-on therapy for refractory childhood epilepsies, mainly by reducing seizure burden.
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Affiliation(s)
- David Neubauer
- Department of Child, Adolescent and Developmental Neurology, University Children's Hospital, University Medical Centre Ljubljana, Slovenia
| | - Mirjana Perković Benedik
- Department of Child, Adolescent and Developmental Neurology, University Children's Hospital, University Medical Centre Ljubljana, Slovenia
| | - Damjan Osredkar
- Department of Child, Adolescent and Developmental Neurology, University Children's Hospital, University Medical Centre Ljubljana, Slovenia.
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484
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Whalley BJ, Lin H, Bell L, Hill T, Patel A, Gray RA, Elizabeth Roberts C, Devinsky O, Bazelot M, Williams CM, Stephens GJ. Species-specific susceptibility to cannabis-induced convulsions. Br J Pharmacol 2018; 176:1506-1523. [PMID: 29457829 PMCID: PMC6487554 DOI: 10.1111/bph.14165] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 01/24/2018] [Accepted: 02/05/2018] [Indexed: 12/13/2022] Open
Abstract
Background and Purpose Numerous claims are made for cannabis' therapeutic utility upon human seizures, but concerns persist about risks. A potential confounder is the presence of both Δ9‐tetrahydrocannabinol (THC), variously reported to be pro‐ and anticonvulsant, and cannabidiol (CBD), widely confirmed as anticonvulsant. Therefore, we investigated effects of prolonged exposure to different THC/CBD cannabis extracts on seizure activity and associated measures of endocannabinoid (eCB) system signalling. Experimental Approach Cannabis extract effects on in vivo neurological and behavioural responses, and on bioanalyte levels, were measured in rats and dogs. Extract effects on seizure activity were measured using electroencephalography telemetry in rats. eCB signalling was also investigated using radioligand binding in cannabis extract‐treated rats and treatment‐naïve rat, mouse, chicken, dog and human tissue. Key Results Prolonged exposure to cannabis extracts caused spontaneous, generalized seizures, subserved by epileptiform discharges in rats, but not dogs, and produced higher THC, but lower 11‐hydroxy‐THC (11‐OH‐THC) and CBD, plasma concentrations in rats versus dogs. In the same rats, prolonged exposure to cannabis also impaired cannabinoid type 1 receptor (CB1 receptor)‐mediated signalling. Profiling CB1 receptor expression, basal activity, extent of activation and sensitivity to THC suggested interspecies differences in eCB signalling, being more pronounced in a species that exhibited cannabis extract‐induced seizures (rat) than one that did not (dog). Conclusions and Implications Sustained cannabis extract treatment caused differential seizure, behavioural and bioanalyte levels between rats and dogs. Supporting radioligand binding data suggest species differences in eCB signalling. Interspecies variations may have important implications for predicting cannabis‐induced convulsions from animal models. Linked Articles This article is part of a themed section on 8th European Workshop on Cannabinoid Research. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v176.10/issuetoc
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Affiliation(s)
- Benjamin J Whalley
- Division of Pharmacology, School of Chemistry, Food and Nutritional Sciences, and Pharmacy, University of Reading, Reading, UK.,GW Research Ltd, Salisbury, UK
| | - Hong Lin
- Division of Pharmacology, School of Chemistry, Food and Nutritional Sciences, and Pharmacy, University of Reading, Reading, UK
| | - Lynne Bell
- School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK
| | - Thomas Hill
- Physiology & Medical Physics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | | | | | - Orrin Devinsky
- Department of Neurology, Comprehensive Epilepsy Center, New York University School of Medicine, New York, NY, USA
| | | | - Claire M Williams
- School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK
| | - Gary J Stephens
- Division of Pharmacology, School of Chemistry, Food and Nutritional Sciences, and Pharmacy, University of Reading, Reading, UK
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485
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Varadkar S. Cannabidiol for drop seizures in Lennox-Gastaut syndrome. Lancet 2018; 391:1006-1007. [PMID: 29395274 DOI: 10.1016/s0140-6736(18)30135-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 01/18/2018] [Indexed: 01/20/2023]
Affiliation(s)
- Sophia Varadkar
- Neuroscience Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK.
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486
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Thiele EA, Marsh ED, French JA, Mazurkiewicz-Beldzinska M, Benbadis SR, Joshi C, Lyons PD, Taylor A, Roberts C, Sommerville K. Cannabidiol in patients with seizures associated with Lennox-Gastaut syndrome (GWPCARE4): a randomised, double-blind, placebo-controlled phase 3 trial. Lancet 2018; 391:1085-1096. [PMID: 29395273 DOI: 10.1016/s0140-6736(18)30136-3] [Citation(s) in RCA: 523] [Impact Index Per Article: 87.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 10/20/2017] [Accepted: 10/24/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with Lennox-Gastaut syndrome, a rare, severe form of epileptic encephalopathy, are frequently treatment resistant to available medications. No controlled studies have investigated the use of cannabidiol for patients with seizures associated with Lennox-Gastaut syndrome. We therefore assessed the efficacy and safety of cannabidiol as an add-on anticonvulsant therapy in this population of patients. METHODS In this randomised, double-blind, placebo-controlled trial done at 24 clinical sites in the USA, the Netherlands, and Poland, we investigated the efficacy of cannabidiol as add-on therapy for drop seizures in patients with treatment-resistant Lennox-Gastaut syndrome. Eligible patients (aged 2-55 years) had Lennox-Gastaut syndrome, including a history of slow (<3 Hz) spike-and-wave patterns on electroencephalogram, evidence of more than one type of generalised seizure for at least 6 months, at least two drop seizures per week during the 4-week baseline period, and had not responded to treatment with at least two antiepileptic drugs. Patients were randomly assigned (1:1) using an interactive voice response system, stratified by age group, to receive 20 mg/kg oral cannabidiol daily or matched placebo for 14 weeks. All patients, caregivers, investigators, and individuals assessing data were masked to group assignment. The primary endpoint was percentage change from baseline in monthly frequency of drop seizures during the treatment period, analysed in all patients who received at least one dose of study drug and had post-baseline efficacy data. All randomly assigned patients were included in the safety analyses. This study is registered with ClinicalTrials.gov, number NCT02224690. FINDINGS Between April 28, 2015, and Oct 15, 2015, we randomly assigned 171 patients to receive cannabidiol (n=86) or placebo (n=85). 14 patients in the cannabidiol group and one in the placebo group discontinued study treatment; all randomly assigned patients received at least one dose of study treatment and had post-baseline efficacy data. The median percentage reduction in monthly drop seizure frequency from baseline was 43·9% (IQR -69·6 to -1·9) in the cannibidiol group and 21·8% (IQR -45·7 to 1·7) in the placebo group. The estimated median difference between the treatment groups was -17·21 (95% CI -30·32 to -4·09; p=0·0135) during the 14-week treatment period. Adverse events occurred in 74 (86%) of 86 patients in the cannabidiol group and 59 (69%) of 85 patients in the placebo group; most were mild or moderate. The most common adverse events were diarrhoea, somnolence, pyrexia, decreased appetite, and vomiting. 12 (14%) patients in the cannabidiol group and one (1%) patient in the placebo group withdrew from the study because of adverse events. One patient (1%) died in the cannabidiol group, but this was considered unrelated to treatment. INTERPRETATION Add-on cannabidiol is efficacious for the treatment of patients with drop seizures associated with Lennox-Gastaut syndrome and is generally well tolerated. The long-term efficacy and safety of cannabidiol is currently being assessed in the open-label extension of this trial. FUNDING GW Pharmaceuticals.
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Affiliation(s)
- Elizabeth A Thiele
- Pediatric Epilepsy Program, Massachusetts General Hospital, Boston, MA, USA.
| | - Eric D Marsh
- Division of Child Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jacqueline A French
- Department of Neurology, New York University School of Medicine, New York, NY, USA
| | | | | | | | - Paul D Lyons
- Winchester Neurological Consultants, Winchester, VA, USA
| | | | | | - Kenneth Sommerville
- Greenwich Biosciences, Research Triangle Park, NC, USA; Duke University, Durham, NC, USA
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487
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Devinsky O, Patel AD, Thiele EA, Wong MH, Appleton R, Harden CL, Greenwood S, Morrison G, Sommerville K. Randomized, dose-ranging safety trial of cannabidiol in Dravet syndrome. Neurology 2018. [PMID: 29540584 PMCID: PMC5890607 DOI: 10.1212/wnl.0000000000005254] [Citation(s) in RCA: 284] [Impact Index Per Article: 47.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective To evaluate the safety and preliminary pharmacokinetics of a pharmaceutical formulation of purified cannabidiol (CBD) in children with Dravet syndrome. Methods Patients aged 4–10 years were randomized 4:1 to CBD (5, 10, or 20 mg/kg/d) or placebo taken twice daily. The double-blind trial comprised 4-week baseline, 3-week treatment (including titration), 10-day taper, and 4-week follow-up periods. Completers could continue in an open-label extension. Multiple pharmacokinetic blood samples were taken on the first day of dosing and at end of treatment for measurement of CBD, its metabolites 6-OH-CBD, 7-OH-CBD, and 7-COOH-CBD, and antiepileptic drugs (AEDs; clobazam and metabolite N-desmethylclobazam [N-CLB], valproate, levetiracetam, topiramate, and stiripentol). Safety assessments were clinical laboratory tests, physical examinations, vital signs, ECGs, adverse events (AEs), seizure frequency, and suicidality. Results Thirty-four patients were randomized (10, 8, and 9 to the 5, 10, and 20 mg/kg/d CBD groups, and 7 to placebo); 32 (94%) completed treatment. Exposure to CBD and its metabolites was dose-proportional (AUC0–t). CBD did not affect concomitant AED levels, apart from an increase in N-CLB (except in patients taking stiripentol). The most common AEs on CBD were pyrexia, somnolence, decreased appetite, sedation, vomiting, ataxia, and abnormal behavior. Six patients taking CBD and valproate developed elevated transaminases; none met criteria for drug-induced liver injury and all recovered. No other clinically relevant safety signals were observed. Conclusions Exposure to CBD and its metabolites increased proportionally with dose. An interaction with N-CLB was observed, likely related to CBD inhibition of cytochrome P450 subtype 2C19. CBD resulted in more AEs than placebo but was generally well-tolerated. Classification of evidence This study provides Class I evidence that for children with Dravet syndrome, CBD resulted in more AEs than placebo but was generally well-tolerated.
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Affiliation(s)
- Orrin Devinsky
- From the NYU Comprehensive Epilepsy Center (O.D.), New York, NY;Nationwide Children's Hospital and the Ohio State University College of Medicine (A.D.P.), Columbus; Massachusetts General Hospital (E.A.T.), Boston; Wake Forest School of Medicine (M.H.W.), Winston-Salem, NC; Alder Hey Children's Health Park (R.A.), Liverpool, UK; Mount Sinai Health System (C.L.H.), New York, NY; GW Research Ltd. (S.G., G.M.), Cambridge, UK; and Greenwich Biosciences (K.S.), Carlsbad, CA.
| | - Anup D Patel
- From the NYU Comprehensive Epilepsy Center (O.D.), New York, NY;Nationwide Children's Hospital and the Ohio State University College of Medicine (A.D.P.), Columbus; Massachusetts General Hospital (E.A.T.), Boston; Wake Forest School of Medicine (M.H.W.), Winston-Salem, NC; Alder Hey Children's Health Park (R.A.), Liverpool, UK; Mount Sinai Health System (C.L.H.), New York, NY; GW Research Ltd. (S.G., G.M.), Cambridge, UK; and Greenwich Biosciences (K.S.), Carlsbad, CA
| | - Elizabeth A Thiele
- From the NYU Comprehensive Epilepsy Center (O.D.), New York, NY;Nationwide Children's Hospital and the Ohio State University College of Medicine (A.D.P.), Columbus; Massachusetts General Hospital (E.A.T.), Boston; Wake Forest School of Medicine (M.H.W.), Winston-Salem, NC; Alder Hey Children's Health Park (R.A.), Liverpool, UK; Mount Sinai Health System (C.L.H.), New York, NY; GW Research Ltd. (S.G., G.M.), Cambridge, UK; and Greenwich Biosciences (K.S.), Carlsbad, CA
| | - Matthew H Wong
- From the NYU Comprehensive Epilepsy Center (O.D.), New York, NY;Nationwide Children's Hospital and the Ohio State University College of Medicine (A.D.P.), Columbus; Massachusetts General Hospital (E.A.T.), Boston; Wake Forest School of Medicine (M.H.W.), Winston-Salem, NC; Alder Hey Children's Health Park (R.A.), Liverpool, UK; Mount Sinai Health System (C.L.H.), New York, NY; GW Research Ltd. (S.G., G.M.), Cambridge, UK; and Greenwich Biosciences (K.S.), Carlsbad, CA
| | - Richard Appleton
- From the NYU Comprehensive Epilepsy Center (O.D.), New York, NY;Nationwide Children's Hospital and the Ohio State University College of Medicine (A.D.P.), Columbus; Massachusetts General Hospital (E.A.T.), Boston; Wake Forest School of Medicine (M.H.W.), Winston-Salem, NC; Alder Hey Children's Health Park (R.A.), Liverpool, UK; Mount Sinai Health System (C.L.H.), New York, NY; GW Research Ltd. (S.G., G.M.), Cambridge, UK; and Greenwich Biosciences (K.S.), Carlsbad, CA
| | - Cynthia L Harden
- From the NYU Comprehensive Epilepsy Center (O.D.), New York, NY;Nationwide Children's Hospital and the Ohio State University College of Medicine (A.D.P.), Columbus; Massachusetts General Hospital (E.A.T.), Boston; Wake Forest School of Medicine (M.H.W.), Winston-Salem, NC; Alder Hey Children's Health Park (R.A.), Liverpool, UK; Mount Sinai Health System (C.L.H.), New York, NY; GW Research Ltd. (S.G., G.M.), Cambridge, UK; and Greenwich Biosciences (K.S.), Carlsbad, CA
| | - Sam Greenwood
- From the NYU Comprehensive Epilepsy Center (O.D.), New York, NY;Nationwide Children's Hospital and the Ohio State University College of Medicine (A.D.P.), Columbus; Massachusetts General Hospital (E.A.T.), Boston; Wake Forest School of Medicine (M.H.W.), Winston-Salem, NC; Alder Hey Children's Health Park (R.A.), Liverpool, UK; Mount Sinai Health System (C.L.H.), New York, NY; GW Research Ltd. (S.G., G.M.), Cambridge, UK; and Greenwich Biosciences (K.S.), Carlsbad, CA
| | - Gilmour Morrison
- From the NYU Comprehensive Epilepsy Center (O.D.), New York, NY;Nationwide Children's Hospital and the Ohio State University College of Medicine (A.D.P.), Columbus; Massachusetts General Hospital (E.A.T.), Boston; Wake Forest School of Medicine (M.H.W.), Winston-Salem, NC; Alder Hey Children's Health Park (R.A.), Liverpool, UK; Mount Sinai Health System (C.L.H.), New York, NY; GW Research Ltd. (S.G., G.M.), Cambridge, UK; and Greenwich Biosciences (K.S.), Carlsbad, CA
| | - Kenneth Sommerville
- From the NYU Comprehensive Epilepsy Center (O.D.), New York, NY;Nationwide Children's Hospital and the Ohio State University College of Medicine (A.D.P.), Columbus; Massachusetts General Hospital (E.A.T.), Boston; Wake Forest School of Medicine (M.H.W.), Winston-Salem, NC; Alder Hey Children's Health Park (R.A.), Liverpool, UK; Mount Sinai Health System (C.L.H.), New York, NY; GW Research Ltd. (S.G., G.M.), Cambridge, UK; and Greenwich Biosciences (K.S.), Carlsbad, CA
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488
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MacCallum CA, Russo EB. Practical considerations in medical cannabis administration and dosing. Eur J Intern Med 2018; 49:12-19. [PMID: 29307505 DOI: 10.1016/j.ejim.2018.01.004] [Citation(s) in RCA: 341] [Impact Index Per Article: 56.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 01/01/2018] [Indexed: 11/23/2022]
Abstract
Cannabis has been employed medicinally throughout history, but its recent legal prohibition, biochemical complexity and variability, quality control issues, previous dearth of appropriately powered randomised controlled trials, and lack of pertinent education have conspired to leave clinicians in the dark as to how to advise patients pursuing such treatment. With the advent of pharmaceutical cannabis-based medicines (Sativex/nabiximols and Epidiolex), and liberalisation of access in certain nations, this ignorance of cannabis pharmacology and therapeutics has become untenable. In this article, the authors endeavour to present concise data on cannabis pharmacology related to tetrahydrocannabinol (THC), cannabidiol (CBD) et al., methods of administration (smoking, vaporisation, oral), and dosing recommendations. Adverse events of cannabis medicine pertain primarily to THC, whose total daily dose-equivalent should generally be limited to 30mg/day or less, preferably in conjunction with CBD, to avoid psychoactive sequelae and development of tolerance. CBD, in contrast to THC, is less potent, and may require much higher doses for its adjunctive benefits on pain, inflammation, and attenuation of THC-associated anxiety and tachycardia. Dose initiation should commence at modest levels, and titration of any cannabis preparation should be undertaken slowly over a period of as much as two weeks. Suggestions are offered on cannabis-drug interactions, patient monitoring, and standards of care, while special cases for cannabis therapeutics are addressed: epilepsy, cancer palliation and primary treatment, chronic pain, use in the elderly, Parkinson disease, paediatrics, with concomitant opioids, and in relation to driving and hazardous activities.
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Affiliation(s)
| | - Ethan B Russo
- International Cannabis and Cannabinoids Institute, Prague, Czech Republic.
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489
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Abrams DI. The therapeutic effects of Cannabis and cannabinoids: An update from the National Academies of Sciences, Engineering and Medicine report. Eur J Intern Med 2018; 49:7-11. [PMID: 29325791 DOI: 10.1016/j.ejim.2018.01.003] [Citation(s) in RCA: 160] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 01/01/2018] [Indexed: 12/30/2022]
Abstract
The National Academies of Sciences, Engineering and Medicine conducted a rapid turn-around comprehensive review of recent medical literature on The Health Effects of Cannabis and Cannabinoids. The 16-member committee adopted the key features of a systematic review process, conducting an extensive search of relevant databases and considered 10,000 recent abstracts to determine their relevance. Primacy was given to recently published systematic reviews and primary research that studied one of the committee's 11 prioritized health endpoints- therapeutic effects; cancer incidence; cardiometabolic risk; respiratory disease; immune function; injury and death; prenatal, perinatal and postnatal outcomes; psychosocial outcomes; mental health; problem Cannabis use; and Cannabis use and abuse of other substances. The committee developed standard language to categorize the weight of evidence regarding whether Cannabis or cannabinoids use for therapeutic purposes are an effective or ineffective treatment for the prioritized health endpoints of interest. In the Therapeutics chapter reviewed here, the report concluded that there was conclusive or substantial evidence that Cannabis or cannabinoids are effective for the treatment of pain in adults; chemotherapy-induced nausea and vomiting and spasticity associated with multiple sclerosis. Moderate evidence was found for secondary sleep disturbances. The evidence supporting improvement in appetite, Tourette syndrome, anxiety, posttraumatic stress disorder, cancer, irritable bowel syndrome, epilepsy and a variety of neurodegenerative disorders was described as limited, insufficient or absent. A chapter of the NASEM report enumerated multiple barriers to conducting research on Cannabis in the US that may explain the paucity of positive therapeutic benefits in the published literature to date.
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Affiliation(s)
- Donald I Abrams
- Hematology-Oncology, Zuckerberg San Francisco General Hospital, Professor of Clinical Medicine, University of California San Francisco Ward 84, 995 Potrero Avenue, San Francisco, CA 94110, USA.
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490
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Porcari GS, Fu C, Doll ED, Carter EG, Carson RP. Efficacy of artisanal preparations of cannabidiol for the treatment of epilepsy: Practical experiences in a tertiary medical center. Epilepsy Behav 2018; 80:240-246. [PMID: 29429908 DOI: 10.1016/j.yebeh.2018.01.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 01/22/2018] [Accepted: 01/23/2018] [Indexed: 01/08/2023]
Abstract
Medically refractory epilepsy continues to be a challenge worldwide, and despite an increasing number of medical therapies, approximately 1 in 3 patients continues to have seizures. Cannabidiol (CBD), one of many constituents of the Cannabis sativa or marijuana plant, has received renewed interest in the treatment of epilepsy. While highly purified CBD awaits Food and Drug Administration (FDA) approval, artisanal formulations of CBD are readily available and are seeing increased use in our patient population. Although randomized controlled trials of CBD are ongoing and promising, data regarding artisanal formulations of CBD are minimal and largely anecdotal. Here, we report a retrospective study to define the efficacy of artisanal CBD preparations in children with epilepsy. Given the known interaction between CBD and clobazam, we also conducted a subgroup comparison to determine if clobazam use was related to any beneficial effects of CBD. Additionally, we compared response rates with CBD and with clobazam alone within an overlapping patient cohort. A pediatric cohort with epilepsy of 108 patients was identified through a medical record search for patients using CBD oil. The addition of CBD resulted in 39% of patients having a >50% reduction in seizures, with 10% becoming seizure-free. The responder rate for clobazam was similar. No patients achieved CBD monotherapy, although the weaning of other antiepileptic drugs (AEDs) became possible in 22% of patients. A comparable proportion had AED additions during CBD therapy. With concomitant use of clobazam, 44% of patients had a 50% reduction in seizures upon addition of CBD compared with 33% in the population not taking clobazam; this difference was not statistically significant. The most common reported side effect of CBD was sedation in less than 4% of patients, all of whom were also taking clobazam. Increased alertness and improved verbal interactions were reported in 14% of patients in the CBD group and 8% of patients in the CBD and clobazam group. Benefits were more marked in the CBD alone group, in contrast to the CBD and clobazam group, but this difference was not statistically significant. In summary, these findings support efficacy of artisanal CBD preparations in seizure reduction with few significant side effects. The response to CBD was independent of concurrent clobazam use, although clobazam may contribute to the sedation seen with concurrent CBD use.
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Affiliation(s)
| | - Cary Fu
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University, Nashville, TN, USA
| | - Emily D Doll
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University, Nashville, TN, USA
| | - Emma G Carter
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University, Nashville, TN, USA
| | - Robert P Carson
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University, Nashville, TN, USA.
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491
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Chadi N, Weitzman ER, Levy S. Understanding the Impact of National and State Medical Marijuana Policies on Adolescents. CURRENT ADDICTION REPORTS 2018. [DOI: 10.1007/s40429-018-0191-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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492
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Chen K, Farrar MA, Cardamone M, Lawson JA. Cannabis for paediatric epilepsy: challenges and conundrums. Med J Aust 2018; 208:132-136. [DOI: 10.5694/mja17.00699] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 11/30/2017] [Indexed: 01/15/2023]
Affiliation(s)
| | - Michelle A Farrar
- Sydney Children's Hospital, Randwick, Sydney, NSW
- UNSW Sydney, Sydney, NSW
| | - Michael Cardamone
- Sydney Children's Hospital, Randwick, Sydney, NSW
- UNSW Sydney, Sydney, NSW
| | - John A Lawson
- Sydney Children's Hospital, Randwick, Sydney, NSW
- UNSW Sydney, Sydney, NSW
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493
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Maggio N, Shavit Stein E, Segal M. Cannabidiol Regulates Long Term Potentiation Following Status Epilepticus: Mediation by Calcium Stores and Serotonin. Front Mol Neurosci 2018; 11:32. [PMID: 29467619 PMCID: PMC5808210 DOI: 10.3389/fnmol.2018.00032] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 01/24/2018] [Indexed: 11/13/2022] Open
Abstract
Epilepsy is a devastating disease, with cognitive and emotional consequences that are not curable. In recent years, it became apparent that cannabinoids help patients to cope with epilepsy. We have studied the effects of cannabidiol (CBD) on the ability to produce long term potentiation (LTP) in stratum radiatum of CA1 region of the mouse hippocampus. Exposure to seizure-producing pilocarpine reduced the ability to generate LTP in the slice. Pre-exposure to CBD prevented this effect of pilocarpine. Furthermore, CBD caused a marked increase in ability to generate LTP, an effect that was blocked by calcium store antagonists as well as by a reduction in serotonin tone. Serotonin, possibly acting at a 5HT1A receptor, or fenfluramine (FFA), which causes release of serotonin from its native terminals, mimicked the effect of CBD. It is proposed that CBD enhances non-NMDA LTP in the slice by facilitating release of serotonin from terminals, consequently ameliorating the detrimental effects of pilocarpine.
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Affiliation(s)
- Nicola Maggio
- Department of Neurology, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Department of Neurology and Neurosurgery, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Efrat Shavit Stein
- Department of Neurology, The Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Menahem Segal
- Department of Neurobiology, The Weizmann Institute of Science, Rehovot, Israel
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494
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Prospects of Cannabidiol for Easing Status Epilepticus-Induced Epileptogenesis and Related Comorbidities. Mol Neurobiol 2018; 55:6956-6964. [PMID: 29372545 DOI: 10.1007/s12035-018-0898-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 01/09/2018] [Indexed: 12/21/2022]
Abstract
The hippocampus is one of the most susceptible regions in the brain to be distraught with status epilepticus (SE) induced injury. SE can occur from numerous causes and is more frequent in children and the elderly population. Administration of a combination of antiepileptic drugs can abolish acute seizures in most instances of SE but cannot prevent the morbidity typically seen in survivors of SE such as cognitive and mood impairments and spontaneous recurrent seizures. This is primarily due to the inefficiency of antiepileptic drugs to modify the evolution of SE-induced initial precipitating injury into a series of epileptogenic changes followed by a state of chronic epilepsy. Chronic epilepsy is typified by spontaneous recurrent seizures, cognitive dysfunction, and depression, which are associated with persistent inflammation, significantly waned neurogenesis, and abnormal synaptic reorganization. Thus, alternative approaches that are efficient not only for curtailing SE-induced initial brain injury, neuroinflammation, aberrant neurogenesis, and abnormal synaptic reorganization but also for thwarting or restraining the progression of SE into a chronic epileptic state are needed. In this review, we confer the promise of cannabidiol, an active ingredient of Cannabis sativa, for preventing or easing SE-induced neurodegeneration, neuroinflammation, cognitive and mood impairments, and the spontaneous recurrent seizures.
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495
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496
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497
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Neale M. Efficacy and safety of cannabis for treating children with refractory epilepsy. Nurs Child Young People 2018; 29:32-37. [PMID: 29115760 DOI: 10.7748/ncyp.2017.e907] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2017] [Indexed: 11/09/2022]
Abstract
The aim of this literature review was to examine the evidence base for the safety and efficacy of cannabis in treating children with refractory epilepsy. Clinical and medical databases were searched and four articles were included in the final analysis, which included retrospective reviews and open-label trials with a total sample size of 424. One clinical trial included administration of cannabidiol, the non-psychoactive compound of cannabis, while the other three articles stated that the compound administered to participants contained tetrahydrocannabidiol, the psychoactive constituent of cannabis. Cannabis may reduce seizures in some children and young people with refractory epilepsy, however, its success may be affected by aetiology of the epilepsy or concomitant anti-epileptic drug use, and a therapeutic dose has not been found. Positive side effects were also found including improved sleep, alertness and mood. More research is needed on this subject, including randomised controlled trials. Nurses who are aware of patients and families wishing to trial cannabis for refractory epilepsy should have full and frank discussions.
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498
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Capasso A. Do Cannabinoids Confer Neuroprotection Against Epilepsy? An Overview. Open Neurol J 2018; 11:61-73. [PMID: 29290836 PMCID: PMC5738750 DOI: 10.2174/1874205x01711010061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 11/02/2017] [Accepted: 11/20/2017] [Indexed: 01/06/2023] Open
Abstract
Objective: Cannabinoid-based medications provide not only relief for specific symptoms, but also arrest or delay of disease progression in patients with pain, multiple sclerosis, and other conditions. Although they also seem to hold potential as anticonvulsant agents, evidence of their efficacy in epilepsy is supported by several evidences. Method: The data reviewed herein lend support to the notion that the endocannabinoid signalling system plays a key modulation role in the activities subserved by the hippocampus, which is directly or indirectly affected in epilepsy patients. Conclusion: The notion is supported by a variety of anatomical, electrophysiological, biochemical and pharmacological findings. These data suggest the need for developing novel treatments using compounds that selectively target individual elements of the endocannabinoid signalling system.
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Affiliation(s)
- Anna Capasso
- Department of Pharmacy, University of Salerno, via Giovanni Paolo II, 84084, Fisciano, Italy
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499
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Taylor L, Gidal B, Blakey G, Tayo B, Morrison G. A Phase I, Randomized, Double-Blind, Placebo-Controlled, Single Ascending Dose, Multiple Dose, and Food Effect Trial of the Safety, Tolerability and Pharmacokinetics of Highly Purified Cannabidiol in Healthy Subjects. CNS Drugs 2018; 32:1053-1067. [PMID: 30374683 PMCID: PMC6223703 DOI: 10.1007/s40263-018-0578-5] [Citation(s) in RCA: 274] [Impact Index Per Article: 45.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND A formal single ascending and multiple dose pharmacokinetic (PK) trial of cannabidiol (CBD) oral solution was required to determine the safety and tolerability of CBD, the maximum tolerated dose, and to examine the effect of food on CBD PK parameters. OBJECTIVE This trial assessed the safety, tolerability and PK of CBD oral solution in healthy adult volunteers, as well as the effect of food on CBD PK parameters. METHODS The study consisted of three arms: single ascending dose (1500, 3000, 4500 or 6000 mg CBD [n = 6 per group]/placebo [n = 8; 2 per CBD dose group]), multiple dose (750 or 1500 mg CBD [n = 9 per group]/placebo [n = 6; 3 per CBD dose group] twice daily), and food effect (1500 mg CBD single dose [n = 12]). All subjects completed all trial arms and were analyzed as planned. RESULTS CBD was generally well tolerated. Diarrhea, nausea, headache, and somnolence were the most common adverse events (AEs) across all trial arms, with an increased incidence of some gastrointestinal and nervous system disorder AEs (most notably diarrhea and headache) apparent in subjects taking CBD compared with placebo. All AEs were of mild or moderate severity; none were severe or serious. There were no deaths or discontinuations in the trial. After single oral doses, CBD appeared rapidly in plasma; time to maximum plasma concentration (tmax) was approximately 4-5 h. The major circulating metabolite was 7-carboxy-CBD, then parent CBD, 7-hydroxy-CBD (active metabolite), and 6-hydroxy-CBD (a relatively minor metabolite). Plasma exposure to CBD [maximum plasma concentration (Cmax) and area under the plasma concentration-time curve from time zero to time t (AUCt)] increased in a less than dose-proportional manner (Cmax slope 0.73; AUCt slope 0.64). Oral clearance of CBD was high (1111-1909 L/h) and apparent volume of distribution was large (20,963-42,849 L). CBD reached steady state after approximately 2 days, with moderate accumulation (1.8- to 2.6-fold) after 750 and 1500 mg CBD twice daily. After 7 days, a twofold increase in CBD dose resulted in 1.6- and 1.9-fold increases in geometric mean Cmax and area under the plasma concentration-time curve over a dosing interval (AUCτ), respectively. CBD elimination was multiphasic; the terminal elimination half-life was approximately 60 h after 750 and 1500 mg CBD twice daily; and effective half-life estimates ranged from 10 to 17 h. Cmax was 541.2 ng/mL and AUCτ was 3236 ng·h/mL after 1500 mg CBD twice daily. A high-fat meal increased CBD plasma exposure (Cmax and AUCt) by 4.85- and 4.2-fold, respectively; there was no effect of food on tmax or terminal half-life. CONCLUSION CBD was generally well tolerated. Most AEs were mild in severity; none were severe or serious. The safety and PK profile support twice-daily administration of CBD.
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Affiliation(s)
| | - Barry Gidal
- University of Wisconsin School of Pharmacy, Madison, WI USA
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Russo EB. The Case for the Entourage Effect and Conventional Breeding of Clinical Cannabis: No "Strain," No Gain. FRONTIERS IN PLANT SCIENCE 2018; 9:1969. [PMID: 30687364 PMCID: PMC6334252 DOI: 10.3389/fpls.2018.01969] [Citation(s) in RCA: 167] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 12/19/2018] [Indexed: 05/02/2023]
Abstract
The topic of Cannabis curries controversy in every sphere of influence, whether politics, pharmacology, applied therapeutics or even botanical taxonomy. Debate as to the speciation of Cannabis, or a lack thereof, has swirled for more than 250 years. Because all Cannabis types are eminently capable of cross-breeding to produce fertile progeny, it is unlikely that any clear winner will emerge between the "lumpers" vs. "splitters" in this taxonomical debate. This is compounded by the profusion of Cannabis varieties available through the black market and even the developing legal market. While labeled "strains" in common parlance, this term is acceptable with respect to bacteria and viruses, but not among Plantae. Given that such factors as plant height and leaflet width do not distinguish one Cannabis plant from another and similar difficulties in defining terms in Cannabis, the only reasonable solution is to characterize them by their biochemical/pharmacological characteristics. Thus, it is best to refer to Cannabis types as chemical varieties, or "chemovars." The current wave of excitement in Cannabis commerce has translated into a flurry of research on alternative sources, particularly yeasts, and complex systems for laboratory production have emerged, but these presuppose that single compounds are a desirable goal. Rather, the case for Cannabis synergy via the "entourage effect" is currently sufficiently strong as to suggest that one molecule is unlikely to match the therapeutic and even industrial potential of Cannabis itself as a phytochemical factory. The astounding plasticity of the Cannabis genome additionally obviates the need for genetic modification techniques.
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