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Riva N, Mora G, Sorarù G, Lunetta C, Ferraro OE, Falzone Y, Leocani L, Fazio R, Comola M, Comi G. Safety and efficacy of nabiximols on spasticity symptoms in patients with motor neuron disease (CANALS): a multicentre, double-blind, randomised, placebo-controlled, phase 2 trial. Lancet Neurol 2018; 18:155-164. [PMID: 30554828 DOI: 10.1016/s1474-4422(18)30406-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 10/10/2018] [Accepted: 10/24/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Spasticity is a major determinant of disability and decline in quality of life in patients with motor neuron disease. Cannabinoids have been approved for symptomatic treatment of spasticity in multiple sclerosis. We investigated whether cannabinoids might also reduce spasticity in patients with motor neuron disease. METHODS We did an investigator-initiated, randomised, double-blind, placebo-controlled, phase 2 clinical trial at four tertiary motor neuron disease centres in Italy. Eligible patients were aged 18-80 years; had possible, laboratory-supported probable, probable, or definite amyotrophic lateral sclerosis as defined by revised El Escorial criteria, or primary lateral sclerosis according to Pringle's criteria; had spasticity symptoms due to motor neuron disease for at least 3 months; had spasticity scores of 1 or greater in at least two muscle groups on the Modified Ashworth Scale; and were taking an antispasticity regimen that was maintained at a stable dose for 30 days before enrolment. Participants were assigned (1:1) by an independent statistician via a computer-generated randomisation sequence to a standardised oromucosal spray (nabiximols) containing a defined combination of delta-9-tetrahydrocannabinol and cannabidiol (each 100 μL actuation contained 2·7 mg delta-9-tetrahydrocannabinol and 2·5 mg cannabidiol) or to placebo for 6 weeks. Participants self-titrated during the first 14 treatment days according to a predefined escalation scheme (maximum 12 actuations per 24 h), then maintained that dose for 4 weeks. The primary endpoint was the change in the score on the Modified Ashworth Scale, which was assessed at baseline and after 6 weeks. Safety and tolerability were also monitored. Participants, investigators, site personnel, and the study statistician were masked to treatment allocation. All randomised participants who received at least one dose of study drug were included in the analysis. This trial is registered with ClinicalTrials.gov, number NCT01776970. The trial is closed to new participants with follow-up completed. FINDINGS Between Jan 19, 2013, and Dec 15, 2014, 60 participants were randomly assigned, and 59 participants were included in the final analysis (29 in the nabiximols group and 30 in the placebo group). Modified Ashworth Scale scores improved by a mean of 0·11 (SD 0·48) in the nabiximols group and deteriorated by a mean of 0·16 (0·47) in the placebo group (adjusted effect estimate -0·32 [95% CI -0·57 to -0·069]; p=0·013). Nabiximols was well tolerated, and no participants withdrew from the double-blind phase of the study. No serious adverse effects occurred. INTERPRETATION In this proof-of-concept trial, nabiximols had a positive effect on spasticity symptoms in patients with motor neuron disease and had an acceptable safety and tolerability profile. These findings should be investigated further in larger clinical trials. FUNDING Italian Research Foundation for Amyotrophic Lateral Sclerosis.
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Affiliation(s)
- Nilo Riva
- Department of Neurology, Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Gabriele Mora
- Department of Neurorehabilitation, Amyotrophic Lateral Sclerosis Centre, Istituti Clinici Scientifici Maugeri, IRCCS, Milan, Italy
| | - Gianni Sorarù
- Department of Neurosciences, Neuromuscular Centre, University of Padova, Padua, Italy
| | | | - Ottavia E Ferraro
- Unit of Biostatistics and Clinical Epidemiology, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Yuri Falzone
- Department of Neurology, Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Letizia Leocani
- Department of Neurology, Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Raffaella Fazio
- Department of Neurology, Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Mauro Comola
- Department of Neurology, Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Giancarlo Comi
- Department of Neurology, Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy.
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Weighing the Benefits and Risks of Medical Marijuana Use: A Brief Review. PHARMACY 2018; 6:pharmacy6040128. [PMID: 30563219 PMCID: PMC6306710 DOI: 10.3390/pharmacy6040128] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 11/26/2018] [Accepted: 12/03/2018] [Indexed: 12/13/2022] Open
Abstract
Despite federal prohibition of medical marijuana possession, sale, and use, marijuana use continues to escalate as state legalization persists and expands. The purpose of this discussion is to provide a brief summary of the evidence regarding both potential benefits and risks of medical marijuana use.
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Donertas B, Unel CC, Erol K. Cannabinoids and agmatine as potential therapeutic alternatives for cisplatin-induced peripheral neuropathy. J Exp Pharmacol 2018; 10:19-28. [PMID: 29950907 PMCID: PMC6018893 DOI: 10.2147/jep.s162059] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Cisplatin is a widely used antineoplastic agent in the treatment of various cancers. Peripheral neuropathy is a well-known side effect of cisplatin and has the potential to result in limiting and/or reducing the dose, decreasing the quality of life. Unfortunately, the mechanism for cisplatin-induced neuropathy has not been completely elucidated. Currently, available treatments for neuropathic pain (NP) are mostly symptomatic, insufficient and are often linked with several detrimental side effects; thus, effective treatments are needed. Cannabinoids and agmatine are endogenous modulators that are implicated in painful states. This review explains the cisplatin-induced neuropathy and antinociceptive effects of cannabinoids and agmatine in animal models of NP and their putative therapeutic potential in cisplatin-induced neuropathy.
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Affiliation(s)
- Basak Donertas
- Department of Medical Pharmacology, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Cigdem Cengelli Unel
- Department of Medical Pharmacology, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Kevser Erol
- Department of Medical Pharmacology, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
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Baron EP, Lucas P, Eades J, Hogue O. Patterns of medicinal cannabis use, strain analysis, and substitution effect among patients with migraine, headache, arthritis, and chronic pain in a medicinal cannabis cohort. J Headache Pain 2018; 19:37. [PMID: 29797104 PMCID: PMC5968020 DOI: 10.1186/s10194-018-0862-2] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 05/04/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Medicinal cannabis registries typically report pain as the most common reason for use. It would be clinically useful to identify patterns of cannabis treatment in migraine and headache, as compared to arthritis and chronic pain, and to analyze preferred cannabis strains, biochemical profiles, and prescription medication substitutions with cannabis. METHODS Via electronic survey in medicinal cannabis patients with headache, arthritis, and chronic pain, demographics and patterns of cannabis use including methods, frequency, quantity, preferred strains, cannabinoid and terpene profiles, and prescription substitutions were recorded. Cannabis use for migraine among headache patients was assessed via the ID Migraine™ questionnaire, a validated screen used to predict the probability of migraine. RESULTS Of 2032 patients, 21 illnesses were treated with cannabis. Pain syndromes accounted for 42.4% (n = 861) overall; chronic pain 29.4% (n = 598;), arthritis 9.3% (n = 188), and headache 3.7% (n = 75;). Across all 21 illnesses, headache was a symptom treated with cannabis in 24.9% (n = 505). These patients were given the ID Migraine™ questionnaire, with 68% (n = 343) giving 3 "Yes" responses, 20% (n = 102) giving 2 "Yes" responses (97% and 93% probability of migraine, respectively). Therefore, 88% (n = 445) of headache patients were treating probable migraine with cannabis. Hybrid strains were most preferred across all pain subtypes, with "OG Shark" the most preferred strain in the ID Migraine™ and headache groups. Many pain patients substituted prescription medications with cannabis (41.2-59.5%), most commonly opiates/opioids (40.5-72.8%). Prescription substitution in headache patients included opiates/opioids (43.4%), anti-depressant/anti-anxiety (39%), NSAIDs (21%), triptans (8.1%), anti-convulsants (7.7%), muscle relaxers (7%), ergots (0.4%). CONCLUSIONS Chronic pain was the most common reason for cannabis use, consistent with most registries. The majority of headache patients treating with cannabis were positive for migraine. Hybrid strains were preferred in ID Migraine™, headache, and most pain groups, with "OG Shark", a high THC (Δ9-tetrahydrocannabinol)/THCA (tetrahydrocannabinolic acid), low CBD (cannabidiol)/CBDA (cannabidiolic acid), strain with predominant terpenes β-caryophyllene and β-myrcene, most preferred in the headache and ID Migraine™ groups. This could reflect the potent analgesic, anti-inflammatory, and anti-emetic properties of THC, with anti-inflammatory and analgesic properties of β-caryophyllene and β-myrcene. Opiates/opioids were most commonly substituted with cannabis. Prospective studies are needed, but results may provide early insight into optimizing crossbred cannabis strains, synergistic biochemical profiles, dosing, and patterns of use in the treatment of headache, migraine, and chronic pain syndromes.
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Affiliation(s)
- Eric P. Baron
- Center for Neurological Restoration - Headache and Chronic Pain Medicine, Department of Neurology, Cleveland Clinic Neurological Institute, 10524 Euclid Avenue, C21, Cleveland, OH 44195 USA
| | - Philippe Lucas
- Tilray, 1100 Maughan Rd, Nanaimo, BC V9X 1J2 Canada
- Social Dimensions of Health, University of Victoria, 3800 Finnerty Rd, Victoria, BC V8P 5C2 Canada
- Canadian Institute for Substance Use Research, 2300 McKenzie Ave, Victoria, BC V8N 5M8 Canada
| | - Joshua Eades
- Tilray, 1100 Maughan Rd, Nanaimo, BC V9X 1J2 Canada
| | - Olivia Hogue
- Section of Biostatistics, Department of Quantitative Health Sciences, Cleveland Clinic Lerner Research Institute, 9500 Euclid Avenue, JJN3, Cleveland, OH 44195 USA
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Kutiel TS, Vornicova O, Bar-Sela G. Cannabis for Vismodegib-Related Muscle Cramps in a Patient With Advanced Basal Cell Carcinoma. J Pain Symptom Manage 2018; 55:e1-e2. [PMID: 29454899 DOI: 10.1016/j.jpainsymman.2018.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 02/05/2018] [Accepted: 02/08/2018] [Indexed: 02/07/2023]
Affiliation(s)
| | - Olga Vornicova
- Division of Oncology, Technion-Israel Institute of Technology, Haifa, Israel
| | - Gil Bar-Sela
- Division of Oncology, Technion-Israel Institute of Technology, Haifa, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
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Darkovska-Serafimovska M, Serafimovska T, Arsova-Sarafinovska Z, Stefanoski S, Keskovski Z, Balkanov T. Pharmacotherapeutic considerations for use of cannabinoids to relieve pain in patients with malignant diseases. J Pain Res 2018; 11:837-842. [PMID: 29719417 PMCID: PMC5922297 DOI: 10.2147/jpr.s160556] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Purpose The aim of this review was to assess the efficacy of cannabis preparations for relieving pain in patients with malignant diseases, through a systematic review of randomized controlled trials (RCTs), which were predominantly double-blind trials that compared cannabis preparation to a placebo. Methods An electronic search of all literature published until June 2017 was made in MEDLINE/PubMed, Embase, The Cochrane Controlled Trials Register and specific web pages devoted to cannabis. Results Fifteen of the 18 trials demonstrated a significant analgesic effect of cannabinoids as compared to placebo. The most commonly reported adverse effects were generally well tolerated, mild to moderate. The main side effects were drowsiness, nausea, vomiting and dry mouth. There is evidence that cannabinoids are safe and modestly effective in neuropathic pain and also for relieving pain in patients with malignant diseases. The proportion of “responders” (patients who at the end of 2 weeks of treatment reported ≥30% reduction in pain intensity on a scale of 0–10, which is considered to be clinically important) was 43% in comparison with placebo (21%). Conclusion The target dose for relieving pain in patients with malignant diseases is most likely about 10 actuations per day, which is about 27 mg tetrahydrocannabinol (THC) and 25 mg cannabidiol (CBD), and the highest approved recommended dose is 12 actuations per day (32 mg THC/30 mg CBD). Further large studies of cannabinoids in homogeneous populations are required.
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Affiliation(s)
| | - Tijana Serafimovska
- Faculty of Pharmacy, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Zorica Arsova-Sarafinovska
- Department of Pharmacology, Faculty of Medical Sciences, Goce Delcev University, Stip, Republic of Macedonia
| | | | | | - Trajan Balkanov
- Department of Pharmacology and Toxicology, Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
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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: 338] [Impact Index Per Article: 56.3] [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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Ware MA, Martel MO, Jovey R, Lynch ME, Singer J. A prospective observational study of problematic oral cannabinoid use. Psychopharmacology (Berl) 2018; 235:409-417. [PMID: 29250737 DOI: 10.1007/s00213-017-4811-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 12/05/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Despite evidence supporting the benefits of cannabinoids for symptom control across a wide range of medical conditions, concerns have been raised regarding the potential misuse and/or problematic use of cannabinoids (CBs). OBJECTIVE The first objective of this study was to examine the incidence of problematic prescription cannabinoid use (PPCBU) over a 12-month period among patients initiating cannabinoid therapy. The second objective was to examine the factors associated with PPCBU. A total of 265 patients who were prescribed oral cannabinoid therapy as part of usual medical practice were enrolled into this prospective observational study. Patients first completed a series of baseline questionnaires assessing demographic, clinical, and substance use variables. Three measures designed to assess PPCBU were then administered at 3, 6, and 12 months after initiation of cannabinoid therapy. RESULTS At each of the follow-up assessment time points, a significantly greater number of patients scored below (vs above) cutoff scores on the three main PPCBU outcomes (all p's < .001). At any follow-up time point, a maximum of roughly 25% of patients demonstrated PPCBU. Heightened odds of PPCBU were observed among patients with a history of psychiatric problems, tobacco smokers, and recreational cannabis users (all p's < .05). Results indicated that past-year substance abuse, assessed using the DAST-20, was the strongest predictor of PPCBU (p < .005). CONCLUSION Findings from the present study could have implications for clinicians considering the use of cannabinoids for the management of patients with medical conditions. Although results indicated that the majority of patients included in this study did not reach cutoff scores on the three main PPCBU outcomes, our findings suggest that PPCBU should be routinely assessed and monitored over the course of cannabinoid therapy, particularly among patients with a history of psychiatric or substance use problems.
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Affiliation(s)
- Mark A Ware
- Department of Anesthesia, Faculty of Medicine, McGill University, Montreal, Canada. .,Department of Family Medicine, McGill University, Montreal, Canada. .,Alan Edwards Pain Management Unit, McGill University Health Centre, Montreal, Canada. .,Montreal General Hospital, A5.140, 1650 Cedar Avenue, Montreal, Quebec, H3G 1A4, Canada.
| | - Marc O Martel
- Department of Anesthesia, Faculty of Medicine, McGill University, Montreal, Canada.,Alan Edwards Pain Management Unit, McGill University Health Centre, Montreal, Canada.,Faculty of Dentistry, McGill University, Montreal, Canada
| | - Roman Jovey
- CPM Centres for Pain Management, Mississauga, Ontario, Canada
| | - Mary E Lynch
- Department of Anesthesia, Pain Medicine, and Perioperative Care, Dalhousie University, Halifax, Canada
| | - Joel Singer
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
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Farzaei MH, Shahpiri Z, Bahramsoltani R, Nia MM, Najafi F, Rahimi R. Efficacy and Tolerability of Phytomedicines in Multiple Sclerosis Patients: A Review. CNS Drugs 2017; 31:867-889. [PMID: 28948486 DOI: 10.1007/s40263-017-0466-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Multiple sclerosis (MS) is a chronic inflammatory and demyelinating disorder of the central nervous system (CNS) that can cause cognition, mobility, and sensory impairments. It is considered one of the most common non-traumatic causes of disability in the world. The aim of the present article was to review the clinical evidence related to medicinal plants in the management of MS symptoms. Electronic databases, including the Cochrane Library, Pubmed, and Scopus, were searched for entries from 1966 to February 2017. Only clinical studies were included in this review. Different medicinal plants have positive effects on MS, including Andrographis paniculata, Boswellia papyrifera, Ruta graveolens, Vaccinium spp., Camellia sinensis, Panax ginseng, Aloysia citrodora, Ginkgo biloba, Oenothera biennis, and Cannabis sativa. C. sativa had the highest level of clinical evidence, supporting its efficacy in MS symptoms. Proanthocyanidins, ginkgo flavone glycosides, ginsenosides, epigallocatechin-3-gallate, cannabinoids (including delta-9-tetrahydrocannabinol and cannabidiol), boswellic acid, and andrographolide were presented as the main bioactive components of medicinal plants with therapeutic benefits in MS. The main complications of MS in which natural drugs were effective include spasticity, fatigue, scotoma, incontinence, urinary urgency, nocturia, memory performance, functional performance, and tremor. Herbal medicines were mostly well tolerated, and the adverse effects were limited to mild to moderate. Further well-designed human studies with a large sample size and longer follow-up period are recommended to confirm the role of medicinal plants and their metabolites in the management of MS.
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Affiliation(s)
- Mohammad Hosein Farzaei
- Pharmaceutical Sciences Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
- Medical Biology Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Zahra Shahpiri
- Department of Traditional Pharmacy, School of Traditional Medicine, Tehran University of Medical Sciences, Tehran, 1417653761, Iran
- PhytoPharmacology Interest Group (PPIG), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Roodabeh Bahramsoltani
- Department of Traditional Pharmacy, School of Traditional Medicine, Tehran University of Medical Sciences, Tehran, 1417653761, Iran
- PhytoPharmacology Interest Group (PPIG), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Marjan Moghaddam Nia
- Medical Biology Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
- PhytoPharmacology Interest Group (PPIG), Universal Scientific Education and Research Network (USERN), Kermanshah, Iran
| | - Fariba Najafi
- Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Roja Rahimi
- Department of Traditional Pharmacy, School of Traditional Medicine, Tehran University of Medical Sciences, Tehran, 1417653761, Iran.
- PhytoPharmacology Interest Group (PPIG), Universal Scientific Education and Research Network (USERN), Tehran, Iran.
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Giacoppo S, Bramanti P, Mazzon E. Sativex in the management of multiple sclerosis-related spasticity: An overview of the last decade of clinical evaluation. Mult Scler Relat Disord 2017; 17:22-31. [DOI: 10.1016/j.msard.2017.06.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 06/20/2017] [Accepted: 06/25/2017] [Indexed: 01/28/2023]
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Keating GM. Delta-9-Tetrahydrocannabinol/Cannabidiol Oromucosal Spray (Sativex ®): A Review in Multiple Sclerosis-Related Spasticity. Drugs 2017; 77:563-574. [PMID: 28293911 DOI: 10.1007/s40265-017-0720-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Delta-9-tetrahydrocannabinol (THC)/cannabidiol (CBD) oromucosal spray (THC/CBD, Sativex®, nabiximols) is available in numerous countries worldwide for the treatment of multiple sclerosis (MS)-related moderate to severe spasticity in patients who have not responded adequately to other anti-spasticity medication and who demonstrate clinically significant improvement in spasticity-related symptoms during an initial trial of therapy. Twelve weeks' therapy with THC/CBD improved MS-related spasticity in patients with an inadequate response to other anti-spasticity agents who had undergone a successful initial trial of THC/CBD therapy, according to the results of a pivotal phase 3 trial. Improvements in spasticity were maintained in the longer term with THC/CBD with no evidence of dose tolerance, and results of real-world studies confirm the effectiveness of THC/CBD in everyday clinical practice. Improvements in health-related quality of life and activities of daily living were also seen with THC/CBD. THC/CBD is generally well tolerated; adverse effects such as dizziness may occur whilst the THC/CBD dosage is being optimized. THC/CBD has low abuse potential and a low risk of psychoactive effects. In conclusion, THC/CBD oromucosal spray is a useful option for the treatment of MS-related spasticity not completely relieved with current anti-spasticity medication.
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Affiliation(s)
- Gillian M Keating
- Springer, Private Bag 65901, Mairangi Bay, 0754, Auckland, New Zealand.
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Carotenuto A, Iodice R, Petracca M, Inglese M, Cerillo I, Cocozza S, Saiote C, Brunetti A, Tedeschi E, Manganelli F, Orefice G. Upper motor neuron evaluation in multiple sclerosis patients treated with Sativex ®. Acta Neurol Scand 2017; 135:442-448. [PMID: 27500463 DOI: 10.1111/ane.12660] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Spasticity in multiple sclerosis (MS) results from an imbalance of inputs from descending pathways to the spinal motor circuits, as well as from a damage of the corticospinal tract (CST). OBJECTIVES To assess CST impairment in MS patients with and without spasticity and to evaluate its evolution under Sativex® treatment. METHODS Ten MS patients with spasticity ("cases") underwent clinical (EDSS, 9-hole Peg, Ashworth scale, Timed 25-Foot Walk, and NRS for spasticity), MRI (CST fractional anisotropy [FA]), and electrophysiological (central motor conduction time [CMCT] and H/M ratio) evaluations at baseline and after 12 months. We selected 20 MS patients without spasticity as control group at baseline. RESULTS At baseline, cases showed a lower CST FA (0.492±0.045 vs 0.543±0.047; P=.01) and a higher CMCT (P=.001) compared to the control group. No correlations were found between clinical, electrophysiological, and MRI features. After 12 months, cases showed a decrease in non-prevalent degree of impairment (PDI) side FA (0.502±0.023 vs 0.516±0.033; P=.01) without differences for electrophysiological features compared to baseline. Treatment with Sativex® resulted in a reduction of NRS for spasticity (P=.01). CONCLUSIONS We confirm the presence of CST impairment in MS patients with spasticity. We did not identify structural/electrophysiological correlates that could explain Sativex® clinical effect.
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Affiliation(s)
- A. Carotenuto
- Department of Neurosciences, Reproductive and Odontostomatological Sciences; Federico II University of Naples; Naples Italy
| | - R. Iodice
- Department of Neurosciences, Reproductive and Odontostomatological Sciences; Federico II University of Naples; Naples Italy
| | - M. Petracca
- Department of Neurosciences, Reproductive and Odontostomatological Sciences; Federico II University of Naples; Naples Italy
- Department of Neurology, Radiology, Neuroscience; Icahn School of Medicine; Mount Sinai NY USA
| | - M. Inglese
- Department of Neurology, Radiology, Neuroscience; Icahn School of Medicine; Mount Sinai NY USA
| | - I. Cerillo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences; Federico II University of Naples; Naples Italy
| | - S. Cocozza
- Department of Advanced Biomedical Sciences; Federico II University of Naples; Naples Italy
| | - C. Saiote
- Department of Neurology; Icahn School of Medicine; Mount Sinai NY USA
| | - A. Brunetti
- Department of Advanced Biomedical Sciences; Federico II University of Naples; Naples Italy
| | - E. Tedeschi
- Department of Advanced Biomedical Sciences; Federico II University of Naples; Naples Italy
| | - F. Manganelli
- Department of Neurosciences, Reproductive and Odontostomatological Sciences; Federico II University of Naples; Naples Italy
| | - G. Orefice
- Department of Neurosciences, Reproductive and Odontostomatological Sciences; Federico II University of Naples; Naples Italy
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Maccarrone M, Maldonado R, Casas M, Henze T, Centonze D. Cannabinoids therapeutic use: what is our current understanding following the introduction of THC, THC:CBD oromucosal spray and others? Expert Rev Clin Pharmacol 2017; 10:443-455. [PMID: 28276775 DOI: 10.1080/17512433.2017.1292849] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The complexity of the endocannabinoid (eCB) system is becoming better understood and new drivers of eCB signaling are emerging. Modulation of the activities of the eCB system can be therapeutic in a number of diseases. Research into the eCB system has been paralleled by the development of agents that interact with cannabinoid receptors. In this regard it should be remembered that herbal cannabis contains a myriad of active ingredients, and the individual cannabinoids have quite distinct biological activities requiring independent studies. Areas covered: This article reviews the most important current data involving the eCB system in relation to human diseases, to reflect the present (based mainly on the most used prescription cannabinoid medicine, THC/CBD oromucosal spray) and potential future uses of cannabinoid-based therapy. Expert commentary: From the different therapeutic possibilities, THC/CBD oromucosal spray has been in clinical use for approximately five years in numerous countries world-wide for the management of multiple sclerosis (MS)-related moderate to severe resistant spasticity. Clinical trials have confirmed its efficacy and tolerability. Other diseases in which different cannabinoids are currently being investigated include various pain states, Alzheimer's disease, Parkinson's disease, Huntington's disease and epilepsy. The continued characterization of individual cannabinoids in different diseases remains important.
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Affiliation(s)
- Mauro Maccarrone
- a Department of Medicine , Campus Bio-Medico University of Rome , Rome , Italy.,b Laboratory of Lipid Neurochemistry, European Center for Brain Research/IRCCS Santa Lucia Foundation , Rome , Italy
| | - Rafael Maldonado
- c Laboratori de Neurofarmacologia, Departament de Ciències Experimentals i de la Salut (CEXS), Facultat de Ciències de la Salut i de la Vida , Universitat Pompeu Fabra , Barcelona , Spain
| | - Miguel Casas
- d Servicio de Psiquiatría , Hospital Universitari Vall d'Hebron , Barcelona , Spain.,e Departamento de Psiquiatría y Medicina Legal , Universitat Autònoma de Barcelona , Barcelona , Spain.,f CIBERSAM , Barcelona , Spain
| | - Thomas Henze
- g Passauer Wolf Reha-Zentrum Nittenau , Nittenau , Germany
| | - Diego Centonze
- h Multiple Sclerosis Clinical and Research Center, Tor Vergata University, Rome & Unit of Neurology , IRCCS Istituto Neurologico Mediterraneo Neuromed , Pozzilli , Italy
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Luongo L, Starowicz K, Maione S, Di Marzo V. Allodynia Lowering Induced by Cannabinoids and Endocannabinoids (ALICE). Pharmacol Res 2017; 119:272-277. [PMID: 28237514 DOI: 10.1016/j.phrs.2017.02.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 02/20/2017] [Accepted: 02/20/2017] [Indexed: 12/14/2022]
Abstract
Neuropathic pain is a neurological disorder that strongly affects the quality of life of patients. The molecular and cellular mechanisms at the basis of the neuropathic pain establishment still need to be clarified. Among the neuromodulators that play a role in the pathological pain pathways, endocannabinoids could be deeply involved in both neuronal and non-neuronal mechanisms responsible for the appearance of tactile allodynia. Indeed, the function and dysfunction of this complex system in the molecular and cellular mechanisms of chronic pain induction and maintenance have been widely studied over the last two decades. In this review article, we highlighted the possible modulation of the endocannabinoid system in the neuronal, glial and microglial modulation in neuropathic pain treatment.
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Affiliation(s)
- Livio Luongo
- Department of Experimental Medicine, Division of Pharmacology, Università della Campania "L. Vanvitelli", Via Costantinopoli 16, Naples, Italy; Endocannabinoid Research Group, Pozzuoli, Italy; Young Against Pain (YAP) Italian Group, Italy.
| | - Katarzyna Starowicz
- Pain Pathophysiology Lab, Department of Pain Pharmacology, Institute of Pharmacology, Polish Academy of Sciences, Krakow, Poland; Endocannabinoid Research Group, Pozzuoli, Italy
| | - Sabatino Maione
- Department of Experimental Medicine, Division of Pharmacology, Università della Campania "L. Vanvitelli", Via Costantinopoli 16, Naples, Italy; Endocannabinoid Research Group, Pozzuoli, Italy
| | - Vincenzo Di Marzo
- Institute of Biomolecular Chemistry, Consiglio Nazionale delle Ricerche, Via Campi Flegrei 34, 80078 Pozzuoli, Naples, Italy; Endocannabinoid Research Group, Pozzuoli, Italy
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Kendall DA, Yudowski GA. Cannabinoid Receptors in the Central Nervous System: Their Signaling and Roles in Disease. Front Cell Neurosci 2017; 10:294. [PMID: 28101004 PMCID: PMC5209363 DOI: 10.3389/fncel.2016.00294] [Citation(s) in RCA: 171] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 12/08/2016] [Indexed: 11/15/2022] Open
Abstract
The identification and cloning of the two major cannabinoid (CB1 and CB2) receptors together with the discovery of their endogenous ligands in the late 80s and early 90s, resulted in a major effort aimed at understanding the mechanisms and physiological roles of the endocannabinoid system (ECS). Due to its expression and localization in the central nervous system (CNS), the CB1 receptor together with its endogenous ligands (endocannabinoids (eCB)) and the enzymes involved in their synthesis and degradation, has been implicated in multiple pathophysiological events ranging from memory deficits to neurodegenerative disorders among others. In this review, we will provide a general overview of the ECS with emphasis on the CB1 receptor in health and disease. We will describe our current understanding of the complex aspects of receptor signaling and trafficking, including the non-canonical signaling pathways such as those mediated by β-arrestins within the context of functional selectivity and ligand bias. Finally, we will highlight some of the disorders in which CB1 receptors have been implicated. Significant knowledge has been achieved over the last 30 years. However, much more research is still needed to fully understand the complex roles of the ECS, particularly in vivo and to unlock its true potential as a source of therapeutic targets.
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Affiliation(s)
- Debra A Kendall
- Department of Pharmaceutical Sciences, University of Connecticut Storrs, CT, USA
| | - Guillermo A Yudowski
- Department of Anatomy and Neurobiology, University of Puerto Rico, Medical Sciences CampusSan Juan, Puerto Rico; Institute of Neurobiology, University of Puerto RicoSan Juan, Puerto Rico
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Clinical/Therapeutic Approaches for Cannabinoid Ligands in Central and Peripheral Nervous System Diseases: Mini Review. Clin Neuropharmacol 2016; 39:94-101. [PMID: 26818043 DOI: 10.1097/wnf.0000000000000132] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Cannabinoids, the components of Cannabis sativa Linnaeus, interact with CB1 and CB2 receptors, which are located both in the central nervous system and in the periphery and thus may exert a widespread biological activity in the body. The main medicinal properties of cannabinoids include analgesic, anti-inflammatory, antitumor, appetite stimulation, antiemesis, and muscle relaxation effects. This mini review aims to explore existing clinical trials that investigated the use of cannabinoids in diseases affecting the nervous system. METHODS We reviewed recent studies of cannabinoid-based therapy for disorders affecting central and peripheral nervous system in human subjects. RESULTS There is evidence that cannabinoid-based drugs may effectively control some symptoms associated with nervous system dysfunction, especially various types of pain and neurologic disorders, although studies are limited. CONCLUSIONS The efficacy of cannabinoid drugs in the treatment of nervous system diseases should be verified in future large-scale randomized clinical trials.
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Babayeva M, Assefa H, Basu P, Chumki S, Loewy Z. Marijuana Compounds: A Nonconventional Approach to Parkinson's Disease Therapy. PARKINSON'S DISEASE 2016; 2016:1279042. [PMID: 28050308 PMCID: PMC5165161 DOI: 10.1155/2016/1279042] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 09/29/2016] [Accepted: 10/10/2016] [Indexed: 12/11/2022]
Abstract
Parkinson's disease (PD), a neurodegenerative disorder, is the second most common neurological illness in United States. Neurologically, it is characterized by the selective degeneration of a unique population of cells, the nigrostriatal dopamine neurons. The current treatment is symptomatic and mainly involves replacement of dopamine deficiency. This therapy improves only motor symptoms of Parkinson's disease and is associated with a number of adverse effects including dyskinesia. Therefore, there is unmet need for more comprehensive approach in the management of PD. Cannabis and related compounds have created significant research interest as a promising therapy in neurodegenerative and movement disorders. In this review we examine the potential benefits of medical marijuana and related compounds in the treatment of both motor and nonmotor symptoms as well as in slowing the progression of the disease. The potential for cannabis to enhance the quality of life of Parkinson's patients is explored.
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Affiliation(s)
- Mariana Babayeva
- Touro College of Pharmacy, 230 West 125th Street, Room 530, New York, NY 10027, USA
| | - Haregewein Assefa
- Touro College of Pharmacy, 230 West 125th Street, Room 530, New York, NY 10027, USA
| | - Paramita Basu
- Touro College of Pharmacy, 230 West 125th Street, Room 530, New York, NY 10027, USA
| | - Sanjeda Chumki
- Touro College of Pharmacy, 230 West 125th Street, Room 530, New York, NY 10027, USA
| | - Zvi Loewy
- Touro College of Pharmacy, 230 West 125th Street, Room 530, New York, NY 10027, USA
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Russo EB. Current Therapeutic Cannabis Controversies and Clinical Trial Design Issues. Front Pharmacol 2016; 7:309. [PMID: 27683558 PMCID: PMC5022003 DOI: 10.3389/fphar.2016.00309] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 08/30/2016] [Indexed: 12/12/2022] Open
Abstract
This overview covers a wide range of cannabis topics, initially examining issues in dispensaries and self-administration, plus regulatory requirements for production of cannabis-based medicines, particularly the Food and Drug Administration "Botanical Guidance." The remainder pertains to various cannabis controversies that certainly require closer examination if the scientific, consumer, and governmental stakeholders are ever to reach consensus on safety issues, specifically: whether botanical cannabis displays herbal synergy of its components, pharmacokinetics of cannabis and dose titration, whether cannabis medicines produce cyclo-oxygenase inhibition, cannabis-drug interactions, and cytochrome P450 issues, whether cannabis randomized clinical trials are properly blinded, combatting the placebo effect in those trials via new approaches, the drug abuse liability (DAL) of cannabis-based medicines and their regulatory scheduling, their effects on cognitive function and psychiatric sequelae, immunological effects, cannabis and driving safety, youth usage, issues related to cannabis smoking and vaporization, cannabis concentrates and vape-pens, and laboratory analysis for contamination with bacteria and heavy metals. Finally, the issue of pesticide usage on cannabis crops is addressed. New and disturbing data on pesticide residues in legal cannabis products in Washington State are presented with the observation of an 84.6% contamination rate including potentially neurotoxic and carcinogenic agents. With ongoing developments in legalization of cannabis in medical and recreational settings, numerous scientific, safety, and public health issues remain.
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Otero-Romero S, Sastre-Garriga J, Comi G, Hartung HP, Soelberg Sørensen P, Thompson AJ, Vermersch P, Gold R, Montalban X. Pharmacological management of spasticity in multiple sclerosis: Systematic review and consensus paper. Mult Scler 2016; 22:1386-1396. [DOI: 10.1177/1352458516643600] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 03/01/2016] [Indexed: 11/16/2022]
Abstract
Background and objectives: Treatment of spasticity poses a major challenge given the complex clinical presentation and variable efficacy and safety profiles of available drugs. We present a systematic review of the pharmacological treatment of spasticity in multiple sclerosis (MS) patients. Methods: Controlled trials and observational studies were identified. Scientific evidence was evaluated according to pre-specified levels of certainty. Results: The evidence supports the use of baclofen, tizanidine and gabapentin as first-line options. Diazepam or dantrolene could be considered if no clinical improvement is seen with the previous drugs. Nabiximols has a positive effect when used as add-on therapy in patients with poor response and/or tolerance to first-line oral treatments. Despite limited evidence, intrathecal baclofen and intrathecal phenol show a positive effect in severe spasticity and suboptimal response to oral drugs. Conclusion: The available studies on spasticity treatment offer some insight to guide clinical practice but are of variable methodological quality. Large, well-designed trials are needed to confirm the effectiveness of antispasticity agents and to produce evidence-based treatment algorithms.
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Affiliation(s)
- Susana Otero-Romero
- Multiple Sclerosis Centre of Catalonia (Cemcat), Department of Neurology-Neuroimmunology, Vall d’Hebron University Hospital, Barcelona, Spain/Preventive Medicine and Epidemiology Department, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Jaume Sastre-Garriga
- Multiple Sclerosis Centre of Catalonia (Cemcat), Department of Neurology-Neuroimmunology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Giancarlo Comi
- Neurological Department, Institute of Experimental Neurology (INSPE), Scientific Institute Hospital San Raffaele, University Vita-Salute San Raffaele, Milan, Italy
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Per Soelberg Sørensen
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Alan J Thompson
- Department of Brain Repair & Rehabilitation, Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Patrick Vermersch
- Université Lille, INSERM, CHU Lille, Lille Inflammation Research International Center (LIRIC) UMR 995, Lille, France
| | - Ralf Gold
- Department of Neurology, Ruhr University, St. Josef-Hospital, Bochum, Germany
| | - Xavier Montalban
- Multiple Sclerosis Centre of Catalonia (Cemcat), Department of Neurology-Neuroimmunology, Vall d’Hebron University Hospital, Barcelona, Spain
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Gajofatto A. Refractory trigeminal neuralgia responsive to nabiximols in a patient with multiple sclerosis. Mult Scler Relat Disord 2016; 8:64-5. [DOI: 10.1016/j.msard.2016.05.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Revised: 02/28/2016] [Accepted: 05/01/2016] [Indexed: 10/21/2022]
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Katchan V, David P, Shoenfeld Y. Cannabinoids and autoimmune diseases: A systematic review. Autoimmun Rev 2016; 15:513-28. [DOI: 10.1016/j.autrev.2016.02.008] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 02/03/2016] [Indexed: 12/21/2022]
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Systematic review of enriched enrolment, randomised withdrawal trial designs in chronic pain: a new framework for design and reporting. Pain 2016; 156:1382-1395. [PMID: 25985142 DOI: 10.1097/j.pain.0000000000000088] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Enriched enrolment, randomised withdrawal (EERW) pain trials select, before randomisation, patients who respond by demonstrating a predetermined degree of pain relief and acceptance of adverse events. There is uncertainty over the value of this design. We report a systematic review of EERW trials in chronic noncancer pain together with a critical appraisal of methods and potential biases in the methods used and recommendations for the design and reporting of future EERW trials. Electronic and other searches found 25 EERW trials published between 1995 and June 2014, involving 5669 patients in a randomised withdrawal phase comparing drug with placebo; 13 (median, 107 patients) had a randomised withdrawal phase of 6 weeks or less, and 12 (median, 334) lasted 12 to 26 weeks. Risks of bias included short duration, inadequate outcome definition, incomplete outcome data reporting, small size, and inadequate dose tapering on randomisation to placebo. Active treatment was usually better than placebo (22/25 trials). This review reduces the uncertainty around the value of EERW trials in pain. If properly designed, conducted, and reported, they are feasible and useful for making decisions about pain therapies. Shorter, small studies can be explanatory; longer, larger studies can inform practice. Current evidence is inadequate for valid comparisons in outcome between EERW and classical trials, although no gross differences were found. This systematic review provides a framework for assessing potential biases and the value of the EERW trials, and for the design of future studies by making recommendations for the conduct and reporting of EERW trials.
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Affiliation(s)
- William Notcutt
- Consultant Anaesthetist in the Department of Pain Management, James Paget University Hospital, Great Yarmouth, Norfolk NR31 6LA
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Morabito D, Soyster P, Ramey-Wright S, Belendiuk KA, Bonn-Miller MO. A Review of Recent Advances in the Therapeutic Uses of Secondary Cannabinoids. CURRENT ADDICTION REPORTS 2016. [DOI: 10.1007/s40429-016-0096-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Gras A, Broughton J. A cost-effectiveness model for the use of a cannabis-derived oromucosal spray for the treatment of spasticity in multiple sclerosis. Expert Rev Pharmacoecon Outcomes Res 2016; 16:771-779. [PMID: 26750641 DOI: 10.1586/14737167.2016.1140574] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Severity of spasticity in multiple sclerosis (MS) directly correlates with the level and cost of care required. This study assessed whether a tetrahydrocannabinol/cannabidiol (THC/CBD) oromucosal spray for treatment of moderate-severe MS spasticity is a cost-effective use of healthcare resources in Wales. METHODS A Markov model was developed to compare THC/CBD plus standard of care (SoC) treatments with SoC alone. RESULTS At 30 years, total incremental cost for THC/CBD plus SoC treatment was estimated at £3,836/patient (ICER: £10,891/quality-adjusted life year [QALY]). Hospital admission costs had the greatest effect on the base case ICER. Inclusion of carer cost led to incremental cost of -£33,609/patient (ICER: -£95,423/QALY). CONCLUSIONS The THC/CBD spray was found to be cost-effective for the treatment of spasticity in MS, and dominant, if home carer costs were included. Use of THC/CBD has the potential to generate cost savings by significantly improving the symptoms of moderate to severe MS spasticity.
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Affiliation(s)
| | - Julie Broughton
- b Health Economics Outcomes Research , Bayer plc , Newbury , UK
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78
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Cannabinoid receptor 1 ligands revisited: Pharmacological assessment in the ACTOne system. Anal Biochem 2016; 498:8-28. [PMID: 26772161 DOI: 10.1016/j.ab.2015.12.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 11/22/2015] [Accepted: 12/29/2015] [Indexed: 11/23/2022]
Abstract
In vitro cannabinoid pharmacology has evolved over time from simple receptor binding to include [(35)S]GTPγ, β-arrestin, and cAMP assays. Each assay has benefits and drawbacks; however, no single functional system has been used for high-throughput evaluation of compounds from binding to pharmacological functionality and antagonist assessment in a well-characterized human cell line. In this study, we evaluated and validated one system-ACTOne human embryonic kidney cells transfected with a cyclic nucleotide gated channel and cannabinoid receptor 1 (CB1)-and compared human CB1 affinity, functional, and antagonistic effects on cAMP with previously published results. The study was conducted on a diverse group of CB1 ligands, including endocannabinoids and related compounds, 2-AG, AEA, MAEA, and ACEA, the phytocannabinoid Δ(9) THC, and synthetic cannabinoids CP 55,940, WIN 55,212-2, SR 141716A, CP 945,598, and WIN 55,212-3. Our results were compared with literature values where human CB1 was used for affinity determination and cAMP was used as a functional readout. Here we report the first detailed evaluation of the ACTOne assay for the pharmacological evaluation of CB1 ligands. The results from the study reveal some interesting deviations from previously reported functional activities of the aforementioned ligands.
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Zettl UK, Rommer P, Hipp P, Patejdl R. Evidence for the efficacy and effectiveness of THC-CBD oromucosal spray in symptom management of patients with spasticity due to multiple sclerosis. Ther Adv Neurol Disord 2016; 9:9-30. [PMID: 26788128 PMCID: PMC4710104 DOI: 10.1177/1756285615612659] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Spasticity, one of the main symptoms of multiple sclerosis (MS), can affect more than 80% of MS patients during the course of their disease and is often not treated adequately. δ-9-Tetrahydrocannabinol-cannabidiol (THC-CBD) oromucosal spray is a plant-derived, standardized cannabinoid-based oromucosal spray medicine for add-on treatment of moderate to severe, resistant multiple sclerosis-induced spasticity. This article reviews the current evidence for the efficacy and safety, with dizziness and fatigue as the most common treatment-related adverse events, being mostly mild to moderate in severity. Results from both randomized controlled phase III studies involving about,1600 MS patients or 1500 patient-years and recently published studies on everyday clinical practice involving more than 1000 patients or more than,1000 patient-years are presented.
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Affiliation(s)
- Uwe K. Zettl
- Department of Neurology, University of Rostock, Gehlsheimer Straße 20, D-18147 Rostock, Germany
| | - Paulus Rommer
- Department of Neurology, University of Rostock, Germany
- Department of Neurology, Medical University of Vienna, Austria
| | | | - Robert Patejdl
- Department of Neurology, University of Rostock, Germany Oscar-Langendorff-Institute of Physiology, University of Rostock, Germany
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81
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Wilkinson ST, Yarnell S, Radhakrishnan R, Ball SA, D'Souza DC. Marijuana Legalization: Impact on Physicians and Public Health. Annu Rev Med 2015; 67:453-66. [PMID: 26515984 DOI: 10.1146/annurev-med-050214-013454] [Citation(s) in RCA: 122] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Marijuana is becoming legal in an increasing number of states for both medical and recreational use. Considerable controversy exists regarding the public health impact of these changes. The evidence for the legitimate medical use of marijuana or cannabinoids is limited to a few indications, notably HIV/AIDS cachexia, nausea/vomiting related to chemotherapy, neuropathic pain, and spasticity in multiple sclerosis. Although cannabinoids show therapeutic promise in other areas, robust clinical evidence is still lacking. The relationship between legalization and prevalence is still unknown. Although states where marijuana use is legal have higher rates of use than nonlegal states, these higher rates were generally found even prior to legalization. As states continue to proceed with legalization for both medical and recreational use, certain public health issues have become increasingly relevant, including the effects of acute marijuana intoxication on driving abilities, unintentional ingestion of marijuana products by children, the relationship between marijuana and opioid use, and whether there will be an increase in health problems related to marijuana use, such as dependence/addiction, psychosis, and pulmonary disorders. In light of this rapidly shifting legal landscape, more research is urgently needed to better understand the impact of legalization on public health.
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Affiliation(s)
- Samuel T Wilkinson
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut 06511;
| | - Stephanie Yarnell
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut 06511;
| | - Rajiv Radhakrishnan
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut 06511; .,VA Connecticut Healthcare System, West Haven, Connecticut 06516.,Abraham Ribicoff Research Facilities, Connecticut Mental Health Center, New Haven, Connecticut 06511
| | - Samuel A Ball
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut 06511; .,VA Connecticut Healthcare System, West Haven, Connecticut 06516.,The National Center on Addiction and Substance Abuse at Columbia University, New York, NY 10027
| | - Deepak Cyril D'Souza
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut 06511; .,VA Connecticut Healthcare System, West Haven, Connecticut 06516.,Abraham Ribicoff Research Facilities, Connecticut Mental Health Center, New Haven, Connecticut 06511
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Ferrè L, Nuara A, Pavan G, Radaelli M, Moiola L, Rodegher M, Colombo B, Keller Sarmiento IJ, Martinelli V, Leocani L, Martinelli Boneschi F, Comi G, Esposito F. Efficacy and safety of nabiximols (Sativex(®)) on multiple sclerosis spasticity in a real-life Italian monocentric study. Neurol Sci 2015; 37:235-42. [PMID: 26474875 DOI: 10.1007/s10072-015-2392-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 10/01/2015] [Indexed: 11/30/2022]
Abstract
Multiple sclerosis (MS) patients frequently suffer from limb spasticity and pain despite antispastic treatments. To investigate nabiximols efficacy and safety in a real-world monocentric Italian cohort, the following data were collected at baseline, week 4, 14 and 48: Ambulation Index (AI), 10-min walking test (10MWT), combined Modified Ashworth scale (cMAS), scores at numerical rating scale for spasticity (sNRS) and pain (pNRS). Responder status was defined as a ≥20 % reduction in sNRS after 4 weeks of treatment. 144 MS patients (123 progressive and 21 relapsing-remitting) complaining of moderate-to-severe spasticity (mean sNRS: 7.5) were included: 138 (95.8 %) completed the first month of therapy and were classified as follows-23.2 % were non-responders, 5.1 % were responders but discontinued treatment due to side effects, 71.7 % were responders with a mean 32 % reduction in sNRS (p < 0.001). In responders sNRS further decreased between 4 and 14 weeks (p = 0.03). Similarly, pNRS improvement was seen during the first month and between 4 and 14 weeks (p < 0.001 and p = 0.004, respectively). Moreover, at 4 weeks responders showed a significant (p < 0.05) improvement in cMAS, AI and 10MWT, which was maintained at 14 weeks. At 1-year follow-up, a benefit was still evident on spasticity and painful symptoms with a low drop-out rate. Confusion/ideomotor slowing, fatigue and dizziness were the most frequent side effects; no major adverse events were reported. Shorter disease duration at treatment start was associated with better response. This real-world study confirms nabiximols efficacy and safety in the treatment of MS-related spasticity and pain, which is maintained up to 48 weeks.
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Affiliation(s)
- Laura Ferrè
- Department of Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy.,Laboratory of Genetics of Complex Neurological Disorders, Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute, Milan, Italy
| | - Arturo Nuara
- Department of Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy.,Experimental Neurophysiology Unit, Institute of Experimental Neurology (INSPE), San Raffaele Scientific Institute, Milan, Italy
| | - Giulia Pavan
- Department of Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy
| | - Marta Radaelli
- Department of Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy
| | - Lucia Moiola
- Department of Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy
| | - Mariaemma Rodegher
- Department of Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy
| | - Bruno Colombo
- Department of Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy
| | - Ignacio Juan Keller Sarmiento
- Department of Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy.,Laboratory of Genetics of Complex Neurological Disorders, Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute, Milan, Italy
| | - Vittorio Martinelli
- Department of Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy
| | - Letizia Leocani
- Department of Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy.,Experimental Neurophysiology Unit, Institute of Experimental Neurology (INSPE), San Raffaele Scientific Institute, Milan, Italy
| | - Filippo Martinelli Boneschi
- Department of Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy. .,Laboratory of Genetics of Complex Neurological Disorders, Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute, Milan, Italy.
| | - Giancarlo Comi
- Department of Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy
| | - Federica Esposito
- Department of Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy. .,Laboratory of Genetics of Complex Neurological Disorders, Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute, Milan, Italy.
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83
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Abstract
Public interest in the use of "medical marijuana" for the treatment of childhood epilepsy has burgeoned in the last few years. This has occurred in parallel with a growing interest in "medical marijuana" in general. Physicians and pediatricians must balance their patients' desire for immediate access to these products with the tenets of evidence-based medicine. This review discusses the biochemistry of cannabis products (the phytocannabinoids) setting this in the context of the endogenous endocannabinoid system. The differing and potentially modulating effects of delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) are reviewed. The evidence-base supporting or not the use of cannabis products for the treatment of neurological disease and specifically epilepsy is explored. The potential for adverse effects and particularly of neurotoxicity is addressed. Finally, public health and sociocultural implications are touched upon. Specific recommendations for interested physicians are provided including advocacy for patients and for a change in the "scheduling" of cannabis in order to better foster much-needed high-quality scientific research in this important area.
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Affiliation(s)
- Francis M Filloux
- Division of Pediatric Neurology, University of Utah School of Medicine and Primary Children's Hospital, Division of Pediatric Neurology, Salt Lake City, USA
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84
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Abstract
The endocannabinoid system was discovered in 1988 but has received little attention for its potential therapeutic possibilities. That has started to change, and since 2000, a significant number of clinical trials of cannabinoids, principally for the control of spasticity in multiple sclerosis, have been undertaken. These studies have been difficult because of the nature of the disease and have involved patients for whom other therapies have failed or proved inadequate. This paper outlines the background to the use of cannabinoids available and discusses the principles of practice associated with their safe use. The focus has been on nabiximols, being the most studied and the only cannabinoid that has been both adequately researched for use in multiple sclerosis and granted a license by the regulators. However, what has emerged is that the effect for many patients can be much wider than just control of spasticity. Within and outside of neurology there seems to be an expanding range of possibilities for the therapeutic use of cannabinoids.
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Affiliation(s)
- William G Notcutt
- Department of Pain Management, James Paget University Hospital, Great Yarmouth, Norfolk, NR31 6LA, UK.
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85
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Parmar JR, Forrest BD, Freeman RA. Medical marijuana patient counseling points for health care professionals based on trends in the medical uses, efficacy, and adverse effects of cannabis-based pharmaceutical drugs. Res Social Adm Pharm 2015; 12:638-54. [PMID: 26443472 DOI: 10.1016/j.sapharm.2015.09.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 09/03/2015] [Accepted: 09/04/2015] [Indexed: 12/19/2022]
Abstract
The purpose of this report is to present a review of the medical uses, efficacy, and adverse effects of the three approved cannabis-based medications and ingested marijuana. A literature review was conducted utilizing key search terms: dronabinol, nabilone, nabiximols, cannabis, marijuana, smoke, efficacy, toxicity, cancer, multiple sclerosis, nausea, vomiting, appetite, pain, glaucoma, and side effects. Abstracts of the included literature were reviewed, analyzed, and organized to identify the strength of evidence in medical use, efficacy, and adverse effects of the approved cannabis-based medications and medical marijuana. A total of 68 abstracts were included for review. Dronabinol's (Marinol) most common medical uses include weight gain, chemotherapy-induced nausea and vomiting (CINV), and neuropathic pain. Nabiximol's (Sativex) most common medical uses include spasticity in multiple sclerosis (MS) and neuropathic pain. Nabilone's (Cesamet) most common medical uses include CINV and neuropathic pain. Smoked marijuana's most common medical uses include neuropathic pain and glaucoma. Orally ingested marijuana's most common medical uses include improving sleep, reducing neuropathic pain, and seizure control in MS. In general, all of these agents share similar medical uses. The reported adverse effects of the three cannabis-based medications and marijuana show a major trend in central nervous system (CNS)-related adverse effects along with cardiovascular and respiratory related adverse effects. Marijuana shares similar medical uses with the approved cannabis-based medications dronabinol (Marinol), nabiximols (Sativex), and nabilone (Cesamet), but the efficacy of marijuana for these medical uses has not been fully determined due to limited and conflicting literature. Medical marijuana also has similar adverse effects as the FDA-approved cannabis-based medications mainly consisting of CNS related adverse effects but also including cardiovascular and respiratory related adverse effects. Finally, insufficient higher-order evidence to support the widespread use of medical marijuana was found, but a limited amount of moderate-level evidence supports its use in pain and seizure management.
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Affiliation(s)
- Jayesh R Parmar
- School of Pharmacy and Health Professions, University of Maryland Eastern Shore, Princess Anne, MD 21853, USA.
| | - Benjamin D Forrest
- School of Pharmacy and Health Professions, University of Maryland Eastern Shore, Princess Anne, MD 21853, USA
| | - Robert A Freeman
- School of Pharmacy and Health Professions, University of Maryland Eastern Shore, Princess Anne, MD 21853, USA
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86
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Devinsky O, Cohen LR, Selig R. WEED: marijuana, medicine and neuroscience: history of the Alfred I. duPont-Columbia University Award. Neurosurgery 2015; 76:357-61. [PMID: 25784003 DOI: 10.1227/neu.0000000000000733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Orrin Devinsky
- Professor of Neurology, Neurosurgery, and Psychiatry, New York University, New York, New York Associate Director, Professional Prizes, Columbia Journalism School, New York, New York Senior Executive Producer and Director of Health, Wellness, and Medical Unit, CNN, New York, New York
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87
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Coghe G, Pau M, Corona F, Frau J, Lorefice L, Fenu G, Spinicci G, Mamusa E, Musu L, Massole S, Massa R, Marrosu MG, Cocco E. Walking improvements with nabiximols in patients with multiple sclerosis. J Neurol 2015; 262:2472-7. [DOI: 10.1007/s00415-015-7866-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Revised: 07/16/2015] [Accepted: 07/17/2015] [Indexed: 11/28/2022]
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88
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Correale J, Flores J, Bonitto JG, Rodríguez CC, Oliveira EML. Use of Fingolimod in the Management of Relapsing-Remitting Multiple Sclerosis: Experience from Latin America. Adv Ther 2015; 32:612-25. [PMID: 26170106 PMCID: PMC4522024 DOI: 10.1007/s12325-015-0226-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Indexed: 11/24/2022]
Abstract
UNLABELLED Once-daily fingolimod 0.5 mg (FTY720; Gilenya(®), Novartis Pharma AG, Basel, Switzerland) is a sphingosine 1-phosphate receptor modulator that is approved for the treatment of relapsing multiple sclerosis (MS); currently, this includes approval in 13 Latin American countries. However, despite a well-characterized efficacy and safety profile in a large clinical development program, thus far there has been limited representation of patients from across the Latin American region. Differences in MS disease characteristics have been reported for the Latin American population compared with Caucasians, which may be additional to recent improvements in MS diagnosis. Furthermore, healthcare provision and regional socioeconomic factors exist that are unique to Latin America compared with other regions. Therefore, to optimize MS treatment pathways and improve patient clinical outcomes, it is important to investigate the efficacy and safety profile of fingolimod using ethnically relevant data. Here, we review key data from Hispanic patients enrolled in the fingolimod clinical trial program, summarize recent findings from the FIRST LATAM study, and appraise fingolimod data from real-world patient populations. FUNDING Novartis Pharma AG, Basel, Switzerland.
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Affiliation(s)
- Jorge Correale
- Department of Neurology, Institute for Neurological Research Raúl Carrea, FLENI, Buenos Aires, Argentina,
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89
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Moreno Torres I, Sanchez AJ, Garcia-Merino A. Evaluation of the tolerability and efficacy of Sativex in multiple sclerosis. Expert Rev Neurother 2015; 14:1243-50. [PMID: 25331416 DOI: 10.1586/14737175.2014.971758] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Refractory spasticity, central neuropathic pain and bladder dysfunction are common clinical problems in patients with multiple sclerosis (MS). None of the currently available oral medications has proven to be reliably effective and can be limited by toxicity. Cannabinoids have shown therapeutic effects on those MS-associated symptoms. Delta-9-tetrahydrocannabinol (THC)/cannabidiol (CBD) Sativex (nabiximols) is an oromucosal spray formulation that contains THC and CBD in an approximate 1:1 ratio and is described as an endocannabinoid system modulator. The efficacy of THC/CBD on MS-associated spasticity, pain and bladder dysfunction has been studied in clinical trials as well as in clinical practice studies. Adverse effects are usually mild or moderate and the low rate of drug discontinuation provides good evidence of long-term tolerability. This article focuses on the pharmacological properties, clinical efficacy and tolerability of THC/CBD in MS patients.
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Affiliation(s)
- Irene Moreno Torres
- Hospital Universitario Puerta de Hierro, Laboratorio de Neuroinmunologia, Majadahonda, 28222, Spain
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90
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Delta-9-tetrahydrocannabinol/cannabidiol (Sativex®): a review of its use in patients with moderate to severe spasticity due to multiple sclerosis. Drugs 2015; 74:563-78. [PMID: 24671907 DOI: 10.1007/s40265-014-0197-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Delta-9-tetrahydrocannabinol (THC)/cannabidiol (CBD) [Sativex®] is an oromucosal spray formulation that contains principally THC and CBD at an approximately 1:1 fixed ratio, derived from cloned Cannabis sativa L. plants. The main active substance, THC, acts as a partial agonist at human cannabinoid receptors (CB1 and CB2), and thus, may modulate the effects of excitatory (glutamate) and inhibitory (gamma-aminobutyric acid) neurotransmitters. THC/CBD is approved in a number of countries, including Germany and the UK, as an add-on treatment for symptom improvement in adult patients with moderate to severe spasticity due to multiple sclerosis who have not responded adequately to other anti-spasticity medication and who demonstrate clinically significant improvement in spasticity-related symptoms during an initial trial of therapy. In the largest multinational clinical trial that evaluated the approved THC/CBD regimen in this population, 12 weeks' double-blind treatment with THC/CBD significantly reduced spasticity severity (primary endpoint) compared with placebo in patients who achieved a clinically significant improvement in spasticity after 4 weeks' single-blind THC/CBD treatment, as assessed by a patient-rated numerical rating scale. A significantly greater proportion of THC/CBD than placebo recipients achieved a ≥ 30% reduction (a clinically relevant reduction) in spasticity severity. The efficacy of THC/CBD has been also shown in at least one everyday clinical practice study (MOVE 2). THC/CBD was generally well tolerated in clinical trials. Dizziness and fatigue were reported most frequently during the first 4 weeks of treatment and resolved within a few days even with continued treatment. Thus, add-on THC/CBD is a useful symptomatic treatment option for its approved indication.
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91
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Baron EP. Comprehensive Review of Medicinal Marijuana, Cannabinoids, and Therapeutic Implications in Medicine and Headache: What a Long Strange Trip It's Been …. Headache 2015; 55:885-916. [PMID: 26015168 DOI: 10.1111/head.12570] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND The use of cannabis, or marijuana, for medicinal purposes is deeply rooted though history, dating back to ancient times. It once held a prominent position in the history of medicine, recommended by many eminent physicians for numerous diseases, particularly headache and migraine. Through the decades, this plant has taken a fascinating journey from a legal and frequently prescribed status to illegal, driven by political and social factors rather than by science. However, with an abundance of growing support for its multitude of medicinal uses, the misguided stigma of cannabis is fading, and there has been a dramatic push for legalizing medicinal cannabis and research. Almost half of the United States has now legalized medicinal cannabis, several states have legalized recreational use, and others have legalized cannabidiol-only use, which is one of many therapeutic cannabinoids extracted from cannabis. Physicians need to be educated on the history, pharmacology, clinical indications, and proper clinical use of cannabis, as patients will inevitably inquire about it for many diseases, including chronic pain and headache disorders for which there is some intriguing supportive evidence. OBJECTIVE To review the history of medicinal cannabis use, discuss the pharmacology and physiology of the endocannabinoid system and cannabis-derived cannabinoids, perform a comprehensive literature review of the clinical uses of medicinal cannabis and cannabinoids with a focus on migraine and other headache disorders, and outline general clinical practice guidelines. CONCLUSION The literature suggests that the medicinal use of cannabis may have a therapeutic role for a multitude of diseases, particularly chronic pain disorders including headache. Supporting literature suggests a role for medicinal cannabis and cannabinoids in several types of headache disorders including migraine and cluster headache, although it is primarily limited to case based, anecdotal, or laboratory-based scientific research. Cannabis contains an extensive number of pharmacological and biochemical compounds, of which only a minority are understood, so many potential therapeutic uses likely remain undiscovered. Cannabinoids appear to modulate and interact at many pathways inherent to migraine, triptan mechanisms ofaction, and opiate pathways, suggesting potential synergistic or similar benefits. Modulation of the endocannabinoid system through agonism or antagonism of its receptors, targeting its metabolic pathways, or combining cannabinoids with other analgesics for synergistic effects, may provide the foundation for many new classes of medications. Despite the limited evidence and research suggesting a role for cannabis and cannabinoids in some headache disorders, randomized clinical trials are lacking and necessary for confirmation and further evaluation.
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Affiliation(s)
- Eric P Baron
- Department of Neurology, Headache Center, Cleveland Clinic Neurological Institute, Cleveland, OH, USA
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92
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Belendiuk KA, Baldini LL, Bonn-Miller MO. Narrative review of the safety and efficacy of marijuana for the treatment of commonly state-approved medical and psychiatric disorders. Addict Sci Clin Pract 2015; 10:10. [PMID: 25896576 PMCID: PMC4636852 DOI: 10.1186/s13722-015-0032-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 04/15/2015] [Indexed: 02/08/2023] Open
Abstract
The present investigation aimed to provide an objective narrative review of the existing literature pertaining to the benefits and harms of marijuana use for the treatment of the most common medical and psychological conditions for which it has been allowed at the state level. Common medical conditions for which marijuana is allowed (i.e., those conditions shared by at least 80 percent of medical marijuana states) were identified as: Alzheimer’s disease, amyotrophic lateral sclerosis, cachexia/wasting syndrome, cancer, Crohn’s disease, epilepsy and seizures, glaucoma, hepatitis C virus, human immunodeficiency virus/acquired immunodeficiency syndrome, multiple sclerosis and muscle spasticity, severe and chronic pain, and severe nausea. Post-traumatic stress disorder was also included in the review, as it is the sole psychological disorder for which medical marijuana has been allowed. Studies for this narrative review were included based on a literature search in PsycINFO, MEDLINE, and Google Scholar. Findings indicate that, for the majority of these conditions, there is insufficient evidence to support the recommendation of medical marijuana at this time. A significant amount of rigorous research is needed to definitively ascertain the potential implications of marijuana for these conditions. It is important for such work to not only examine the effects of smoked marijuana preparations, but also to compare its safety, tolerability, and efficacy in relation to existing pharmacological treatments.
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Affiliation(s)
- Katherine A Belendiuk
- Institute of Human Development, University of California, 1121 Tolman Hall #1690, Berkeley, CA, 94720, USA.
| | - Lisa L Baldini
- Palo Alto University, 1791 Arastradero Road, Palo Alto, CA, 94304, USA.
| | - Marcel O Bonn-Miller
- Center of Excellence in Substance Abuse Treatment and Education, Philadelphia VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA, 19104, USA. .,Center for Innovation to Implementation and National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA. .,Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3440 Market Street, Philadelphia, PA, 19104, USA.
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93
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Brucki SMD, Frota NA, Schestatsky P, Souza AH, Carvalho VN, Manreza MLG, Mendes MF, Comini-Frota E, Vasconcelos C, Tumas V, Ferraz HB, Barbosa E, Jurno ME. Cannabinoids in neurology – Brazilian Academy of Neurology. ARQUIVOS DE NEURO-PSIQUIATRIA 2015; 73:371-4. [DOI: 10.1590/0004-282x20150041] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 03/13/2015] [Indexed: 11/22/2022]
Abstract
The use of cannabidiol in some neurological conditions was allowed by Conselho Regional de Medicina de São Paulo and by Agência Nacional de Vigilância Sanitária (ANVISA). Specialists on behalf of Academia Brasileira de Neurologia prepared a critical statement about use of cannabidiol and other cannabis derivatives in neurological diseases.
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94
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Slof J, Ruiz L, Vila C. Cost-effectiveness of Sativex in multiple sclerosis spasticity: new data and application to Italy. Expert Rev Pharmacoecon Outcomes Res 2015; 15:379-91. [PMID: 25771713 DOI: 10.1586/14737167.2015.1025759] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Multiple sclerosis (MS) is a chronic progressive disease that carries a high socioeconomic burden. Spasticity (rigidity and spasms) is common in MS and contributes to MS-related disability. This study aims to evaluate the cost-effectiveness of Sativex(®) (9-delta-tetrahydrocannabinol plus cannabidiol oromucosal spray) when used as add-on therapy for management of resistant MS-related spasticity in the context of the Italian healthcare system. A previously published Markov model-based analysis for the German and Spanish context was replicated, adapting it to the Italian setting. Model parameters were updated to reflect recent findings about MS-related spasticity and use of Sativex in daily clinical practice. The base case incremental cost-effectiveness ratio for Sativex use in Italy over a 5-year period was estimated to be €4968 per quality-adjusted life-year gained (year of costing: 2013). Sativex remained an efficient option in the Italian healthcare context - below the commonly accepted incremental threshold of €30,000 per quality-adjusted life-year gained - when deterministic and probabilistic sensitivity analyses were conducted. Sativex can be regarded as a cost-effective treatment option for patients with MS-related spasticity in Italy.
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Affiliation(s)
- John Slof
- Universitat Autònoma de Barcelona, Campus de la UAB, 08193, Bellaterra, Spain
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95
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Di Marzo V, Centonze D. Placebo effects in a multiple sclerosis spasticity enriched clinical trial with the oromucosal cannabinoid spray (THC/CBD): dimension and possible causes. CNS Neurosci Ther 2015; 21:215-21. [PMID: 25475413 PMCID: PMC6495119 DOI: 10.1111/cns.12358] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 10/21/2014] [Accepted: 10/22/2014] [Indexed: 11/26/2022] Open
Abstract
Regulatory authorities admit clinical studies with an initial enrichment phase to select patients that respond to treatment before randomization (Enriched Design Studies; EDSs). The trial period aims to prevent long-term drug exposure risks in patients with limited chances of improvement while optimizing costs. In EDSs for symptom control therapies providing early improvements and without a wash-out period, it is difficult to show further improvements and thus large therapeutic gains versus placebo. Moreover, in trials with cannabinoids, the therapeutic gains can be further biased in the postenrichment randomized phase because of carryover and other effects. The aims of the present review article are to examine the placebo effects in the enrichment and postenrichment phases of an EDS with Δ(9) -tetrahydrocannabinol and cannabidiol (THC/CBD) oromucosal spray in patients with multiple sclerosis (MS) spasticity and to discuss the possible causes of maintained efficacy after randomization in the placebo-allocated patients. The overall mean therapeutic gain of THC/CBD spray over placebo in resistant MS spasticity after 16 weeks can be estimated as a ~1.27-point improvement on the spasticity 0-10 Numerical Rating Scale (NRS; ~-20.1% of the baseline NRS score). We conclude that careful interpretation of the results of EDSs is required, especially when cannabinoid-based medications are being investigated.
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Affiliation(s)
- Vincenzo Di Marzo
- Endocannabinoid Research GroupInstitute of Biomolecular ChemistryConsiglio Nazionale delle RicerchePozzuoliNaplesItaly
| | - Diego Centonze
- Department of Systems MedicineMultiple Sclerosis Clinical and Research CenterTor Vergata UniversityRomeItaly
- IRCCS Santa Lucia FoundationRomeItaly
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96
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Turcotte D, Doupe M, Torabi M, Gomori A, Ethans K, Esfahani F, Galloway K, Namaka M. Nabilone as an Adjunctive to Gabapentin for Multiple Sclerosis-Induced Neuropathic Pain: A Randomized Controlled Trial. PAIN MEDICINE 2015; 16:149-59. [DOI: 10.1111/pme.12569] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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97
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Freidel M, Tiel-Wilck K, Schreiber H, Prechtl A, Essner U, Lang M. Drug-resistant MS spasticity treatment with Sativex(®) add-on and driving ability. Acta Neurol Scand 2015; 131:9-16. [PMID: 25208898 DOI: 10.1111/ane.12287] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of the present observational study was to determine the effects of a delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) oromucosal spray (Sativex(®) spray), brand name Sativex(®), indicated for drug-resistant MS spasticity, on the driving ability of treated MS patients. METHODS The study was conducted over a period of 4-6 weeks. Thirty-three MS patients with moderate to severe treatment-resistant spasticity and planned to begin add-on treatment with Sativex(®) were enrolled at three specialized MS centres in Germany. A set of five driving test procedures from a validated computerized test battery was used to evaluate the driving ability of eligible patients. Tests were performed by patients at baseline and repeated after 4-6 weeks of treatment with Sativex(®) oromucosal spray. According to German normative data, the test thresholds achieved by the general population served as a reference to allow for a fitness/unfitness to drive classification. RESULTS Patients showed comparable driving test results at baseline and at final visits. Only two patients changed classification shifting from 'unfit' to drive to 'fit' and vice versa. The mean severity of spasticity, as self-reported by the patients, improved with statistical significance. Sativex(®) was generally well tolerated. CONCLUSIONS Treatment of MS patients with Sativex(®) does not negatively impact on driving ability and may improve moderate to severe treatment-resistant MS spasticity.
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Affiliation(s)
- M. Freidel
- NTD Study Group; NeuroPraxis - MS-Zentrum; Kaltenkirchen/Holstein Germany
| | - K. Tiel-Wilck
- NTD Study Group; NeuroTransData GmbH; Berlin Germany
| | - H. Schreiber
- NTD Study Group; NeuroPoint Studienzentrum; Ulm Germany
| | | | - U. Essner
- O. MEANY Consultancy GmbH; Hamburg Germany
| | - M. Lang
- NTD Study Group; NeuroPoint Studienzentrum; Ulm Germany
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98
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McDonough P, McKenna JP, McCreary C, Downer EJ. Neuropathic orofacial pain: cannabinoids as a therapeutic avenue. Int J Biochem Cell Biol 2014; 55:72-8. [PMID: 25150831 DOI: 10.1016/j.biocel.2014.08.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 08/07/2014] [Accepted: 08/09/2014] [Indexed: 01/09/2023]
Abstract
Neuropathic orofacial pain (NOP) exists in several forms including pathologies such as burning mouth syndrome (BMS), persistent idiopathic facial pain (PIFP), trigeminal neuralgia (TN) and postherpetic neuralgia (PHN). BMS and PIFP are classically diagnosed by excluding other facial pain syndromes. TN and PHN are most often diagnosed based on a typical history and presenting pain characteristics. The pathophysiology of some of these conditions is still unclear and hence treatment options tend to vary and include a wide variety of treatments including cognitive behaviour therapy, anti-depressants, anti-convulsants and opioids; however such treatments often have limited efficacy with a great amount of inter-patient variability and poorly tolerated side effects. Analgesia is one the principal therapeutic targets of the cannabinoid system and many studies have demonstrated the efficacy of cannabinoid compounds in the treatment of neuropathic pain. This review will investigate the potential use of cannabinoids in the treatment of symptoms associated with NOP.
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Affiliation(s)
- Patrick McDonough
- Cork University Dental School and Hospital, University College Cork, Cork, Ireland
| | - Joseph P McKenna
- Cork University Dental School and Hospital, University College Cork, Cork, Ireland
| | - Christine McCreary
- Cork University Dental School and Hospital, University College Cork, Cork, Ireland
| | - Eric J Downer
- Department of Anatomy and Neuroscience, Western Gateway Building, University College Cork, Cork, Ireland.
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99
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Sexton M, Cudaback E, Abdullah RA, Finnell J, Mischley LK, Rozga M, Lichtman AH, Stella N. Cannabis use by individuals with multiple sclerosis: effects on specific immune parameters. Inflammopharmacology 2014; 22:295-303. [PMID: 25135301 DOI: 10.1007/s10787-014-0214-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 08/04/2014] [Indexed: 11/30/2022]
Abstract
Cannabinoids affect immune responses in ways that may be beneficial for autoimmune diseases. We sought to determine whether chronic Cannabis use differentially modulates a select number of immune parameters in healthy controls and individuals with multiple sclerosis (MS cases). Subjects were enrolled and consented to a single blood draw, matched for age and BMI. We measured monocyte migration isolated from each subject, as well as plasma levels of endocannabinoids and cytokines. Cases met definition of MS by international diagnostic criteria. Monocyte cell migration measured in control subjects and individuals with MS was similarly inhibited by a set ratio of phytocannabinoids. The plasma levels of CCL2 and IL17 were reduced in non-naïve cannabis users irrespective of the cohorts. We detected a significant increase in the endocannabinoid arachidonoylethanolamine (AEA) in serum from individuals with MS compared to control subjects, and no significant difference in levels of other endocannabinoids and signaling lipids irrespective of Cannabis use. Chronic Cannabis use may affect the immune response to similar extent in individuals with MS and control subjects through the ability of phytocannabinoids to reduce both monocyte migration and cytokine levels in serum. From a panel of signaling lipids, only the levels of AEA are increased in individuals with MS, irrespective of Cannabis use or not. Our results suggest that both MS cases and controls respond similarly to chronic Cannabis use with respect to the immune parameters measured in this study.
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Affiliation(s)
- Michelle Sexton
- Center for the Study of Cannabis and Social Policy, Seattle, WA, 98028, USA,
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Koppel BS, Brust JCM, Fife T, Bronstein J, Youssof S, Gronseth G, Gloss D. Systematic review: efficacy and safety of medical marijuana in selected neurologic disorders: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2014; 82:1556-63. [PMID: 24778283 DOI: 10.1212/wnl.0000000000000363] [Citation(s) in RCA: 352] [Impact Index Per Article: 35.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To determine the efficacy of medical marijuana in several neurologic conditions. METHODS We performed a systematic review of medical marijuana (1948-November 2013) to address treatment of symptoms of multiple sclerosis (MS), epilepsy, and movement disorders. We graded the studies according to the American Academy of Neurology classification scheme for therapeutic articles. RESULTS Thirty-four studies met inclusion criteria; 8 were rated as Class I. CONCLUSIONS The following were studied in patients with MS: (1) Spasticity: oral cannabis extract (OCE) is effective, and nabiximols and tetrahydrocannabinol (THC) are probably effective, for reducing patient-centered measures; it is possible both OCE and THC are effective for reducing both patient-centered and objective measures at 1 year. (2) Central pain or painful spasms (including spasticity-related pain, excluding neuropathic pain): OCE is effective; THC and nabiximols are probably effective. (3) Urinary dysfunction: nabiximols is probably effective for reducing bladder voids/day; THC and OCE are probably ineffective for reducing bladder complaints. (4) Tremor: THC and OCE are probably ineffective; nabiximols is possibly ineffective. (5) Other neurologic conditions: OCE is probably ineffective for treating levodopa-induced dyskinesias in patients with Parkinson disease. Oral cannabinoids are of unknown efficacy in non-chorea-related symptoms of Huntington disease, Tourette syndrome, cervical dystonia, and epilepsy. The risks and benefits of medical marijuana should be weighed carefully. Risk of serious adverse psychopathologic effects was nearly 1%. Comparative effectiveness of medical marijuana vs other therapies is unknown for these indications.
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Affiliation(s)
- Barbara S Koppel
- From the Department of Neurology (B.S.K.), New York Medical College, New York; the Department of Neurology (J.C.M.B.), Columbia University College of Physicians & Surgeons, New York Neurological Institute, New York; University of Arizona College of Medicine (T.F.), Phoenix; the Department of Neurology (J.B.), David Geffen School of Medicine at University of California Los Angeles, The VA Greater Los Angeles Healthcare System; the Department of Neurology (S.Y.), University of New Mexico Health Sciences Center, Albuquerque; the Department of Neurology (G.G.), University of Kansas School of Medicine, Kansas City; and the Department of Neurology (D.G.), Geisinger Health System, Danville, PA
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