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Borowicz-Reutt K, Czernia J, Krawczyk M. CBD in the Treatment of Epilepsy. Molecules 2024; 29:1981. [PMID: 38731471 PMCID: PMC11085483 DOI: 10.3390/molecules29091981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 04/09/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024] Open
Abstract
It has been several years since highly purified cannabidiol (CBD) was registered as a medication that can be used in children of at least 2 years of age to treat different types of seizures related to Lennox-Gastaut syndrome (LGS), Dravet syndrome (DS), and more recently tuberous sclerosis complex (TSC). During this time, 39 randomized clinical trials (RCTs) and 13 meta-analyses on the efficacy and safety of CBD treatment have been published. Each of the meta-analyses had its own criteria for the RCTs' inclusion and, therefore, slightly different interpretations of the analyzed data. Each of them contributed in its own way to the understanding of CBD pharmacology, mechanisms of therapeutic action, development of adverse reactions, and drug-drug interactions. Hence, it seemed reasonable to gather the most relevant data in one article and present all the current knowledge on the use of CBD in epilepsy. The results of the 13 meta-analyses presented herein confirmed the effectiveness and safety of CBD in children and adolescents with DREs. In adults, reliable conclusions cannot be drawn due to insufficient data.
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Affiliation(s)
- Kinga Borowicz-Reutt
- Independent Unit of Experimental Neuropathophysiology, Department of Toxicology, Medical University of Lublin, Jaczewskiego 8b, PL-20-090 Lublin, Poland; (J.C.); (M.K.)
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Xia D, Zhang P, Chen Y, Liu X, Chen Y. Efficacy of pharmacological treatments for Dravet syndrome: Systematic review and network meta-analysis. Seizure 2024; 117:90-97. [PMID: 38354598 DOI: 10.1016/j.seizure.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 02/03/2024] [Accepted: 02/05/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Numerous anti-seizure medications (ASMs) have been developed to treat Dravet syndrome (DS). This network meta-analysis aimed to comprehensively analyse the efficacy of ASMs in DS patients, especially in non-seizure-free patients after treatment. METHODS PubMed, EMBASE, Cochrane Library, and Chinese National Knowledge Infrastructure databases were searched. The treatment efficacy was assessed by the percentage reduction in monthly convulsive seizure frequency (MCSF) from baseline or individuals who achieved at least a 50 % or 75 % reduction from baseline in convulsive seizure frequency (CSF). RESULTS Six randomised controlled trials with 633 participants and seven regimens based on four add-on ASMs-fenfluramine (FFA), stiripentol (STP), cannabidiol (CBD), and soticlestat-were included. All drug regimens were superior to the placebo at achieving at least 50 % and 75 % reductions in CSF, but only STP, 0.4 mg/kg/d FFA (FFA0.4), and 0.7 mg/kg/d FFA (FFA0.7) reduced MCSF. STP (50 mg/kg/d) had the highest correlation with reducing MCSF and achieving at least a 50 % reduction from baseline in CSF, followed by FFA0.4 and FFA0.7. Soticlestat and CBD may also be effective in reducing seizures in DS patients. CONCLUSION STP can be recommended as the first choice among the included drug regimens for reducing seizures in DS patients, while FFA0.4 may be considered the second choice. Other drug regimens can be used as alternative treatments. STP, FFA0.4, and FFA0.7 may consistently present favourable efficacy in most DS patients, while other regimens may present prominent inter-individual variability. Appropriate dose selection and intense monitoring are necessary when treating DS using these drugs.
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Affiliation(s)
- Dujiang Xia
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, 74 Linjiang Road, Yuzhong District, Chongqing, China
| | - Peng Zhang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, 74 Linjiang Road, Yuzhong District, Chongqing, China
| | - Yankun Chen
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, 74 Linjiang Road, Yuzhong District, Chongqing, China
| | - Xi Liu
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, 74 Linjiang Road, Yuzhong District, Chongqing, China.
| | - Yangmei Chen
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, 74 Linjiang Road, Yuzhong District, Chongqing, China.
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Aderinto N, Olatunji G, Kokori E, Ajayi YI, Akinmoju O, Ayedun AS, Ayoola OI, Aderinto NO. The efficacy and safety of cannabidiol (CBD) in pediatric patients with Dravet Syndrome: a narrative review of clinical trials. Eur J Med Res 2024; 29:182. [PMID: 38500226 PMCID: PMC10949818 DOI: 10.1186/s40001-024-01788-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/11/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Dravet Syndrome (DS) is a rare and severe form of childhood epilepsy that is often refractory to conventional antiepileptic drugs. Emerging evidence suggests that Cannabidiol (CBD) offer therapeutic benefits for DS. This review aims to evaluate the efficacy and safety of CBD in pediatric patients with DS based on data from ten clinical trials. METHODS A review was conducted to identify clinical trials assessing the efficacy and safety of CBD in pediatric patients diagnosed with DS. PubMed, MEDLINE, Scopus, Web of Science, and relevant grey literature were systematically searched for relevant articles up to October 2023, and clinical trials within the last 10 years were included. The search strategy incorporated controlled vocabulary terms and keywords related to "Cannabidiol," "Dravet Syndrome," and "pediatric patients." RESULTS The analysis revealed promising efficacy outcomes. Notably, CBD demonstrated substantial reductions in seizure frequency, with some patients achieving seizure freedom. The findings emphasised the consistency of CBD's efficacy across different patient subgroups. The safety profile of CBD was generally acceptable, with adverse events often being manageable. CONCLUSION This review consolidates evidence from multiple clinical trials, affirming the potential of CBD as a promising treatment option for pediatric patients with DS. While further research is needed to address existing knowledge gaps, CBD's efficacy and acceptable safety profile make it a valuable addition to the therapeutic tools for DS.
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Affiliation(s)
- Nicholas Aderinto
- Department of Medicine and Surgery, Ladoke Akintola University Teaching Hospital, Ogbomoso, Nigeria.
- Department of Medicine and Surgery, Ladoke Akintola University of Technology, PMB 5000, Ogbomosho, Nigeria.
| | - Gbolahan Olatunji
- Department of Medicine and Surgery, University of Ilorin, Ilorin, Nigeria
| | - Emmanuel Kokori
- Department of Medicine and Surgery, University of Ilorin, Ilorin, Nigeria
| | - Yusuf Ismaila Ajayi
- Department of Medicine and Surgery, Obafemi Awolowo University Teaching Hospital, Ife, Nigeria
| | - Olumide Akinmoju
- Department of Medicine and Surgery, University of Ibadan, Ibadan, Nigeria
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Lersch R, Jannadi R, Grosse L, Wagner M, Schneider MF, von Stülpnagel C, Heinen F, Potschka H, Borggraefe I. Targeted Molecular Strategies for Genetic Neurodevelopmental Disorders: Emerging Lessons from Dravet Syndrome. Neuroscientist 2023; 29:732-750. [PMID: 35414300 PMCID: PMC10623613 DOI: 10.1177/10738584221088244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Dravet syndrome is a severe developmental and epileptic encephalopathy mostly caused by heterozygous mutation of the SCN1A gene encoding the voltage-gated sodium channel α subunit Nav1.1. Multiple seizure types, cognitive deterioration, behavioral disturbances, ataxia, and sudden unexpected death associated with epilepsy are a hallmark of the disease. Recently approved antiseizure medications such as fenfluramine and cannabidiol have been shown to reduce seizure burden. However, patients with Dravet syndrome are still medically refractory in the majority of cases, and there is a high demand for new therapies aiming to improve behavioral and cognitive outcome. Drug-repurposing approaches for SCN1A-related Dravet syndrome are currently under investigation (i.e., lorcaserin, clemizole, and ataluren). New therapeutic concepts also arise from the field of precision medicine by upregulating functional SCN1A or by activating Nav1.1. These include antisense nucleotides directed against the nonproductive transcript of SCN1A with the poison exon 20N and against an inhibitory noncoding antisense RNA of SCN1A. Gene therapy approaches such as adeno-associated virus-based upregulation of SCN1A using a transcriptional activator (ETX101) or CRISPR/dCas technologies show promising results in preclinical studies. Although these new treatment concepts still need further clinical research, they offer great potential for precise and disease modifying treatment of Dravet syndrome.
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Affiliation(s)
- Robert Lersch
- Department of Pediatrics, Division of Pediatric Neurology, Developmental Medicine and Social Pediatrics, University Hospital of Munich, Ludwig Maximilians University, Munich, Germany
| | - Rawan Jannadi
- Department of Pediatrics, Division of Pediatric Neurology, Developmental Medicine and Social Pediatrics, University Hospital of Munich, Ludwig Maximilians University, Munich, Germany
- Institute of Human Genetics, University Hospital of Munich, Ludwig Maximilians University, Munich, Germany
| | - Leonie Grosse
- Department of Pediatrics, Division of Pediatric Neurology, Developmental Medicine and Social Pediatrics, University Hospital of Munich, Ludwig Maximilians University, Munich, Germany
| | - Matias Wagner
- Department of Pediatrics, Division of Pediatric Neurology, Developmental Medicine and Social Pediatrics, University Hospital of Munich, Ludwig Maximilians University, Munich, Germany
- Institute of Human Genetics, Technical University of Munich, Munich, Germany
- Institute for Neurogenomics, Helmholtz Centre Munich, German Research Center for Health and Environment (GmbH), Munich, Germany
| | - Marius Frederik Schneider
- Metabolic Biochemistry, Biomedical Center Munich, Medical Faculty, Ludwig Maximilians University, Munich, Germany
- International Max Planck Research School (IMPRS) for Molecular Life Sciences, Planegg-Martinsried, Germany
| | - Celina von Stülpnagel
- Department of Pediatrics, Division of Pediatric Neurology, Developmental Medicine and Social Pediatrics, University Hospital of Munich, Ludwig Maximilians University, Munich, Germany
- Research Institute for Rehabilitation, Transition and Palliation, Paracelsus Medical Private University (PMU), Salzburg, Austria
| | - Florian Heinen
- Department of Pediatrics, Division of Pediatric Neurology, Developmental Medicine and Social Pediatrics, University Hospital of Munich, Ludwig Maximilians University, Munich, Germany
| | - Heidrun Potschka
- Institute of Pharmacology, Toxicology, and Pharmacy, Ludwig Maximilians University, Munich, Germany
| | - Ingo Borggraefe
- Department of Pediatrics, Division of Pediatric Neurology, Developmental Medicine and Social Pediatrics, University Hospital of Munich, Ludwig Maximilians University, Munich, Germany
- Comprehensive Epilepsy Center, University Hospital of Munich, Ludwig Maximilians University, Munich, Germany
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Fawcett J, Davis S, Manford M. Further advances in epilepsy. J Neurol 2023; 270:5655-5670. [PMID: 37458794 DOI: 10.1007/s00415-023-11860-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/29/2023] [Accepted: 06/29/2023] [Indexed: 10/15/2023]
Abstract
In 2017, one of us reviewed advances in epilepsy (Manford in J Neurol 264:1811-1824, 2017). The current paper brings that review up to date and gives a slight change in emphasis. Once again, the story is of evolution rather than revolution. In recognition that most of our current medications act on neurotransmitters or ion channels, and not on the underlying changes in connectivity and pathways, they have been renamed as antiseizure (ASM) medications rather than antiepileptic drugs. Cenobamate is the one newly licensed medication for broader use in focal epilepsy but there have been a number of developments for specific disorders. We review new players and look forward to new developments in the light of evolving underlying science. We look at teratogenicity; old villains and new concerns in which clinicians play a vital role in explaining and balancing the risks. Medical treatment of status epilepticus, long without evidence, has benefitted from high-quality trials to inform practice; like buses, several arriving at once. Surgical treatment continues to be refined with improvements in the pre-surgical evaluation of patients, especially with new imaging techniques. Alternatives including stereotactic radiotherapy have received further focus and targets for palliative stimulation techniques have grown in number. Individuals' autonomy and quality of life continue to be the subject of research with refinement of what clinicians can do to help persons with epilepsy (PWE) achieve control. This includes seizure management but extends to broader considerations of human empowerment, needs and desires, which may be aided by emerging technologies such as seizure detection devices. The role of specialist nurses in improving that quality has been reinforced by specific endorsement from the International League against Epilepsy (ILAE).
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Affiliation(s)
- Joanna Fawcett
- Department of Neurology, Royal United Hospital, Bath, UK
| | - Sarah Davis
- Department of Neurology, Royal United Hospital, Bath, UK
| | - Mark Manford
- Department of Neurology, Royal United Hospital, Bath, UK.
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Lattanzi S, Trinka E, Russo E, Del Giovane C, Matricardi S, Meletti S, Striano P, Damavandi PT, Silvestrini M, Brigo F. Pharmacotherapy for Dravet Syndrome: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials. Drugs 2023; 83:1409-1424. [PMID: 37695433 PMCID: PMC10582139 DOI: 10.1007/s40265-023-01936-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Dravet syndrome (DS) is a severe developmental and epileptic encephalopathy characterized by drug-resistant, lifelong seizures. The management of seizures in DS has changed in recent years with the approval of new antiseizure medications (ASMs). OBJECTIVE The aim of this study was to estimate the comparative efficacy and tolerability of the ASMs for the treatment of seizures associated with DS using a network meta-analysis (NMA). METHODS Studies were identified by conducting a systematic search (week 4, January 2023) of the MEDLINE (accessed by PubMed), EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and US National Institutes of Health Clinical Trials Registry ( http://www. CLINICALTRIALS gov ) databases. Any randomized, controlled, double- or single-blinded, parallel-group study comparing at least one ASM therapy against placebo, another ASM, or a different dose of the same ASM in participants with a diagnosis of DS was identified. The efficacy outcomes were the proportions of participants with ≥ 50% (seizure response) and 100% reduction (seizure freedom) in baseline convulsive seizure frequency during the maintenance period. The tolerability outcomes included the proportions of patients who withdrew from treatment for any reason and who experienced at least one adverse event (AE). Effect sizes were estimated by network meta-analyses within a frequentist framework. RESULTS Eight placebo-controlled trials were included, and the active add-on treatments were stiripentol (n = 2), pharmaceutical-grade cannabidiol (n = 3), fenfluramine hydrochloride (n = 2), and soticlestat (n = 1). The studies recruited 680 participants, of whom 409 were randomized to active treatments (stiripentol = 33, pharmaceutical-grade cannabidiol = 228, fenfluramine hydrochloride = 122, and soticlestat = 26) and 271 to placebo. Pharmaceutical-grade cannabidiol was associated with a lower rate of seizure response than fenfluramine hydrochloride (odds ratio [OR] 0.20, 95% confidence interval [CI] 0.07-0.54), and stiripentol was associated with a higher seizure response rate than pharmaceutical-grade cannabidiol (OR 14.07, 95% CI 2.57-76.87). No statistically significant differences emerged across the different ASMs for the seizure freedom outcome. Stiripentol was associated with a lower probability of drug discontinuation for any reason than pharmaceutical-grade cannabidiol (OR 0.45, 95% CI 0.04-5.69), and pharmaceutical-grade cannabidiol was associated with a lower proportion of participants experiencing any AE than fenfluramine hydrochloride (OR 0.22, 95% CI 0.06-0.78). Stiripentol had a higher risk of AE occurrence than pharmaceutical-grade cannabidiol (OR 75.72, 95% CI 3.59-1598.58). The study found high-quality evidence of efficacy and tolerability of the four ASMs in the treatment of convulsive seizures in DS. CONCLUSIONS There exists first-class evidence that documents the efficacy and tolerability of stiripentol, pharmaceutical-grade cannabidiol, fenfluramine hydrochloride, and soticlestat for the treatment of seizures associated with DS, and allows discussion about the expected outcomes regarding seizure frequency reduction and tolerability profiles.
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Affiliation(s)
- Simona Lattanzi
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Via Conca 71, 60020, Ancona, Italy.
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
- Center for Cognitive Neuroscience, Salzburg, Austria
- Public Health, Health Services Research and HTA, University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Emilio Russo
- Science of Health Department, University Magna Grecia of Catanzaro, Catanzaro, Italy
| | - Cinzia Del Giovane
- Department of Medical and Surgical Sciences for Children and Adults, University-Hospital of Modena and Reggio Emilia, Modena, Italy
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Sara Matricardi
- Department of Pediatrics, University of Chieti, Chieti, Italy
| | - Stefano Meletti
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy
- Department of Biomedical, Metabolic and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, "G. Gaslini" Institute, University of Genoa, Genoa, Italy
| | - Payam Tabaee Damavandi
- Department of Neurology, Fondazione IRCCS San Gerardo, School of Medicine and Surgery and Milan Center for Neuroscience, University of Milano-Bicocca, Monza, Italy
| | - Mauro Silvestrini
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Via Conca 71, 60020, Ancona, Italy
| | - Francesco Brigo
- Division of Neurology, "Franz Tappeiner" Hospital, Merano, BZ, Italy
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Solmi M, De Toffol M, Kim JY, Choi MJ, Stubbs B, Thompson T, Firth J, Miola A, Croatto G, Baggio F, Michelon S, Ballan L, Gerdle B, Monaco F, Simonato P, Scocco P, Ricca V, Castellini G, Fornaro M, Murru A, Vieta E, Fusar-Poli P, Barbui C, Ioannidis JPA, Carvalho AF, Radua J, Correll CU, Cortese S, Murray RM, Castle D, Shin JI, Dragioti E. Balancing risks and benefits of cannabis use: umbrella review of meta-analyses of randomised controlled trials and observational studies. BMJ 2023; 382:e072348. [PMID: 37648266 PMCID: PMC10466434 DOI: 10.1136/bmj-2022-072348] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/27/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVE To systematically assess credibility and certainty of associations between cannabis, cannabinoids, and cannabis based medicines and human health, from observational studies and randomised controlled trials (RCTs). DESIGN Umbrella review. DATA SOURCES PubMed, PsychInfo, Embase, up to 9 February 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Systematic reviews with meta-analyses of observational studies and RCTs that have reported on the efficacy and safety of cannabis, cannabinoids, or cannabis based medicines were included. Credibility was graded according to convincing, highly suggestive, suggestive, weak, or not significant (observational evidence), and by GRADE (Grading of Recommendations, Assessment, Development and Evaluations) (RCTs). Quality was assessed with AMSTAR 2 (A Measurement Tool to Assess Systematic Reviews 2). Sensitivity analyses were conducted. RESULTS 101 meta-analyses were included (observational=50, RCTs=51) (AMSTAR 2 high 33, moderate 31, low 32, or critically low 5). From RCTs supported by high to moderate certainty, cannabis based medicines increased adverse events related to the central nervous system (equivalent odds ratio 2.84 (95% confidence interval 2.16 to 3.73)), psychological effects (3.07 (1.79 to 5.26)), and vision (3.00 (1.79 to 5.03)) in people with mixed conditions (GRADE=high), improved nausea/vomit, pain, spasticity, but increased psychiatric, gastrointestinal adverse events, and somnolence among others (GRADE=moderate). Cannabidiol improved 50% reduction of seizures (0.59 (0.38 to 0.92)) and seizure events (0.59 (0.36 to 0.96)) (GRADE=high), but increased pneumonia, gastrointestinal adverse events, and somnolence (GRADE=moderate). For chronic pain, cannabis based medicines or cannabinoids reduced pain by 30% (0.59 (0.37 to 0.93), GRADE=high), across different conditions (n=7), but increased psychological distress. For epilepsy, cannabidiol increased risk of diarrhoea (2.25 (1.33 to 3.81)), had no effect on sleep disruption (GRADE=high), reduced seizures across different populations and measures (n=7), improved global impression (n=2), quality of life, and increased risk of somnolence (GRADE=moderate). In the general population, cannabis worsened positive psychotic symptoms (5.21 (3.36 to 8.01)) and total psychiatric symptoms (7.49 (5.31 to 10.42)) (GRADE=high), negative psychotic symptoms, and cognition (n=11) (GRADE=moderate). In healthy people, cannabinoids improved pain threshold (0.74 (0.59 to 0.91)), unpleasantness (0.60 (0.41 to 0.88)) (GRADE=high). For inflammatory bowel disease, cannabinoids improved quality of life (0.34 (0.22 to 0.53) (GRADE=high). For multiple sclerosis, cannabinoids improved spasticity, pain, but increased risk of dizziness, dry mouth, nausea, somnolence (GRADE=moderate). For cancer, cannabinoids improved sleep disruption, but had gastrointestinal adverse events (n=2) (GRADE=moderate). Cannabis based medicines, cannabis, and cannabinoids resulted in poor tolerability across various conditions (GRADE=moderate). Evidence was convincing from observational studies (main and sensitivity analyses) in pregnant women, small for gestational age (1.61 (1.41 to 1.83)), low birth weight (1.43 (1.27 to 1.62)); in drivers, car crash (1.27 (1.21 to 1.34)); and in the general population, psychosis (1.71 (1.47 to 2.00)). Harmful effects were noted for additional neonatal outcomes, outcomes related to car crash, outcomes in the general population including psychotic symptoms, suicide attempt, depression, and mania, and impaired cognition in healthy cannabis users (all suggestive to highly suggestive). CONCLUSIONS Convincing or converging evidence supports avoidance of cannabis during adolescence and early adulthood, in people prone to or with mental health disorders, in pregnancy and before and while driving. Cannabidiol is effective in people with epilepsy. Cannabis based medicines are effective in people with multiple sclerosis, chronic pain, inflammatory bowel disease, and in palliative medicine but not without adverse events. STUDY REGISTRATION PROSPERO CRD42018093045. FUNDING None.
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Affiliation(s)
- Marco Solmi
- Department of Psychiatry, University of Ottawa, Ontario, ON, Canada
- On Track: The Champlain First Episode Psychosis Program, Department of Mental Health, The Ottawa Hospital, Ontario, ON, Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Early Psychosis: Interventions and Clinical detection Lab, Institute of Psychiatry, Psychology and Neuroscience, Department of Psychosis Studies, King's College London, London, UK
- Centre for Innovation in Mental Health-Developmental Lab, School of Psychology, University of Southampton, and NHS Trust, Southampton, UK
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
| | - Marco De Toffol
- Psychiatry Unit, Veris Delli Ponti Scorrano Hospital, Department of Mental Health, ASL Lecce, Lecce, Italy
| | - Jong Yeob Kim
- Yonsei University College of Medicine, Seoul, South Korea
| | - Min Je Choi
- Yonsei University College of Medicine, Seoul, South Korea
| | - Brendon Stubbs
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London, UK
| | - Trevor Thompson
- Centre of Chronic Illness and Ageing, University of Greenwich, London, UK
| | - Joseph Firth
- Division of Psychology and Mental Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Alessandro Miola
- Neurosciences Department, Padua Neuroscience Center, University of Padua, Italy
| | - Giovanni Croatto
- Mental Health Department, AULSS 3 Serenissima, Mestre, Venice, Italy
| | - Francesca Baggio
- Mental Health Department, AULSS 3 Serenissima, Mestre, Venice, Italy
| | - Silvia Michelon
- Department of Mental Health, AULSS 7 Pedemontana Veneto, Italy
| | - Luca Ballan
- Department of Mental Health, AULSS 7 Pedemontana Veneto, Italy
| | - Björn Gerdle
- Pain and Rehabilitation Centre, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Francesco Monaco
- Department of Mental Health, Asl Salerno, Salerno, Italy
- European Biomedical Research Institute of Salerno, Salerno, Italy
| | - Pierluigi Simonato
- Department of Clinical, Pharmaceutical and Biological Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Paolo Scocco
- Mental Health Department, ULSS 6 Euganea, Padova, Italy
| | - Valdo Ricca
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy
| | - Giovanni Castellini
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy
| | - Michele Fornaro
- Section of Psychiatry, Department of Neuroscience, University School of Medicine Federico II, Naples, Italy
| | - Andrea Murru
- Institute of Neuroscience, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Eduard Vieta
- Institute of Neuroscience, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Paolo Fusar-Poli
- Early Psychosis: Interventions and Clinical detection Lab, Institute of Psychiatry, Psychology and Neuroscience, Department of Psychosis Studies, King's College London, London, UK
- Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy
| | - Corrado Barbui
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - John P A Ioannidis
- Meta-Research Innovation Center at Stanford, Stanford University, Stanford, CA, USA
- Meta-Research Innovation Center Berlin, Berlin Institute of Health, Charité Universitätsmedizin, Berlin, Germany
- Departments of Medicine, of Epidemiology and Population Health, of Biomedical Data Science, and of Statistics, Stanford University, Stanford, CA, USA
| | - Andrè F Carvalho
- IMPACT - The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Deakin University, Geelong, VIC, Australia
| | - Joaquim Radua
- Institut d'Investigacions Biomediques August Pi i Sunyer, CIBERSAM, Instituto de Salud Carlos III, University of Barcelona, Barcelona, Spain
| | - Christoph U Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Samuele Cortese
- Centre for Innovation in Mental Health-Developmental Lab, School of Psychology, University of Southampton, and NHS Trust, Southampton, UK
- Clinical and Experimental Sciences (Central Nervous System and Psychiatry), Faculty of Medicine, University of Southampton, Southampton, UK
- Solent NHS Trust, Southampton, UK
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
- Hassenfeld Children's Hospital at NYU Langone, New York University Child Study Center, New York City, New York, NY, USA
| | - Robin M Murray
- Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College of London, London, UK
| | - David Castle
- Department of Psychiatry, University of Tasmania, Sandy Bay, TAS, Australia
- Co-Director, Centre for Mental Health Service Innovation, Department of Health, Tasmania, Australia
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, South Korea
- Severance Underwood Meta-research Center, Institute of Convergence Science, Yonsei University, Seoul, South Korea
| | - Elena Dragioti
- Pain and Rehabilitation Centre, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Research Laboratory Psychology of Patients, Families and Health Professionals, Department of Nursing, School of Health Sciences, University of Ioannina, Ioannina, Greece
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Coskun Y, Yildirim C. A 3-year-old child with multi-drug resistant epilepsy responding to pharmacological and nonpharmacological treatments. Int J Neurosci 2023; 133:322-326. [PMID: 33843424 DOI: 10.1080/00207454.2021.1916488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Despite the development of new antiseizure drugs (ASDs), around one third of epilepsy patients become refractory to treatment or experience adverse events due to ASDs. Therefore, discovery of new ASDs and new therapy options are crucial to improve the quality of life. Herein, we report a 3-year-old child with multi-drug resistant epilepsy caused by perinatal asphyxia whose seizures were reduced by 90% after the introduction of ketogenic diet, vagal nerve stimulation (VNS) AspireSR (SR-seizure response) and oral cannabidiol.Case presentation: A 9-month-old female infant had a history of multidrug resistant epilepsy due to perinatal asphyxia. At admission, she was experiencing up to 20-25 seizures per day lasting for 2-3 minutes. In addition to antiseizure drugs (ASDs), she was put on ketogenic diet (KD), vagal nerve stimulation (VNS) aspire seizure response (AspireSR) was inserted and oral cannabidiol (CBD) was started sequentially. Using pharmacological and nonph armacological therapies, her seizures have been reduced by 90%.Conclusion: The concurrent use of pharmacological and nonpharmacological therapies may be beneficial to improve seizures in infants with multi- Furthermore, our patient is the youngest child inserted VNS AspireSR in Turkey.
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Affiliation(s)
- Yesim Coskun
- Department of Pediatrics, Koc University Hospital, Istanbul, Turkey
| | - Canan Yildirim
- Department of Pediatrics, Division of Pediatric Neurology, Okan University School of Medicine, Istanbul, Turkey
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Efficacy and Safety of Fenfluramine in Epilepsy: A Systematic Review and Meta-analysis. Neurol Ther 2023; 12:669-686. [PMID: 36853503 PMCID: PMC10043095 DOI: 10.1007/s40120-023-00452-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 02/07/2023] [Indexed: 03/01/2023] Open
Abstract
INTRODUCTION Fenfluramine (FFA) is an amphetamine derivative that promotes the release and blocks the neuronal reuptake of serotonin. Initially introduced as an appetite suppressant, FFA also showed antiseizure properties. This systematic review aimed to assess the efficacy and safety of FFA for the treatment of seizures in patients with epilepsy. METHODS We systematically searched (in week 3 of June 2022) MEDLINE, the Cochrane Central Register of Controlled Trials, and the US National Institutes of Health Clinical Trials Registry. Randomized, double- or single-blinded, placebo-controlled studies of FFA in patients with epilepsy and uncontrolled seizures were identified. Efficacy outcomes included the proportions of patients with ≥ 50% and 100% reductions in baseline seizure frequency during the treatment period. Tolerability outcomes included the proportions of patients who withdrew from treatment for any reason and suffered adverse events (AEs). The risk of bias in the included studies was assessed according to the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions. The risk ratio (RR) along with the 95% confidence interval (CI) were estimated for each outcome. RESULTS Three trials were identified and a total of 469 Dravet syndrome (DS) and Lennox-Gastaut syndrome (LGS) subjects were randomized. All three trials were judged to be at low risk of biases. In patients with DS, the RRs for ≥ 50% and 100% reductions in convulsive seizure frequency for the FFA group compared to placebo were 5.61 (95% CI 2.73-11.54) and 4.71 (95% CI 0.57-39.30), respectively. In patients with LGS, the corresponding RRs for ≥ 50% and 100% reductions in drop seizure frequency were 2.58 (95% CI 1.33-5.02) and 0.50 (95% CI 0.031-7.81), respectively. The drug was withdrawn for any reason in 10.1% and 5.8% of patients receiving FFA and placebo, respectively (RR 1.79, 95% CI 0.89-3.59). Treatment discontinuation due to AEs occurred in 5.4% and 1.2% of FFA- and placebo-treated patients, respectively (RR 3.63, 95% CI 0.93-14.16). Decreased appetite, diarrhoea, fatigue, and weight loss were AEs associated with FFA treatment. CONCLUSION Fenfluramine reduces the frequency of seizures in patients with DS and LGS. Decreased appetite, diarrhoea, fatigue, and weight loss are non-cardiovascular AEs associated with FFA.
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Reddy TS, Zomer R, Mantri N. Nanoformulations as a strategy to overcome the delivery limitations of cannabinoids. Phytother Res 2023; 37:1526-1538. [PMID: 36748949 DOI: 10.1002/ptr.7742] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 11/22/2022] [Accepted: 11/28/2022] [Indexed: 02/08/2023]
Abstract
Medical cannabis has received significant interest in recent years due to its promising benefits in the management of pain, anxiety, depression and neurological and movement disorders. Specifically, the major phytocannabinoids derived from the cannabis plant such as (-) trans-Δ9 -tetrahydrocannabinol (THC) and cannabidiol (CBD), have been shown to be responsible for the pharmacological and therapeutic properties. Recently, these phytocannabinoids have also attracted special attention in cancer treatment due to their well-known palliative benefits in chemotherapy-induced nausea, vomiting, pain and loss of appetite along with their anticancer activities. Despite the enormous pharmacological benefits, the low aqueous solubility, high instability (susceptibility to extensive first pass metabolism) and poor systemic bioavailability restrict their utilization at clinical perspective. Therefore, drug delivery strategies based on nanotechnology are emerging to improve pharmacokinetic profile and bioavailability of cannabinoids as well as enhance their targeted delivery. Here, we critically review the nano-formulation systems engineered for overcoming the delivery limitations of native phytocannabinoids including polymeric and lipid-based nanoparticles (lipid nano capsules (LNCs), nanostructured lipid carriers (NLCs), nanoemulsions (NE) and self-emulsifying drug delivery systems (SEDDS)), ethosomes and cyclodextrins as well as their therapeutic applications.
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Affiliation(s)
- T Srinivasa Reddy
- The Pangenomics Group, Biosciences and Food Technology, School of Science, RMIT University, Melbourne, Victoria, Australia
| | - Roby Zomer
- MGC Pharmaceuticals Limited, West Perth, Western Australia, Australia
| | - Nitin Mantri
- The Pangenomics Group, Biosciences and Food Technology, School of Science, RMIT University, Melbourne, Victoria, Australia.,The UWA Institute of Agriculture, The University of Western Australia, Perth, Western Australia, Australia
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11
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Zhang L, Li Y, Wang W, Wang C. Comparative antiseizure medications of adjunctive treatment for children with drug-resistant focal-onset seizures: A systematic review and network meta-analysis. Front Pharmacol 2022; 13:978876. [PMID: 36588743 PMCID: PMC9800847 DOI: 10.3389/fphar.2022.978876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 12/05/2022] [Indexed: 12/23/2022] Open
Abstract
Purpose: In this study, we intended to compare and rank the efficacy and acceptability of antiseizure medications (ASMs) for adjunctive treatment of children with drug-resistant focal-onset seizures. Method: We conducted a computerized search of PubMed, EMBASE, Cochrane Library, Web of Science, and Google Scholar to identify eligible randomized controlled trials (RCTs) published before 31 May 2022. We included studies evaluating the efficacy and tolerability of antiseizure medications for children with drug-resistant focal-onset seizures. The efficacy and safety were reported in terms of responder and dropout rate along with serious adverse events, the outcomes were ranked with the surface under the cumulative ranking curve (SUCRA). Results: A total of 14 studies (16 trials) with 2,464 patients were included, involving 10 active antiseizure medications. For the primary endpoint of at least 50% reduction in focal-onset seizures, the surface under the cumulative ranking curve ranking suggested that lamotrigine and levetiracetam were more effective as compared with other antiseizure medications; moreover, levetiracetam had the highest probability of rank first for achieving seizure freedom. Concerning tolerability, oxcarbazepine and eslicarbazepine acetate were associated with higher dropout rates relative to other antiseizure medications and placebo, and topiramate was associated with higher occurrence of side effects. No significant differences were found between active antiseizure medications concerning dropout for side effects. Conclusion: According to the surface under the cumulative ranking curve ranking, lamotrigine, levetiracetam, and oxcarbazepine were more efficacious than other active antiseizure medications in terms of responder rate. Concerning tolerability, oxcarbazepine was more likely to lead to dropout and topiramate was associated with higher occurrence of side effects.
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12
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Effectiveness and tolerability of adjunctive perampanel in the treatment of pediatric patients with uncontrolled epilepsy: A retrospective, single-center, real-world study. Epilepsy Behav 2022; 137:108961. [PMID: 36327645 DOI: 10.1016/j.yebeh.2022.108961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 10/06/2022] [Accepted: 10/15/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The main aim of this study was to assess the efficacy, safety, and tolerability of adjunctive perampanel (PER) in the treatment of children and adolescents with epilepsy. METHODS Pediatric patients who visited the pediatric epilepsy clinic of Henan Provincial People's Hospital between May 2020 and December 2021 were recruited. All participants were treated with PER as adjunctive therapy and were seen routinely (minimum: a baseline and 12-week visit). The efficacy and tolerability of adjunctive PER for the treatment of epilepsy were investigated. RESULTS One hundred and fourteen patients were enrolled, among whom 7 (6.1%) were lost to follow-up. At 12 weeks, the responder rate and the seizure-free rate were 56.1% (60/107) and 32.7% (35/107), respectively. The responder rate increased with the duration of PER administration and was significantly higher when PER was used as an early add-on (after ≤2 prior antiseizure medications (ASMs)) than a late add-on (after >2 prior ASMs). However, there was no significant difference in the treatment efficacy of adjunctive PER in patients with different epilepsy etiologies or types. Adverse events, including irritability, dizziness, somnolence, ataxic gait, weight gain, and tinnitus, were reported in thirty-two patients (29.9%). CONCLUSIONS In a routine clinical setting of pediatric patients with epilepsy, good effectiveness and tolerability of adjunctive PER were demonstrated. Notably, patients initiating PER as an early add-on showed a better seizure outcome than those initiating PER as a late add-on.
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Tang Y, Tonkovich KL, Rudisill TM. The Effectiveness and Safety of Cannabidiol in Non-seizure-related Indications: A Systematic Review of Published Randomized Clinical Trials. Pharmaceut Med 2022; 36:353-385. [PMID: 36271316 PMCID: PMC9708636 DOI: 10.1007/s40290-022-00446-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Legislative changes have fueled the global availability of cannabis and cannabis-derived compounds, such as cannabidiol. Little is known about the effectiveness and safety of cannabidiol for treating health conditions other than seizure disorders. OBJECTIVE A systematic review of the literature was performed to investigate other health conditions, characteristics of the studied populations, and the effectiveness of cannabidiol in randomized clinical trials. METHODS Seven publication databases were searched from February to March 2021. The inclusion criteria for studies were: (1) utilized a randomized clinical trial design; (2) published in a peer-reviewed journal or thesis/dissertation; (3) published in English; (4) investigated either prescription (i.e., Epidiolex) or non-prescription CBD that was derived from the Cannabis sativa plant with < 3% ∆9-tetrahydrocannabinol; and (5) reported at least one outcome. This review excluded seizure-related disorders as several previous reviews have been done on this topic; it also excluded published protocols, other systematic reviews, or meta-analyses of randomized clinical trials that investigated cannabidiol. Independent reviewing, risk of bias assessment, and data abstraction were performed by two authors. RESULTS Fifty-eight studies from eight countries were included in this review. Twenty-seven studies (47%) were conducted in healthy populations, 14% were restricted to male individuals (n = 8), and 72% had sample sizes of fewer than 40 participants. Doses of cannabidiol used in these studies ranged from 400 µg to 6000 mg. The effect of cannabidiol on mental health was the most studied topic (53%), which focused mainly on anxiety, psychosis, schizophrenia, and substance use disorders. The remaining studies investigated neurological conditions (19%) and a myriad of other health conditions or outcomes. While cannabidiol appears to be anxiolytic, its effectiveness for other conditions was highly variable. CONCLUSIONS This review highlights the inconsistencies of cannabidiol as a treatment for non-seizure-related health conditions or outcomes. Studies incorporating larger sample sizes in more diverse populations are encouraged. While cannabidiol was generally safe and well tolerated even in high doses among the included studies, clearer dosing guidelines and increased regulation of cannabidiol products are also needed.
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Affiliation(s)
- Yuni Tang
- Department of Epidemiology and Biostatistics, School of Public Health, West Virginia University, PO BOX 9190, Morgantown, WV, 26506, USA
| | - Kolbi L Tonkovich
- Department of Family Medicine, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Toni Marie Rudisill
- Department of Epidemiology and Biostatistics, School of Public Health, West Virginia University, PO BOX 9190, Morgantown, WV, 26506, USA.
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Pigliasco F, Malaca S, Lo Faro AF, Tini A, Cangemi G, Cafaro A, Barco S, Riva A, Pisati A, Amadori E, Striano P, Tagliabracci A, Huestis MA, Busardò FP. Cannabidiol, ∆9-tetrahydrocannabinol, and metabolites in human blood by volumetric absorptive microsampling and LC-MS/MS following controlled administration in epilepsy patients. Front Pharmacol 2022; 13:1038754. [PMID: 36353497 PMCID: PMC9637868 DOI: 10.3389/fphar.2022.1038754] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 10/10/2022] [Indexed: 12/03/2022] Open
Abstract
Cannabidiol (CBD) exhibits anti-inflammatory, anxiolytic, antiseizure, and neuroprotective proprieties without addictive or psychotropic side effects, as opposed to Δ9-tetrahydrocannabinol (THC). While recreational cannabis contains higher THC and lower CBD concentrations, medical cannabis contains THC and CBD in different ratios, along with minor phytocannabinoids, terpenes, flavonoids and other chemicals. A volumetric absorptive microsampling (VAMS) method combined with ultra-high-performance liquid chromatography coupled with mass spectrometry in tandem for quantification of CBD, THC and their respective metabolites: cannabidiol-7-oic acid (7-COOH-CBD); 7-hydroxy-cannabidiol (7-OH-CBD); 6-alpha-hydroxy-cannabidiol (6-α-OH-CBD); and 6-beta-hydroxycannabidiol (6-β-OH-CBD); 11- Hydroxy-Δ9-tetrahydrocannabinol (11-OH-THC) and 11-Nor-9-carboxy-Δ9-tetrahydrocannabinol (THCCOOH). After overnight enzymatic glucuronide hydrolysis at 37°C, samples underwent acidic along with basic liquid-liquid extraction with hexane: ethyl acetate (9:1, v/v). Chromatographic separation was carried out on a C18 column, with the mass spectrometer operated in multiple reaction monitoring mode and negative electrospray ionization. Seven patients with intractable epilepsy were dosed with various CBD-containing formulations and blood collected just before their daily morning administration. The method was validated following international guidelines in toxicology. Linear ranges were (ng/ml) 0.5–25 THC, 11-OH-THC, THCCOOH, 6-α-OH-CBD and 6-β-OH-CBD; 10–500 CBD and 7-OH-CBD; and 20–5000 7-COOH-CBD. 7-COOH-CBD was present in the highest concentrations, followed by 7-OH-CBD and CBD. This analytical method is useful for investigating CBD, THC and their major metabolites in epilepsy patients treated with CBD preparations employing a minimally invasive microsampling technique requiring only 30 µL blood.
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Affiliation(s)
- Federica Pigliasco
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Sara Malaca
- Department of Excellence-Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Alfredo Fabrizio Lo Faro
- Department of Excellence-Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Anastasio Tini
- Department of Excellence-Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Giuliana Cangemi
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analyses, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Alessia Cafaro
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analyses, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Department of Internal Medicine, Pharmacology & Toxicology Unit, University of Genoa, Genoa, Italy
| | - Sebastiano Barco
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analyses, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- *Correspondence: Sebastiano Barco,
| | - Antonella Riva
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Angelica Pisati
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Elisabetta Amadori
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Pasquale Striano
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
- Paediatric Neurology and Muscular Disease Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Adriano Tagliabracci
- Department of Excellence-Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Marilyn Ann Huestis
- Institute of Emerging Health Professions, Thomas Jefferson University, Philadelphia, PA, United States
| | - Francesco Paolo Busardò
- Department of Excellence-Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
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15
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Stolar O, Hazan A, Vissoker RE, Kishk IA, Barchel D, Lezinger M, Dagan A, Treves N, Meiri D, Berkovitch M, Kohn E, Heyman E. Medical cannabis for the treatment of comorbid symptoms in children with autism spectrum disorder: An interim analysis of biochemical safety. Front Pharmacol 2022; 13:977484. [PMID: 36249785 PMCID: PMC9559854 DOI: 10.3389/fphar.2022.977484] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 08/26/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Autistic Spectrum Disorder (ASD) is a common neurodevelopmental disorder and no effective treatment for the core symptoms is currently available. The present study is part of a larger clinical trial assessing the effects of cannabis oil on autism co-morbidities.Objectives: The aim of the present study was to assess the safety of a CBD-rich oil treatment in children and adolescents with ASD.Methods: Data from 59 children and young adults (ages 5–25 years) from a single-arm, ongoing, prospective, open-label, one center, phase III study was analyzed. Participants received the Nitzan Spectrum® Oil, with cannabis extracts infused in medium chain triglyceride (MCT) oil with a cannabidiol:THC ratio of 20:1, for 6 months. Blood analysis was performed before treatment initiation, and after 3 months. Complete blood count, glucose, urea, creatinine, electrolytes, liver enzymes (AST, ALT, gamma glutamyl transferase), bilirubin, lipid profile, TSH, FT4, thyroid antibodies, prolactin, and testosterone measurements were performed at baseline, prior to starting treatment and at study midpoint, after 3 months of treatment.Results: 59 children (85% male and 15% female) were followed for 18 ± 8 weeks (mean ±SD). The mean total daily dose was 7.88 ± 4.24 mg/kg body weight. No clinically significant differences were found in any of the analytes between baseline and 3 months follow up. Lactate dehydrogenase was significantly higher before treatment (505.36 ± 95.1 IU/l) as compared to its level after 3 months of treatment (470.55 ± 84.22 IU/L) (p = 0.003). FT4 was significantly higher after 3 months of treatment (15.54 ± 1.9) as compared to its level before treatment (15.07 ± 1.88) (p = 0.03), as was TSH [(2.34 ± 1.17) and (2.05 ± 1.02)] before and after 3 months of treatment, respectively (p = 0.01). However, all these values were within normal range. A comparison of the group with additional medications (n = 14) to those who received solely medical cannabis (n = 45) showed no difference in biochemical analysis, including liver enzymes, which remained stable, except for change in potassium level which was significantly higher in the group that did not receive additional medications (0.04 ± 0.37) compared to the group receiving concomitant drug therapy (-0.2 ± 0.33) (p = 0.04). A comparison of patients who received a high dose of the cannabis oil (upper quartile-16 patients), with those receiving a low dose (lower quartile—14 patients) showed no significant difference between the two groups, except for the mean change of total protein, which was significantly higher among patients receiving high dose of CBD (0.19 ± 2.74) compared to those receiving a low dose of CBD (1.71 ± 2.46 (p = 0.01), and mean change in number of platelets, that was significantly lower among patients who received high dose of CBD (13.46 ± 31.38) as compared to those who received low dose of CBD (29.64 ± 26.2) (p = 0.0007). However, both of these changes lack clinical significance.Conclusion: CBD-rich cannabis oil (CBD: THC 20:1), appears to have a good safety profile. Long-term monitoring with a larger number of participants is warranted.
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Affiliation(s)
- Orit Stolar
- Autism Center/ALUT, Shamir (Assaf Harofeh) Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Zerifin
- *Correspondence: Orit Stolar,
| | - Ariela Hazan
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Zerifin
| | - Roni Enten Vissoker
- Autism Center/ALUT, Shamir (Assaf Harofeh) Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Zerifin
| | - Ibrahim Abu Kishk
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Zerifin
| | - Dana Barchel
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Zerifin
| | - Mirit Lezinger
- Pediatric Neurology Department, Shamir (Assaf Harofeh) Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Zerifin
| | - Adi Dagan
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Zerifin
| | - Nir Treves
- Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - David Meiri
- Technion—Israel Institute of Technology, Haifa, Israel
| | - Matitiahu Berkovitch
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Zerifin
| | - Elkana Kohn
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Zerifin
| | - Eli Heyman
- Pediatric Neurology Department, Shamir (Assaf Harofeh) Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Zerifin
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Cannabidiol treatment for seizures in tuberous sclerosis complex. Epilepsy Behav 2022; 132:108761. [PMID: 35636350 DOI: 10.1016/j.yebeh.2022.108761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 11/23/2022]
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17
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Chen Y, Chen J, Zhuang X, Chen X, Zeng J, Wang R, Miao J. Risk factors of elevated blood ammonia level in epilepsy patients treated with lamotrigine. Medicine (Baltimore) 2022; 101:e29780. [PMID: 35776999 PMCID: PMC9239605 DOI: 10.1097/md.0000000000029780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
AbstractThe aim of this study was to explore the effect of lamotrigine (LTG) on blood ammonia level in patients with epilepsy and identify risk factors affecting blood ammonia level. This study included 91 epilepsy patients who were treated with LTG at Department of Neurology, Zhongshan Hospital, Xiamen University from January 2011 to April 2016, and were followed up for 3 years. Blood samples were taken during the interictal state and analyzed for blood LTG and ammonia levels. Total of 46.1% of the samples exceeded the median blood ammonia level, and 2.1% of patients had hyperammonemia. Blood ammonia level was positively correlated with LTG blood concentration. LTG combined with valproic acid therapy, seizure within 1 year, and elevated neutrophils affected blood ammonia level. Blood ammonia level was significantly correlated with plasma concentration of LTG. LTG combined with valproic acid therapy, seizure within 1 year, and elevated neutrophils may be risk factors for elevated blood ammonia level in epilepsy patients treated with LTG.
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Affiliation(s)
- Yiqian Chen
- Department of Neurology, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Jingzhen Chen
- Department of Neurology, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Xiaorong Zhuang
- Department of Neurology, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Xingyu Chen
- Department of Neurology, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Jianqi Zeng
- Department of Neurology, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Ru Wang
- Department of Neurology, Weinan Central Hospital, Weinan, China
| | - Jiayin Miao
- Department of Neurology, Zhongshan Hospital, Xiamen University, Xiamen, China
- *Correspondence: Jiayin Miao, Department of Neurology, Zhongshan Hospital, Xiamen University, Xiamen 361004, China (e-mail )
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Atogepant for the Prevention of Episodic Migraine in Adults: A Systematic Review and Meta-Analysis of Efficacy and Safety. Neurol Ther 2022; 11:1235-1252. [PMID: 35705886 PMCID: PMC9338214 DOI: 10.1007/s40120-022-00370-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 05/25/2022] [Indexed: 12/05/2022] Open
Abstract
Introduction The inhibition of the calcitonin gene-related peptide (CGRP) pathway has attracted interest in pharmacological research on migraine. Atogepant is a potent, selective, orally available antagonist of the CGRP receptor approved as a preventive treatment of episodic migraine. This systematic review with meta-analysis aims to evaluate the efficacy and safety of atogepant for the prevention of episodic migraine in adult patients. Methods Randomized, placebo-controlled, single or double-blinded trials were identified through a systematic literature search (December week 4, 2021). Main outcomes included the changes from baseline in monthly migraine days and the incidence of adverse events (AEs) and treatment withdrawal due to AEs. Mean difference (MD) and risk ratio (RR) with 95% confidence intervals (95% CIs) were estimated. Results Two trials were included, overall enrolling 1550 patients. A total of 408 participants were randomized to placebo, 314 to atogepant 10 mg, 411 to atogepant 30 mg, and 417 to atogepant 60 mg once daily. The mean age of the patients was 41.0 years and 87.7% were women. The reduction in the mean number of migraine days from baseline across the 12-week treatment period was significantly greater among patients treated with atogepant at either the daily dose of 10 mg (MD − 1.16, 95% CI − 1.60 to − 0.73, p < 0.001), 30 mg (MD − 1.15, 95% CI − 1.54 to − 0.76, p < 0.001), or 60 mg (MD − 1.20, 95% CI − 2.18 to − 0.22, p = 0.016) than with placebo. There were no differences in the occurrence of AEs and drug withdrawal due to AEs between atogepant and placebo groups. Constipation was more commonly observed in patients treated with atogepant at 30 mg/day than placebo (RR 5.19, 95% CI 2.00–13.46; p = 0.001). Treatment with atogepant at the daily dose of 60 mg was associated with a higher risk of constipation (RR 4.92, 95% CI 1.89–12.79; p = 0.001) and nausea (RR 2.73, 95% CI 1.47–5.06; p = 0.001) than placebo. Conclusion Atogepant is an efficacious and overall well-tolerated treatment for the prevention of episodic migraine in adults. Supplementary Information The online version contains supplementary material available at 10.1007/s40120-022-00370-8.
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Misri S, Kaul K, Mishra S, Charan M, Verma AK, Barr MP, Ahirwar DK, Ganju RK. Cannabidiol Inhibits Tumorigenesis in Cisplatin-Resistant Non-Small Cell Lung Cancer via TRPV2. Cancers (Basel) 2022; 14:cancers14051181. [PMID: 35267489 PMCID: PMC8909073 DOI: 10.3390/cancers14051181] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/10/2022] [Accepted: 02/15/2022] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Drug resistance is the key factor contributing to the therapeutic failure of lung cancer and the deaths related to lung cancer. Our study demonstrated that small molecular weight non-psychotropic phytochemical, cannabidiol (CBD), inhibits growth and metastasis of drug-resistant non-small cell lung cancer cells (NSCLC) cells in-vitro and in-vivo. We further discovered that CBD mediates its anti-cancer effects in part via an ion channel receptor, TRPV2, present on lung adenocarcinoma. Moreover, we showed that CBD induces apoptosis of cisplatin-resistant cells by modulating oxidative stress pathways. Overall, these studies indicate that CBD could be used as a promising therapeutic strategy in TRPV2 expressing cisplatin-resistant NSCLC. Abstract Chemotherapy forms the backbone of current treatments for many patients with advanced non-small-cell lung cancer (NSCLC). However, the survival rate is low in these patients due to the development of drug resistance, including cisplatin resistance. In this study, we developed a novel strategy to combat the growth of cisplatin-resistant (CR) NSCLC cells. We have shown that treatment with the plant-derived, non-psychotropic small molecular weight molecule, cannabidiol (CBD), significantly induced apoptosis of CR NSCLC cells. In addition, CBD treatment significantly reduced tumor progression and metastasis in a mouse xenograft model and suppressed cancer stem cell properties. Further mechanistic studies demonstrated the ability of CBD to inhibit the growth of CR cell lines by reducing NRF-2 and enhancing the generation of reactive oxygen species (ROS). Moreover, we show that CBD acts through Transient Receptor Potential Vanilloid-2 (TRPV2) to induce apoptosis, where TRPV2 is expressed on human lung adenocarcinoma tumors. High expression of TRPV2 correlates with better overall survival of lung cancer patients. Our findings identify CBD as a novel therapeutic agent targeting TRPV2 to inhibit the growth and metastasis of this aggressive cisplatin-resistant phenotype in NSCLC.
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Affiliation(s)
- Swati Misri
- Department of Pathology, The Ohio State University, Columbus, OH 43210, USA; (S.M.); (K.K.); (S.M.); (M.C.); (A.K.V.)
| | - Kirti Kaul
- Department of Pathology, The Ohio State University, Columbus, OH 43210, USA; (S.M.); (K.K.); (S.M.); (M.C.); (A.K.V.)
| | - Sanjay Mishra
- Department of Pathology, The Ohio State University, Columbus, OH 43210, USA; (S.M.); (K.K.); (S.M.); (M.C.); (A.K.V.)
| | - Manish Charan
- Department of Pathology, The Ohio State University, Columbus, OH 43210, USA; (S.M.); (K.K.); (S.M.); (M.C.); (A.K.V.)
| | - Ajeet Kumar Verma
- Department of Pathology, The Ohio State University, Columbus, OH 43210, USA; (S.M.); (K.K.); (S.M.); (M.C.); (A.K.V.)
| | - Martin P. Barr
- Thoracic Oncology Research Group, Trinity St. James’s Cancer Institute, St. James’s Hospital, D08 W9RT Dublin, Ireland;
- School of Medicine, Trinity Translational Medicine Institute, Trinity College Dublin, D08 W9RT Dublin, Ireland
| | - Dinesh K. Ahirwar
- Department of Pathology, The Ohio State University, Columbus, OH 43210, USA; (S.M.); (K.K.); (S.M.); (M.C.); (A.K.V.)
- Correspondence: (D.K.A.); (R.K.G.)
| | - Ramesh K. Ganju
- Department of Pathology, The Ohio State University, Columbus, OH 43210, USA; (S.M.); (K.K.); (S.M.); (M.C.); (A.K.V.)
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH 43210, USA
- Correspondence: (D.K.A.); (R.K.G.)
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Suraev A, Benson MJ, Martin L, Lintzeris N, McGregor IS. Determination of contaminants in artisanal cannabis products used for childhood epilepsy in the Australian community: A sub-analysis of the 'PELICAN' study. Epilepsy Behav 2022; 127:108496. [PMID: 34954507 DOI: 10.1016/j.yebeh.2021.108496] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/07/2021] [Accepted: 12/02/2021] [Indexed: 12/19/2022]
Abstract
Despite recent approval of pharmaceutical-grade cannabis products for the treatment of childhood epilepsy, some families continue to use artisanal cannabis products as a way to manage seizures in their children. However, such products are typically of unknown composition and quality, and may therefore pose an unpredictable health risk to the child. In the present analysis, 78 samples of cannabis products collected (as part of a previous study) from families of children with epilepsy (average age 8.8 ± 4.6 years) were analyzed for heavy metals (arsenic, cadmium, lead, and mercury), residual solvents (panel of 19 solvents) and pesticides (panel of 57 pesticides). Due to small sample volumes obtained, only a subset of samples was used in each analysis. Results showed that no cannabis sample exceeded the toxicity limits for heavy metals (n = 51 samples tested). Of the 58 cannabis samples tested for residual solvents, 17 (29%) contained concentrations of ethanol or isopropanol above the generally accepted limit of 5000 parts per million. With the volumes consumed, it was thought unlikely that children were consuming hazardous amounts of residual solvents, although this could not be ruled out in every case. Most samples (n = 31 samples tested) yielded inconclusive results for the pesticides, although one sample contained concentrations of bifenthrin that were 4.9 times higher than the acceptable limit. Overall, these results highlight the need for improved access to quality-assured cannabis products and the education of doctors, patients, and artisanal manufacturers around the contaminant exposure risk in unregulated cannabis products.
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Affiliation(s)
- Anastasia Suraev
- The University of Sydney, Lambert Initiative for Cannabinoid Therapeutics, Sydney, Australia; The University of Sydney, Brain and Mind Centre, Sydney, Australia; The University of Sydney, Faculty of Science, School of Psychology, Sydney, Australia.
| | - Melissa J Benson
- The University of Sydney, Lambert Initiative for Cannabinoid Therapeutics, Sydney, Australia; The University of Sydney, Brain and Mind Centre, Sydney, Australia; The University of Sydney, Faculty of Science, School of Psychology, Sydney, Australia.
| | - Lewis Martin
- The University of Sydney, Lambert Initiative for Cannabinoid Therapeutics, Sydney, Australia; The University of Sydney, Brain and Mind Centre, Sydney, Australia; The University of Sydney, Faculty of Science, School of Psychology, Sydney, Australia.
| | - Nicholas Lintzeris
- Drug and Alcohol Services, South East Sydney Local Health District, Sydney, Australia; Division Addiction Medicine, Faculty Medicine and Health, Sydney, Australia; NSW DACRIN (Drug and Alcohol Clinical Research and Improvement Network), Sydney, Australia.
| | - Iain S McGregor
- The University of Sydney, Lambert Initiative for Cannabinoid Therapeutics, Sydney, Australia; The University of Sydney, Brain and Mind Centre, Sydney, Australia; The University of Sydney, Faculty of Science, School of Psychology, Sydney, Australia.
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21
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Caraballo R, Reyes G, Demirdjian G, Huaman M, Gutierrez R. Long-term use of cannabidiol-enriched medical cannabis in a prospective cohort of children with drug-resistant developmental and epileptic encephalopathy. Seizure 2022; 95:56-63. [PMID: 34999381 DOI: 10.1016/j.seizure.2022.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/21/2021] [Accepted: 01/02/2022] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE We report our findings regarding effectiveness, safety, and tolerability of cannabidiol (CBD)-enriched medical cannabis as add-on therapy in children with drug-resistant epileptic encephalopathies (DEEs) after a median follow-up of 20 months. METHODS A prospective cohort study was conducted to assess effectiveness, safety, and tolerability of CBD-enriched medical cannabis oil added to standard antiseizure medications in children with drug-resistant DEE seen at a single center. RESULTS Between October 2018 and March 2020, 59 patients were enrolled. Mean age at enrollment was 10.5 years (range, 2-17 years). Median treatment duration was 20 months (range, 12-32). Median age at first seizure was 8 months (range, 1 day - 10 years). At the end of follow-up, 78% of the children had a ≥ 50% decrease in seizure frequency and 47.5% had a > 75% decrease. Seven patients (11.9%) were seizure free. The number of seizures was reduced from a median of 305/month to 90/month, amounting to a mean reduction of 57% and a median reduction of 71% (p < 0.0001). Adverse effects were mostly mild or moderate. CBD was discontinued in 17 patients (28.8%) due to lack of response to treatment, increased seizure frequency, intolerance to the drug, or poor compliance. CONCLUSION In children with drug-resistant DEEs, long-term treatment of CBD-enriched medical cannabis as an adjuvant therapy to antiseizure therapy was found to be safe, well tolerated, and effective. Sustained reductions in seizure frequency and improvement of aspects of daily living were observed compared to our preliminary findings.
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Affiliation(s)
- Roberto Caraballo
- Department of Neurology, Hospital de Pediatría "Prof. Dr. Juan P Garrahan", Combate de los Pozos 1881, Buenos Aires CP 1245, Argentina.
| | - Gabriela Reyes
- Department of Neurology, Hospital de Pediatría "Prof. Dr. Juan P Garrahan", Combate de los Pozos 1881, Buenos Aires CP 1245, Argentina
| | - Graciela Demirdjian
- Health Technology Assessment Unit Coordinator, Hospital de Pediatría "Juan P. Garrahan", Buenos Aires, Argentina.
| | - Marina Huaman
- Department of Neurology, Hospital de Pediatría "Prof. Dr. Juan P Garrahan", Combate de los Pozos 1881, Buenos Aires CP 1245, Argentina.
| | - Robinson Gutierrez
- Department of Neurology, Hospital de Pediatría "Prof. Dr. Juan P Garrahan", Combate de los Pozos 1881, Buenos Aires CP 1245, Argentina
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22
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Xu C, Zhang Y, Gozal D, Carney P. Channelopathy of Dravet Syndrome and Potential Neuroprotective Effects of Cannabidiol. J Cent Nerv Syst Dis 2021; 13:11795735211048045. [PMID: 34992485 PMCID: PMC8724990 DOI: 10.1177/11795735211048045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Dravet syndrome (DS) is a channelopathy, neurodevelopmental, epileptic encephalopathy characterized by seizures, developmental delay, and cognitive impairment that includes susceptibility to thermally induced seizures, spontaneous seizures, ataxia, circadian rhythm and sleep disorders, autistic-like behaviors, and premature death. More than 80% of DS cases are linked to mutations in genes which encode voltage-gated sodium channel subunits, SCN1A and SCN1B, which encode the Nav1.1α subunit and Nav1.1β1 subunit, respectively. There are other gene mutations encoding potassium, calcium, and hyperpolarization-activated cyclic nucleotide-gated (HCN) channels related to DS. One-third of patients have pharmacoresistance epilepsy. DS is unresponsive to standard therapy. Cannabidiol (CBD), a non-psychoactive phytocannabinoid present in Cannabis, has been introduced for treating DS because of its anticonvulsant properties in animal models and humans, especially in pharmacoresistant patients. However, the etiological channelopathiological mechanism of DS and action mechanism of CBD on the channels are unclear. In this review, we summarize evidence of the direct and indirect action mechanism of sodium, potassium, calcium, and HCN channels in DS, especially sodium subunits. Some channels' loss-of-function or gain-of-function in inhibitory or excitatory neurons determine the balance of excitatory and inhibitory are associated with DS. A great variety of mechanisms of CBD anticonvulsant effects are focused on modulating these channels, especially sodium, calcium, and potassium channels, which will shed light on ionic channelopathy of DS and the precise molecular treatment of DS in the future.
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Affiliation(s)
- Changqing Xu
- Department of Child Health and the Child Health Research Institute, School of Medicine, University of Missouri, Columbia, MO, USA
| | - Yumin Zhang
- Department of Anatomy, Physiology and Genetics; Department of Neuroscience, Uniformed Services University School of Medicine, Bethesda, MD, USA
| | - David Gozal
- Department of Child Health and the Child Health Research Institute, School of Medicine, University of Missouri, Columbia, MO, USA
| | - Paul Carney
- Departments of Child Health and Neurology, School of Medicine, University of Missouri, Columbia, MO, USA
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23
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Riera R, Pacheco RL, Bagattini ÂM, Martimbianco ALC. Efficacy and safety of therapeutic use of cannabis derivatives and their synthetic analogs: Overview of systematic reviews. Phytother Res 2021; 36:5-21. [PMID: 34841610 DOI: 10.1002/ptr.7263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 08/05/2021] [Accepted: 08/14/2021] [Indexed: 01/08/2023]
Abstract
The debate on the use of cannabinoids for therapeutic purposes is constantly on the rise. This overview aimed to map the evidence on the therapeutic effects of cannabis derivatives and their synthetic analogs. Systematic reviews (SRs) of randomized trials were identified through a comprehensive search in several databases, and their methodological quality were evaluated with AMSTAR-2. The results for main outcomes are presented, prioritizing those from updated and better quality SRs. Finally, 68 SRs, addressing 37 different health conditions, were included. The methodological quality was high for eight SRs. The evidence certainty (GRADE) for the effects of cannabinoids is not high for any of the outcomes identified. Evidence certainty was moderate for the following: (a) cannabidiol appears to be beneficial for quality of life but increases the risk of adverse events in ulcerative colitis; (b) cannabinoids in general appear to have no clinically important benefit for chronic non-oncologic pain, spasticity-related pain in multiple sclerosis, or for acute post-operative pain; (c) cannabinoids in general appear to have a benefit in reducing chemotherapy-related nausea and vomiting. For all other outcomes from remaining comparisons, the evidence certainty was low, very low, or not evaluated, which prevents recommendations for or against their routine use.
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Affiliation(s)
- Rachel Riera
- Health Technology Assessment Centre, Hospital Sírio-Libanês, São Paulo - SP, Brazil.,Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (Unifesp), São Paulo - SP, Brazil
| | - Rafael Leite Pacheco
- Health Technology Assessment Centre, Hospital Sírio-Libanês, São Paulo - SP, Brazil.,Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (Unifesp), São Paulo - SP, Brazil.,Centro de Pesquisa Médica, Centro Universitário São Camilo (CUSC), São Paulo - SP, Brazil
| | - Ângela Maria Bagattini
- Health Technology Assessment Centre, Hospital Sírio-Libanês, São Paulo - SP, Brazil.,Instituto de Medicina Tropical e Saúde Publica, Universidade Federal de Goiás (UFG), Goiânia - GO, Brazil
| | - Ana Luiza Cabrera Martimbianco
- Health Technology Assessment Centre, Hospital Sírio-Libanês, São Paulo - SP, Brazil.,Mestrado Profissional em Saúde e Meio Ambiente, Universidade Metropolitana de Santos (Unimes), Santos - SP, Brazil
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24
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Adams PJ, Rychert M, Wilkins C. How does the influence of the cannabis industry differ from that of alcohol and tobacco? Addiction 2021; 116:2951-2952. [PMID: 34327753 DOI: 10.1111/add.15637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 06/25/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Peter J Adams
- Centre for Addiction Research, School of Population Health, University of Auckland, Auckland, New Zealand
| | - Marta Rychert
- Social and Health Outcomes Research and Evaluation (SHORE), SHORE and Whaariki Research Centre, College of Health, Massey University, Auckland, New Zealand
| | - Chris Wilkins
- Social and Health Outcomes Research and Evaluation (SHORE), SHORE and Whaariki Research Centre, College of Health, Massey University, Auckland, New Zealand
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25
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Pejčić A, Janković SM, Đešević M, Gojak R, Lukić S, Marković N, Milosavljević M. Novel and emerging therapeutics for genetic epilepsies. Expert Rev Neurother 2021; 21:1283-1301. [PMID: 34633254 DOI: 10.1080/14737175.2021.1992275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Disease-specific treatments are available only for a minority of patients with genetic epilepsies, while the rest are treated with anticonvulsants, which are ineffective in almost one-third of patients. AREAS COVERED Recently approved and the most effective emerging therapeutics under development for the treatment of genetic epilepsies are overviewed after systematic search and analysis of relevant literature. EXPERT OPINION New and emerging drugs for genetic epilepsies exploit one of the two approaches: inhibiting hyperactive brain foci through blocking excitatory or augmenting inhibitory neurotransmission, or correcting the underlying genetic defect. The first is limited by insufficient selectivity of available compounds, and the second by imperfection of currently used vectors of genetic material, unselective and transient transgene expression. Besides, the treatment may come too late, after structural abnormalities and epilepsy deterioration takes place. However, with recent improvements, we can expect to see soon gradual decline in the number of patients with therapy-resistant genetic epilepsies.
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Affiliation(s)
- Ana Pejčić
- University of Kragujevac, Faculty of Medical Sciences, Kragujevac, Serbia
| | | | - Miralem Đešević
- Private Policlinic Center Eurofar Sarajevo, Cardiology Department, Sarajevo, Bosnia and Herzegovina
| | - Refet Gojak
- Infectious diseases Clinic, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Snežana Lukić
- University of Kragujevac, Faculty of Medical Sciences, Kragujevac, Serbia
| | - Nenad Marković
- University of Kragujevac, Faculty of Medical Sciences, Kragujevac, Serbia
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Hakami T. Neuropharmacology of Antiseizure Drugs. Neuropsychopharmacol Rep 2021; 41:336-351. [PMID: 34296824 PMCID: PMC8411307 DOI: 10.1002/npr2.12196] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/01/2021] [Accepted: 07/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Antiseizure drugs (ASDs) are the primary therapy for epilepsy, with more than 20 drugs introduced into clinical practice to date. These drugs are typically grouped by their mechanisms of action and therapeutic spectrum. This article aims to educate non-neurologists and medical students about the new frontiers in the pharmacology of ASDs and presents the current state of the literature on the efficacy and tolerability of these agents. METHODS Randomized controlled trials, observational studies, and evidence-based meta-analyses of ASD efficacy and tolerability as initial monotherapy for epileptic seizures and syndromes were identified in PubMed, EMBASE, the Cochrane Library, and Elsevier Clinical Pharmacology. RESULTS The choice of ASD varies primarily according to the seizure type. Practical guidelines for ASD selection in patients with new-onset and drug-resistant epilepsy were recently published. The guidelines have shown that the newer-generation drugs, which have unique mechanistic and pharmacokinetic properties, are better tolerated but have similar efficacy compared with the older drugs. Several ASDs are effective as first-line monotherapy in focal seizures, including lamotrigine, carbamazepine, phenytoin, levetiracetam, and zonisamide. Valproate remains the first-line drug for many patients with generalized and unclassified epilepsies. However, valproate should be avoided, if possible, in women of childbearing potential because of teratogenicity. Toxicity profile precludes several drugs from use as first-line treatment, for example, vigabatrin, felbamate, and rufinamide. CONCLUSIONS Antiseizure drugs have different pharmacologic profiles that should be considered when selecting and prescribing these agents for epilepsy. These include pharmacokinetic properties, propensity for drug-drug interactions, and adverse effects.
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Affiliation(s)
- Tahir Hakami
- The Faculty of MedicineJazan UniversityJazanSaudi Arabia
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27
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Treating of focal epilepsy: a patent review. Pharm Pat Anal 2021; 10:165-173. [PMID: 34076528 DOI: 10.4155/ppa-2021-0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Focal epilepsy is one of the most frequent specific type of epilepsies, with 30% treatment-resistant patients. There are several directions researchers can follow to improve existing treatment of focal epilepsy: synthesis of new compounds with anticonvulsant activity, repurposing drugs approved for other indications, finding drugs targeted to specific genetic and biochemical defects that underlie focal epilepsy syndromes, development of viral vectors for specific gene therapy, creation of devices and methods for suppression of seizures by electrostimulation and development of methods to increase safety of epilepsy surgery. Improvement of efficacy and safety of current therapies is necessary, as well as developing targeted treatment of genetic epilepsy syndromes that will not only suppress seizures, but stop further epileptogenesis.
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28
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Hordowicz M, Klimkiewicz A, Jarosz J, Wysocka M, Jastrzębska M. Knowledge, attitudes, and prescribing patterns of cannabis and cannabinoid-containing medicines among European healthcare workers: a systematic literature review. Drug Alcohol Depend 2021; 221:108652. [PMID: 33667785 DOI: 10.1016/j.drugalcdep.2021.108652] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 01/20/2021] [Accepted: 02/17/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Since the introduction of the National Medical Cannabis Programme in The Netherlands, many other countries in Europe have made medical cannabis (MC) and cannabis-based medicines (CBMs) available. However, each of them has implemented a unique legal framework and reimbursement strategy for these products. Therefore, it is vital to study healthcare professionals' knowledge level (HCP) and HCPs in-training regarding both medical uses and indications and understand their safety concerns and potential barriers for MC use in clinical practice. METHODS A comprehensive, systematic literature review was performed using PubMed/MEDLINE, EMBASE, and Google Scholar databases, as well as PsychINFO. Grey literature was also included. Due to the high diversity in the questionnaires used in the studies, a narrative synthesis was performed. RESULTS From 6995 studies retrieved, ten studies, all of them being quantitative survey-based studies, were included in the review. In most studies, the majority of participants were in favor of MC and CBMs use for medical reasons. Other common findings were: the necessity to provide additional training regarding medical applications of cannabinoids, lack of awareness about the legal status of and regulations regarding MC among both certified physicians, as well as prospective doctors and students of other medicals sciences (e.g., nursing, pharmacy). CONCLUSIONS For most European countries, we could not identify any studies evaluating HCPs' knowledge and attitudes towards medicinal cannabis. Therefore, similar investigations are highly encouraged. Available evidence demonstrates a need to provide medical training to the HCPs in Europe regarding medical applications of cannabinoids.
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Affiliation(s)
| | | | - Jerzy Jarosz
- Hospice of St. Christopher in Warsaw, Warsaw, Poland
| | - Maria Wysocka
- Hospice of St. Christopher in Warsaw, Warsaw, Poland; Medical University of Warsaw, Warsaw, Poland; Nowowiejski Hospital in Warsaw, Warsaw, Poland
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Lattanzi S, Riva A, Striano P. Ganaxolone treatment for epilepsy patients: from pharmacology to place in therapy. Expert Rev Neurother 2021; 21:1317-1332. [PMID: 33724128 DOI: 10.1080/14737175.2021.1904895] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Nonsulfated neurosteroids can provide phasic and tonic inhibition through activation of synaptic and extra-synaptic γ-aminobutyric acid (GABA)A receptors, exhibiting a greater potency for the latter. These actions occur by interacting with modulatory sites that are distinct from those bound by benzodiazepines and barbiturates. Ganaxolone (GNX) is a synthetic analog of the endogenous neurosteroid allopregnanolone and a member of a novel class of neuroactive steroids called epalons.Areas covered: The authors review the pharmacology of GNX, summarize the main clinical evidence about its antiseizure efficacy and tolerability, and suggest implications for clinical practice and future research.Expert opinion: The clinical development of GNX is mainly oriented to target unmet needs and focused on status epilepticus and rare genetic epilepsies that have few or no treatment options.The availability of oral and intravenous formulations allows reaching adult and pediatric patients in acute and chronic care settings. Further evidence will complement the understanding of the potentialities of GNX and possibly lead to indications for use in clinical practice.
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Affiliation(s)
- Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Antonella Riva
- Pediatric Neurology and Muscular Diseases Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, "G. Gaslini" Institute, University of Genoa, Genova, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, "G. Gaslini" Institute, University of Genoa, Genova, Italy
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30
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Lattanzi S, Trinka E, Striano P, Rocchi C, Salvemini S, Silvestrini M, Brigo F. Highly Purified Cannabidiol for Epilepsy Treatment: A Systematic Review of Epileptic Conditions Beyond Dravet Syndrome and Lennox-Gastaut Syndrome. CNS Drugs 2021; 35:265-281. [PMID: 33754312 PMCID: PMC8005394 DOI: 10.1007/s40263-021-00807-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Cannabidiol (CBD), which is one major constituent of the Cannabis sativa plant, has anti-seizure properties and does not produce euphoric or intrusive side effects. A plant-derived, highly purified CBD formulation with a known and constant composition has been approved by the US Food and Drug Administration for the treatment of seizures associated with Dravet syndrome, Lennox-Gastaut syndrome, and tuberous sclerosis complex. In the European Union, the drug has been authorized by the European Medicines Agency for the treatment of seizures associated with Dravet syndrome and Lennox-Gastaut syndrome, in conjunction with clobazam, and is under regulatory review for the treatment of seizures in patients with tuberous sclerosis complex. OBJECTIVES This systematic review aimed to summarize the currently available body of knowledge about the use of this US Food and Drug Administration/European Medicines Agency-approved oral formulation of pharmaceutical-grade CBD in patients with epileptic conditions, especially developmental and epileptic encephalopathies other than Dravet syndrome and Lennox-Gastaut syndrome. METHODS The relevant studies were identified through MEDLINE and the US National Institutes of Health Clinical Trials Registry in October 2020. There were no date limitations or language restrictions. The following types of studies were included: clinical trials, cohorts, case-control, cross-sectional, clinical series, and case reports. Participants had to meet the following criteria: any sex, any ethnicity, any age, diagnosis of epilepsy, receiving plant-derived, highly purified (> 98% w/w) CBD in a sesame oil-based oral solution for the treatment of seizures. Data extracted from selected records included efficacy, tolerability, and safety outcomes. RESULTS Five hundred and seventy records were identified by database and trial register searching. Fifty-seven studies were retrieved for detailed assessment, of which 42 were eventually included for the review. The participants of the studies included patients of both pediatric and adult age. Across the trials, purified CBD was administered at dosages up to 50 mg/kg/day. In a randomized double-blind controlled trial in patients with tuberous sclerosis complex, CBD was associated with a significantly greater percent reduction in seizure frequency than placebo over the treatment period. Open-label studies suggested the effectiveness of CBD in the treatment of children and adults presenting with other epilepsy syndromes than those addressed by regulatory trials, including CDKL5 deficiency disorder and Aicardi, Dup15q, and Doose syndromes, SYNGAP1 encephalopathy, and epilepsy with myoclonic absences. The most common adverse events observed during treatment with CBD included somnolence, decreased appetite, diarrhea, and increased serum aminotransferases. CONCLUSIONS The currently available data suggest that response to treatment with a highly purified, plant-derived CBD oil-based solution can be seen in patients across a broad range of epilepsy disorders and etiologies. The existing evidence can provide preliminary support for additional research.
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Affiliation(s)
- Simona Lattanzi
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Via Conca 71, 60020, Ancona, Italy.
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria.,Center for Cognitive Neuroscience, Salzburg, Austria.,Public Health, Health Services Research and HTA, University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, "G. Gaslini" Institute, University of Genoa, Genoa, Italy
| | - Chiara Rocchi
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Via Conca 71, 60020, Ancona, Italy
| | - Sergio Salvemini
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Via Conca 71, 60020, Ancona, Italy
| | - Mauro Silvestrini
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Via Conca 71, 60020, Ancona, Italy
| | - Francesco Brigo
- Department of Neuroscience, Biomedicine and Movement Science, University of Verona, Verona, Italy.,Division of Neurology, "Franz Tappeiner" Hospital, Merano, BZ, Italy
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Nabbout R, Chemaly N, Chiron C, Kuchenbuch M. Safety considerations selecting antiseizure medications for the treatment of individuals with Dravet syndrome. Expert Opin Drug Saf 2021; 20:561-576. [PMID: 33645379 DOI: 10.1080/14740338.2021.1890025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Management of individuals with Dravet Syndrome has evolved significantly over the past 10 years. Progress has been made in understanding the pathophysiology, the long-term outcome and possible consequences of inappropriate therapies, new drugs have been approved by the regulatory authorities and patients and families expressed their needs beyond seizures' control.Areas covered: The authors aimed at providing an overview of the main antiseizure medications used in Dravet syndrome with a particular focus on safety considerations. As the highly active phase of seizures takes place before the age of 5 years, the characteristics of antiseizure medications in infancy and childhood have also been considered due to their impact on antiseizure medication safety.Expert opinion: Recent treatments, evaluated via randomized clinical trials, are promising in terms of efficacy and safety in individuals with DS. However, the balance between expected benefits and risks taken must be accurately assessed on an individual basis. There is a lack of data to understand the needs of patients and families, a major point particularly in this population, where the evaluation of efficacy and safety beyond seizures is difficult due to cognitive delay and behavioral disorders and where this evaluation is coming almost exclusively from caregivers.
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Affiliation(s)
- Rima Nabbout
- Reference Centre for Rare Epilepsies, Department of Pediatric Neurology, Necker Enfants Malades University Hospital, Université De Paris, Paris, France.,Institut National De La Santé Et De La Recherche Médicale (INSERM), UMR 1163, Institut Imagine, Université De Paris, Paris, France
| | - N Chemaly
- Reference Centre for Rare Epilepsies, Department of Pediatric Neurology, Necker Enfants Malades University Hospital, Université De Paris, Paris, France.,Institut National De La Santé Et De La Recherche Médicale (INSERM), UMR 1163, Institut Imagine, Université De Paris, Paris, France
| | - C Chiron
- Reference Centre for Rare Epilepsies, Department of Pediatric Neurology, Necker Enfants Malades University Hospital, Université De Paris, Paris, France.,INSERM U1141, Paris, France & Neurospin, CEA, Gif/Yvette, France
| | - M Kuchenbuch
- Reference Centre for Rare Epilepsies, Department of Pediatric Neurology, Necker Enfants Malades University Hospital, Université De Paris, Paris, France.,Institut National De La Santé Et De La Recherche Médicale (INSERM), UMR 1163, Institut Imagine, Université De Paris, Paris, France
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Verrotti A, Striano P. Novel therapeutic options for Dravet and Lennox-Gastaut syndrome. Expert Rev Neurother 2021; 21:1191-1194. [PMID: 33297778 DOI: 10.1080/14737175.2020.1862651] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, IRRCS Istituto Giannina Gaslini, Genova, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Università Degli Studi di Genova, Genova, Italy
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Abstract
Lennox-Gastaut syndrome (LGS), a childhood-onset severe developmental and epileptic encephalopathy (DEE), is an entity that encompasses a heterogenous group of aetiologies, with no single genetic cause. It is characterised by multiple seizure types, an abnormal EEG with generalised slow spike and wave discharges and cognitive impairment, associated with high morbidity and profound effects on the quality of life of patients and their families. Drug-refractory seizures are a hallmark and treatment is further complicated by its multiple morbidities, which evolve over the patient's lifetime. This review provides a comprehensive overview of the current and future options for the treatment of seizures associated with LGS. Six treatments are specifically indicated as adjunct therapies for the treatment of seizures associated with LGS in the US: lamotrigine, clobazam, rufinamide, topiramate, felbamate and most recently cannabidiol. These therapies have demonstrated reductions in drop seizures in 15%-68% of patients across trials, with responder rates (≥ 50% reduction in drop seizures) of 37%-78%. Valproate is still the preferred first-line treatment, generally in combination with lamotrigine or clobazam. Other treatments frequently used off-label include the broad spectrum anti-epileptic drugs (AED) levetiracetam, zonisamide and perampanel, while recent evidence from observational studies has indicated that a newer AED, the levetiracetam analogue brivaracetam, may be effective and well tolerated in LGS patients. Other treatments in clinical development include fenfluramine in late phase III, perampanel, soticlestat-OV953/TAK-953, carisbamate and ganaxolone. Non-pharmacologic interventions include the ketogenic diet, vagus nerve stimulation and surgical interventions; these are also expanding, with the potential for less invasive techniques for corpus callosotomy that have promise for reducing complications. However, despite these advancements, patients continue to experience a significant burden. Because LGS is not a single entity, tailoring of treatment is needed as opposed to a 'one size fits all' approach. Further research is needed into the underlying aetiologies and pathophysiology of LGS, together with advancements in treatments that encompass the spectrum of seizures associated with this complex syndrome.
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Metternich B, Wagner K, Geiger MJ, Hirsch M, Schulze-Bonhage A, Klotz KA. Cognitive and behavioral effects of cannabidiol in patients with treatment-resistant epilepsy. Epilepsy Behav 2021; 114:107558. [PMID: 33246899 DOI: 10.1016/j.yebeh.2020.107558] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 09/16/2020] [Accepted: 10/09/2020] [Indexed: 01/12/2023]
Abstract
PURPOSE Therapeutic use of cannabidiol (CBD) in intractable epilepsies has increased considerably over the last ten years. As more evidence for the potentially beneficial effects of CBD on different epilepsy types is emerging, it is important to monitor potential cognitive and behavioral side effects. So far, studies including standardized neuropsychological data in the context of treatment with CBD in epilepsy patients are sparse. The present open-label study examines cognitive and behavioral effects of CBD in children and adults with treatment resistant epilepsy. METHOD Thirty-nine patients with treatment-resistant epilepsy completed the study protocol, i.e. they were tested at baseline (T0) and after three months of CBD treatment (T1). Patients completed standardized neuropsychological tests on memory, executive functions and attention if they were capable. For cognitively impaired patients who could not complete cognitive tests, caregiver interviews were conducted and caregiver questionnaires completed. RESULTS Significant cognitive decline from T0 to T1 was observed on none of the included measures. There was a significant improvement on a measure of selective attention and on a caregiver-rated behavioral measure. More than 89% of all individual test results remained stable or showed reliable improvement from T0 to T1. Cognitive and behavioral changes from T0 to T1 were not significantly correlated with CBD dose. Improvements in short-term/working memory were significantly related to better therapy response. CONCLUSION No adverse group-level effects of CBD treatment were detected. On an individual level, most test results remained stable or were improved. Cognitive change was not related to CBD dose. The present results show that, from a cognitive and behavioral point of view, CBD seems to have an encouraging side-effect profile. The results need to be replicated with larger samples.
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Affiliation(s)
- Birgitta Metternich
- Epilepsy Center, Medical Center-University of Freiburg, Faculty of Medicine University of Freiburg Germany, Breisacher Straße 64, 79106 Freiburg, Germany.
| | - Kathrin Wagner
- Epilepsy Center, Medical Center-University of Freiburg, Faculty of Medicine University of Freiburg Germany, Breisacher Straße 64, 79106 Freiburg, Germany
| | - Maximilian J Geiger
- Epilepsy Center, Medical Center-University of Freiburg, Faculty of Medicine University of Freiburg Germany, Breisacher Straße 64, 79106 Freiburg, Germany
| | - Martin Hirsch
- Epilepsy Center, Medical Center-University of Freiburg, Faculty of Medicine University of Freiburg Germany, Breisacher Straße 64, 79106 Freiburg, Germany
| | - Andreas Schulze-Bonhage
- Epilepsy Center, Medical Center-University of Freiburg, Faculty of Medicine University of Freiburg Germany, Breisacher Straße 64, 79106 Freiburg, Germany
| | - Kerstin A Klotz
- Epilepsy Center, Medical Center-University of Freiburg, Faculty of Medicine University of Freiburg Germany, Breisacher Straße 64, 79106 Freiburg, Germany; Department of Neuropediatrics and Muscle Disorders, Medical Center-University of Freiburg, Faculty of Medicine University of Freiburg, Mathildenstraße 1, 79106 Freiburg, Germany; Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Germany
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Devinsky O, Thiele EA, Wright S, Checketts D, Morrison G, Dunayevich E, Knappertz V. Cannabidiol efficacy independent of clobazam: Meta-analysis of four randomized controlled trials. Acta Neurol Scand 2020; 142:531-540. [PMID: 32592183 PMCID: PMC7689899 DOI: 10.1111/ane.13305] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/15/2020] [Accepted: 06/19/2020] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The efficacy of cannabidiol (CBD) with and without concomitant clobazam (CLB) was evaluated in stratified analyses of four large randomized controlled trials, two in Lennox-Gastaut syndrome, and two in Dravet syndrome. METHODS Each trial of CBD (Epidiolex® in the US; Epidyolex® in the EU; 10 and 20 mg/kg/day) was evaluated by CLB use. The treatment ratio was analyzed using negative binomial regression for changes in seizure frequency and logistic regression for the 50% responder rate, where the principle analysis combined both indications and CBD doses in a stratified meta-analysis. Pharmacokinetic data were examined for an exposure/response relationship based on CLB presence/absence. Safety data were analyzed using descriptive statistics. RESULTS The meta-analysis favored CBD vs. placebo regardless of CLB use. The treatment ratio (95% CI) of CBD over placebo for the average reduction in seizure frequency was 0.59 (0.52, 0.68; P < .0001) with CLB and 0.85 (0.73, 0.98; P = .0226) without CLB, and the 50% responder rate odds ratio (95% CI) was 2.51 (1.69, 3.71; P < .0001) with CLB and 2.40 (1.38, 4.16; P = .0020) without CLB. Adverse events (AEs) related to somnolence, rash, pneumonia, or aggression were more common in patients with concomitant CLB. There was a significant exposure/response relationship for CBD and its active metabolite. CONCLUSIONS These results indicate CBD is efficacious with and without CLB, but do not exclude the possibility of a synergistic effect associated with the combination of agents. The safety and tolerability profile of CBD without CLB show a lower rate of certain AEs than with CLB.
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Affiliation(s)
- Orrin Devinsky
- Comprehensive Epilepsy Center New York University Langone Medical Center New York NY USA
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Dubois S, Marchese F, Pigliasco F, Barco S, Tripodi G, Lomonaco T, Lattanzi S, Russo E, Cangemi G, Striano P. A Volumetric Absorptive Microsampling Technique to Monitor Cannabidiol Levels in Epilepsy Patients. Front Pharmacol 2020; 11:582286. [PMID: 33364956 PMCID: PMC7751733 DOI: 10.3389/fphar.2020.582286] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 10/14/2020] [Indexed: 12/14/2022] Open
Abstract
Purpose: Interest in cannabis-based therapies has recently increased, due to the availability of cannabidiol (CBD) for the treatment of epilepsy without psychoactive effects. Therapeutic drug monitoring can prevent drug interactions and minimize drug toxicity. We evaluated a volumetric absorptive microsampling (VAMS) method combined with LC-MS/MS (liquid chromatography coupled to tandem mass spectrometry) for the quantification of CBD blood levels in patients with refractory epilepsy. Methods: Prospective observation of patients with Dravet syndrome receiving open-label, add-on GW-purified CBD (Epidyolex®) at different doses. CBD plasma samples were obtained from venipuncture and LC-MS/MS was used to measure CBD in venous and capillary blood samples collected by VAMS. Results: We enrolled five patients with a mean age of 13 (range: 4–27) years. CBD levels measured by VAMS on capillary blood did not differ from CBD levels measured in plasma by venipuncture (R2 > 0.93). Conclusion: This proof-of-concept study suggests that VAMS allows monitoring of CBD plasma levels and can offer valuable support for personalized therapy in refractory epilepsy.
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Affiliation(s)
- Sara Dubois
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Francesca Marchese
- Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Federica Pigliasco
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analyses, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Sebastiano Barco
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analyses, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Gino Tripodi
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analyses, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Tommaso Lomonaco
- Department of Chemistry and Industrial Chemistry, University of Pisa, Pisa, Italy
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Emilio Russo
- Science of Health Department, School of Medicine, University Magna Graecia, Catanzaro, Italy
| | - Giuliana Cangemi
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analyses, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Pasquale Striano
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy.,Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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Lattanzi S, Zaccara G, Russo E, La Neve A, Lodi MAM, Striano P. Practical use of pharmaceutically purified oral cannabidiol in Dravet syndrome and Lennox-Gastaut syndrome. Expert Rev Neurother 2020; 21:99-110. [PMID: 33026899 DOI: 10.1080/14737175.2021.1834383] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Pharmaceutically purified oral cannabidiol (CBD) has been recently approved by the US Food and Drug Administration and European Medicines Agency as treatment of seizures associated with Dravet syndrome (DS) and Lennox-Gastaut syndrome (LGS), which are severe and difficult-to-treat developmental and epileptic encephalopathies with onset in early childhood. AREAS COVERED This review will critically review the pharmacokinetic properties of CBD, the interactions with antiseizure and non-antiseizure medications, and the main tolerability and safety issues to provide guidance for its use in everyday practice. EXPERT OPINION CBD is metabolized in the liver and can influence the activity of enzymes involved in drug metabolism. The best characterized drug-drug interaction is between CBD and clobazam. The most common adverse events include somnolence, gastrointestinal discomfort, and increase in serum transaminases. High-grade purified CBD oral solution represents an effective therapeutic option in patients with DS and LGS. The findings cannot be extrapolated to other cannabis-based products, synthetic cannabinoids for medicinal use and non-medicinal cannabis and CBD derivatives.
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Affiliation(s)
- Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University , Ancona, Italy
| | | | - Emilio Russo
- Department of Science of Health, University of Catanzaro , Catanzaro, Italy
| | - Angela La Neve
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari , Italy
| | - Monica Anna Maria Lodi
- Department of Child Neuropsychiatry, Epilepsy Center, Fatebenefratelli Hospital , Milan, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, "G. Gaslini" Institute, University of Genoa , Genova, Italy
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Mula M. Pharmacological treatment of focal epilepsy in adults: an evidence based approach. Expert Opin Pharmacother 2020; 22:317-323. [PMID: 32990097 DOI: 10.1080/14656566.2020.1829594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Focal seizures represent the most common seizure type and focal epilepsies the most common epilepsy type. Anti-seizure medications (ASMs) still represent the main form of treatment for epilepsy. AREAS COVERED The aim of this review article is to provide an overview of available evidence about current and upcoming pharmacological options and strategies for adults with focal epilepsy focusing on the last 5 years. EXPERT OPINION Seventeen drugs are currently approved for the treatment of focal seizures including cenobamate as the very latest option. Ten of these drugs are also licensed for monotherapy. Level A evidence for initial monotherapy is available for seven drugs with no robust data supporting that one drug is superior to the other. Safety, tolerability as well as pharmacoeconomic reasons would then drive treatment decisions. Data on adjunctive treatment are available for 13 ASMs showing again no obvious difference in terms of efficacy. Evidence on specific drug combinations is almost non-existent and the final decision of combining specific drugs is based on the experience of the individual clinician rather than on robust evidence. Current outcome measures do not consider number of previously failed drugs and the observation period is often too short.
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Affiliation(s)
- Marco Mula
- Institute of Medical and Biomedical Education, St George's University of London and Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust , London, UK
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Raucci U, Pietrafusa N, Paolino MC, Di Nardo G, Villa MP, Pavone P, Terrin G, Specchio N, Striano P, Parisi P. Cannabidiol Treatment for Refractory Epilepsies in Pediatrics. Front Pharmacol 2020; 11:586110. [PMID: 33117180 PMCID: PMC7550750 DOI: 10.3389/fphar.2020.586110] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 09/09/2020] [Indexed: 12/31/2022] Open
Abstract
Cannabis extracts in oil are becoming increasingly available, and, during the last years, there has been growing public and scientific interest about therapeutic properties of these compounds for the treatment of several neurologic diseases, not just epilepsy. The discovered role of the endocannabinoid system in epileptogenesis has provided the basis to investigate the pharmacological use of exogenously produced cannabinoids, to treat epilepsy. Although, physicians show reluctance to recommend Cannabis extracts given the lack of high-quality safety available data, from literature data cannabidiol (CBD) results to be a promising and safe anticonvulsant drug with low side-effect. In particular, according to early studies, CBD can reduce the frequency of seizures and lead to improvements in quality of life in children affected by refractory epilepsy. So, for these reasons, the detailed study of the interactions between CBD and anticonvulsant drugs (AEDs) administered simultaneously in polytherapy, is arousing increasing interest, to clarify and to assess the incidence of adverse effects and the relation between dose escalation and quality of life measures. To date, in pediatric age, CBD efficacy and safety is not supported by well-designed trials and strong scientific evidence are not available. These studies are either retrospective or small-scale observational and only during the last years Class I evidence data for a pure form of CBD have been available, as demonstrated in placebo-controlled RCTs for patients affected by Lennox-Gastaut syndrome and Dravet syndrome. It is necessary to investigate CBD safety, pharmacokinetics and interaction with other AEDs alongside performing double-blinded placebo-controlled trials to obtain conclusive data on its efficacy and safety in the most frequent epilepsies in children, not just in the epileptic encephalopathy. This review was aimed to revise the available data to describe the scientific evidence for CBD in Pediatric Epilepsies.
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Affiliation(s)
- Umberto Raucci
- Pediatric Emergency Department, Bambino Gesù Children's Hospital, Istituto di Ricerca e Cura a Carattere Scientifico, Rome, Italy
| | - Nicola Pietrafusa
- Rare and Complex Epilepsy Unit, Department of Neuroscience and Neurorehabilitation, Member of European Reference Network EpiCare, Bambino Gesù Children's Hospital, Istituto di Ricerca e Cura a Carattere Scientifico, Rome, Italy
| | - Maria Chiara Paolino
- Child Neurology, Chair of Pediatrics, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Giovanni Di Nardo
- Child Neurology, Chair of Pediatrics, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Maria Pia Villa
- Child Neurology, Chair of Pediatrics, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Piero Pavone
- Department of Clinical and Experimental Medicine, Section of Paediatrics & Child Neuropsychiatry, Catania University, Catania, Italy
| | - Gianluca Terrin
- Department of Gynecological Obstetric and Urological Sciences, Faculty of Medicine and Dentistry, Sapienza University of Rome, Rome, Italy
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience and Neurorehabilitation, Member of European Reference Network EpiCare, Bambino Gesù Children's Hospital, Istituto di Ricerca e Cura a Carattere Scientifico, Rome, Italy
| | - Pasquale Striano
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 'G. Gaslini' Institute, Genova, Italy
| | - Pasquale Parisi
- Child Neurology, Chair of Pediatrics, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
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Menezes LFS, Sabiá Júnior EF, Tibery DV, Carneiro LDA, Schwartz EF. Epilepsy-Related Voltage-Gated Sodium Channelopathies: A Review. Front Pharmacol 2020; 11:1276. [PMID: 33013363 PMCID: PMC7461817 DOI: 10.3389/fphar.2020.01276] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/31/2020] [Indexed: 12/29/2022] Open
Abstract
Epilepsy is a disease characterized by abnormal brain activity and a predisposition to generate epileptic seizures, leading to neurobiological, cognitive, psychological, social, and economic impacts for the patient. There are several known causes for epilepsy; one of them is the malfunction of ion channels, resulting from mutations. Voltage-gated sodium channels (NaV) play an essential role in the generation and propagation of action potential, and malfunction caused by mutations can induce irregular neuronal activity. That said, several genetic variations in NaV channels have been described and associated with epilepsy. These mutations can affect channel kinetics, modifying channel activation, inactivation, recovery from inactivation, and/or the current window. Among the NaV subtypes related to epilepsy, NaV1.1 is doubtless the most relevant, with more than 1500 mutations described. Truncation and missense mutations are the most observed alterations. In addition, several studies have already related mutated NaV channels with the electrophysiological functioning of the channel, aiming to correlate with the epilepsy phenotype. The present review provides an overview of studies on epilepsy-associated mutated human NaV1.1, NaV1.2, NaV1.3, NaV1.6, and NaV1.7.
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Affiliation(s)
- Luis Felipe Santos Menezes
- Laboratório de Neurofarmacologia, Departamento de Ciências Fisiológicas, Universidade de Brasília, Brasília, Brazil
| | - Elias Ferreira Sabiá Júnior
- Laboratório de Neurofarmacologia, Departamento de Ciências Fisiológicas, Universidade de Brasília, Brasília, Brazil
| | - Diogo Vieira Tibery
- Laboratório de Neurofarmacologia, Departamento de Ciências Fisiológicas, Universidade de Brasília, Brasília, Brazil
| | - Lilian Dos Anjos Carneiro
- Faculdade de Medicina, Centro Universitário Euro Americano, Brasília, Brazil.,Faculdade de Medicina, Centro Universitário do Planalto Central, Brasília, Brazil
| | - Elisabeth Ferroni Schwartz
- Laboratório de Neurofarmacologia, Departamento de Ciências Fisiológicas, Universidade de Brasília, Brasília, Brazil
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41
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Strzelczyk A, Schubert-Bast S. Therapeutic advances in Dravet syndrome: a targeted literature review. Expert Rev Neurother 2020; 20:1065-1079. [PMID: 32799683 DOI: 10.1080/14737175.2020.1801423] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Dravet syndrome (DS), a prototypic developmental and genetic epileptic encephalopathy (DEE), is characterized by an early onset of treatment-refractory seizures, together with impairments in motor control, behavior, and cognition. Even with multiple conventional anti-epileptic drugs, seizures remain poorly controlled, and there has been a considerable unmet need for effective and tolerable treatments. AREAS COVERED This targeted literature review aims to highlight recent changes to the therapeutic landscape for DS by summarizing the most up-to-date, evidence-based research, including pivotal data from the clinical development of stiripentol, cannabidiol, and fenfluramine, which are important milestones for DS treatment, together with the latest findings of other pharmacotherapies in development. In phase III, double-blind, placebo-controlled randomized controlled trials stiripentol, cannabidiol, and fenfluramine have shown clinically relevant reductions in convulsive seizure frequency, and are generally well tolerated. Stiripentol was associated with responder rates (greater than 50% reduction in convulsive seizure frequency) of 67%-71%, when added to valproic acid and clobazam; cannabidiol was associated with responder rates of 43%-49% (48%-63% in conjunction with clobazam), and fenfluramine of 54%-68% across studies. Therapies in development include soticlestat, ataluren, verapamil, and clemizole, with strategies to treat the underlying cause of DS, including gene therapy and antisense oligonucleotides beginning to emerge from preclinical studies. EXPERT OPINION Despite the challenges of drug development in rare diseases, this is an exciting time for the treatment of DS, with the promise of new efficacious and well-tolerated therapies, which may pave the way for treatment advances in other DEEs.
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Affiliation(s)
- Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt , Frankfurt am Main, Germany.,LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt , Frankfurt am Main, Germany
| | - Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt , Frankfurt am Main, Germany.,LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt , Frankfurt am Main, Germany.,Department of Neuropediatrics, Goethe-University Frankfurt , Frankfurt am Main, Germany
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Cannabidiol Determination on Peripheral Capillary Blood Using a Microsampling Method and Ultra-High-Performance Liquid Chromatography Tandem Mass Spectrometry with On-Line Sample Preparation. Molecules 2020; 25:molecules25163608. [PMID: 32784413 PMCID: PMC7464345 DOI: 10.3390/molecules25163608] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/04/2020] [Accepted: 08/06/2020] [Indexed: 02/04/2023] Open
Abstract
The aim of this work is to evaluate volumetric absorptive microsampling (VAMS) from capillary blood as an alternative strategy for therapeutic drug monitoring (TDM) in patients treated with the newly available GW-purified form of cannabidiol (Epidiolex®). A fast ultra-high-performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) coupled to an online sample preparation system analysis was carried out on a Thermo Scientific Ultimate 3000 LC system coupled to a TSQ Quantiva triple quadrupole for the quantification of cannabidiol (CBD) and, in addition, delta-9-tetrahydrocannabinol (Δ9-THC). After validation using European Medicine Agency (EMA) guidelines the method was applied to samples obtained by finger prick of five pediatric patients treated with Epidiolex® and the results were compared to those obtained from venous blood and plasma. The method is linear in the range of 1–800 µg/L for both CBD and THC with intra- and inter-day precisions ranging from 5% to 14% and accuracies from −13% to +14% starting from 30 µL of sample. Stability in VAMS is ensured for up to 4 weeks at 25 °C thus allowing simple delivery. There was no difference (p = 0.69) between concentrations of CBD measured from VAMS sampled from capillary or venous blood (range: 52.19–330.14 or 72.15–383.45 µg/L) and those obtained from plasma (range: 64.3–374.09 µg/L) The VAMS-LC-MS/MS method represents a valid alternative strategy for therapeutic drug monitoring of patients treated with Epidiolex®.
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Tallon MJ. Cannabis sativa L. and Its Extracts: Regulation of Cannabidiol in the European Union and United Kingdom. J Diet Suppl 2020; 17:503-516. [DOI: 10.1080/19390211.2020.1795044] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Mark J. Tallon
- Legal Foods Ltd., Cambridgeshire Business Park, Cambridgeshire, UK
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Caraballo R, Demirdjian G, Reyes G, Huaman M, Gutierrez R. Effectiveness of cannabidiol in a prospective cohort of children with drug-resistant epileptic encephalopathy in Argentina. Seizure 2020; 80:75-80. [DOI: 10.1016/j.seizure.2020.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/31/2020] [Accepted: 06/02/2020] [Indexed: 01/25/2023] Open
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Marchese F, Vari MS, Balagura G, Riva A, Salpietro V, Verrotti A, Citraro R, Lattanzi S, Minetti C, Russo E, Striano P. An Open Retrospective Study of a Standardized Cannabidiol Based-Oil in Treatment-Resistant Epilepsy. Cannabis Cannabinoid Res 2020; 7:199-206. [PMID: 33998856 PMCID: PMC9070734 DOI: 10.1089/can.2019.0082] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Introduction: Cannabidiol (CBD) has antiseizure properties but no psychoactive effects. Randomized controlled trials of an oral, pharmaceutical formulation of highly purified CBD are promising; however, data regarding other formulations are sparse and anecdotal. We evaluated the effectiveness of add-on therapy with a standardized CBD-based oil in treatment-resistant epilepsy (TRE) patients. Materials and Methods: An open retrospective study was carried out on patients with refractory epilepsy of different etiology. We reviewed clinical data from medical charts and caregiver's information. Participants received add-on with 24% CBD-based oil, sublingually administered, at the starting dose of 5–10 mg/[kg·day] up to the maximum dose of 50 mg/[kg·day], based on clinical efficacy. Efficacy was evaluated based on patients being seizure free or experiencing at ≥50% improvement on seizure frequency. Tolerability and suspected adverse drug reaction data were also analyzed. Results: We included 37 patients (46% female) with a median age of 16.1 (range: 2–54) years. Twenty-two (60%) patients suffered from epileptic encephalopathy, 9 (24%) from focal epilepsy, and 6 (16%) from generalized epilepsy. Mean follow-up duration was 68 (range: 24–72) weeks. The average age at seizure onset was 3.8±2.1 years (range: 7 days–21 years). The median achieved CBD-based oil dose was 4.2±11.4 (range: 0.6–50) mg/[kg·day]. At 40-month follow-up, 7 (19%) patients were seizure free, 27 (73%) reported >50% improvement, 2 (5%) patients reported <50% improvement, and 1 patient discontinued therapy due to lack of efficacy. Weaning from concomitant antiepileptic drugs was obtained after 24 weeks from CBD introduction in 10 subjects. Mild and transitory adverse events, including somnolence or loss of appetite, occurred in nine (25%) patients. Discussion and Conclusion: We showed the efficacy of a CBD-based oil formulation with few significant side effects in patients with TRE of various etiologies.
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Affiliation(s)
- Francesca Marchese
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Maria Stella Vari
- Paediatric Neurology and Muscular Disease Unit, IRCCS "Giannina Gaslini" Institute, Genoa, Italy
| | - Ganna Balagura
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Antonella Riva
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Vincenzo Salpietro
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy.,Paediatric Neurology and Muscular Disease Unit, IRCCS "Giannina Gaslini" Institute, Genoa, Italy
| | - Alberto Verrotti
- Department of Pediatrics, University of L'Aquila, L'Aquila, Italy
| | - Rita Citraro
- Department of Science of Health, School of Medicine and Surgery, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Carlo Minetti
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy.,Paediatric Neurology and Muscular Disease Unit, IRCCS "Giannina Gaslini" Institute, Genoa, Italy
| | - Emilio Russo
- Department of Science of Health, School of Medicine and Surgery, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Pasquale Striano
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy.,Paediatric Neurology and Muscular Disease Unit, IRCCS "Giannina Gaslini" Institute, Genoa, Italy
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Lattanzi S, Brigo F, Trinka E. Cannabidiol efficacy and clobazam coadministration: Where do we stand now? Epilepsia 2020; 61:1795-1796. [PMID: 32662877 DOI: 10.1111/epi.16607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 06/17/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Simona Lattanzi
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Francesco Brigo
- Department of Neuroscience, Biomedicine and Movement Science, University of Verona, Verona, Italy.,Division of Neurology, "Franz Tappeiner" Hospital, Merano, Italy
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria.,Center for Cognitive Neuroscience, Salzburg, Austria.,Public Health, Health Services Research and HTA, University for Health Sciences, Medical Informatics and Technology, Hall i.T, Austria
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Lattanzi S, Trinka E, Striano P, Zaccara G, Del Giovane C, Nardone R, Silvestrini M, Brigo F. Cannabidiol efficacy and clobazam status: A systematic review and meta‐analysis. Epilepsia 2020; 61:1090-1098. [DOI: 10.1111/epi.16546] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 04/26/2020] [Accepted: 04/27/2020] [Indexed: 01/11/2023]
Affiliation(s)
- Simona Lattanzi
- Neurological Clinic Department of Experimental and Clinical Medicine Marche Polytechnic University Ancona Italy
| | - Eugen Trinka
- Department of Neurology Christian Doppler Clinic Paracelsus Medical University Salzburg Austria
- Center for Cognitive Neuroscience Salzburg Austria
- Public Health, Health Services Research, and Health Technology Assessment University for Health Sciences, Medical Informatics, and Technology Hall in Tyrol Austria
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health G. Gaslini Institute University of Genoa Genoa Italy
| | | | - Cinzia Del Giovane
- Institute of Primary Health Care, Bernese Institute of Family Medicine University of Bern Bern Switzerland
| | - Raffaele Nardone
- Department of Neurology Christian Doppler Clinic Paracelsus Medical University Salzburg Austria
- Department of Neuroscience, Biomedicine, and Movement Science University of Verona Verona Italy
| | - Mauro Silvestrini
- Neurological Clinic Department of Experimental and Clinical Medicine Marche Polytechnic University Ancona Italy
| | - Francesco Brigo
- Department of Neuroscience, Biomedicine, and Movement Science University of Verona Verona Italy
- Division of Neurology Franz Tappeiner Hospital Merano Italy
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Dos Santos RG, Guimarães FS, Crippa JAS, Hallak JEC, Rossi GN, Rocha JM, Zuardi AW. Serious adverse effects of cannabidiol (CBD): a review of randomized controlled trials. Expert Opin Drug Metab Toxicol 2020; 16:517-526. [PMID: 32271618 DOI: 10.1080/17425255.2020.1754793] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Recent trials using cannabidiol (CBD) have shown that most acute and prolonged adverse effects of CBD are mild to moderate, with rare serious adverse effects (SAEs). This review focused on analyzing SAEs of CBD and their possible relation to drug-drug interactions. AREAS COVERED We systematically analyzed the SAEs reported in randomized controlled trials (RCTs) involving the administration of oral CBD for at least 1 week in both healthy volunteers and clinical samples. EXPERT OPINION SAEs related to CBD in RCT are rare and include mainly elevated transaminases, convulsion, sedation, lethargy, and upper respiratory tract infections. Elevated transaminases are related to concomitant valproate use, while sedation, lethargy, and upper respiratory tract infections are related to concomitant clobazam use. Epileptic patients should be monitored when using CBD concomitantly with these and other antiepileptic drugs for other possible drug-drug interactions.
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Affiliation(s)
- Rafael G Dos Santos
- Department of Neurosciences and Behavior, Ribeirão Preto Medical School, University of São Paulo , Ribeirão Preto, Brazil.,National Institute of Science and Technology - Translational Medicine , Brazil
| | - Francisco S Guimarães
- National Institute of Science and Technology - Translational Medicine , Brazil.,Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo , Ribeirão Preto, Brazil
| | - José Alexandre S Crippa
- Department of Neurosciences and Behavior, Ribeirão Preto Medical School, University of São Paulo , Ribeirão Preto, Brazil.,National Institute of Science and Technology - Translational Medicine , Brazil
| | - Jaime E C Hallak
- Department of Neurosciences and Behavior, Ribeirão Preto Medical School, University of São Paulo , Ribeirão Preto, Brazil.,National Institute of Science and Technology - Translational Medicine , Brazil
| | - Giordano Novak Rossi
- Department of Neurosciences and Behavior, Ribeirão Preto Medical School, University of São Paulo , Ribeirão Preto, Brazil
| | - Juliana Mendes Rocha
- Department of Neurosciences and Behavior, Ribeirão Preto Medical School, University of São Paulo , Ribeirão Preto, Brazil
| | - Antônio W Zuardi
- Department of Neurosciences and Behavior, Ribeirão Preto Medical School, University of São Paulo , Ribeirão Preto, Brazil.,National Institute of Science and Technology - Translational Medicine , Brazil
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Abstract
BACKGROUND Cenobamate is a novel tetrazole-derived carbamate compound with a dual mechanism of action. This drug can enhance the inactivated state of voltage-gated sodium channels, preferentially inhibiting the persistent component of the sodium channel current, and acts as a positive allosteric modulator of GABAA receptors, binding at a non-benzodiazepine site. OBJECTIVE We assessed the efficacy and safety of adjunctive cenobamate for the treatment of focal-onset seizures in adult patients with epilepsy using meta-analytical techniques. METHODS We systematically searched (May, week 4, 2020) MEDLINE (accessed by PubMed), the Cochrane Central Register of Controlled Trials (CENTRAL), and the US National Institutes of Health Clinical Trials Registry ( http://www.clinicaltrials.gov ). There were no date limitations or language restrictions. Randomized, placebo-controlled, single or double-blinded, add-on trials of cenobamate in adult patients with uncontrolled focal-onset seizures were identified. Main outcomes included the proportion of patients with ≥ 50 and 100% reduction in seizure frequency during the maintenance treatment period compared with baseline and the incidence of treatment withdrawal and adverse events (AEs). Risk ratio (RR) with 95% confidence interval (CI) was estimated for each outcome. RESULTS Two trials were included, overall enrolling 659 patients (442 for the add-on cenobamate group and 217 for the add-on placebo group). Seizure frequency reduction by at least 50% occurred during the maintenance phase in 50.1% of the patients randomized to cenobamate and 23.5% of the placebo-treated participants (RR 2.18, 95% CI 1.67-2.85; p < 0.001). The pooled estimated RR to achieve seizure freedom for the cenobamate group in comparison with placebo was 3.71 (95% CI 1.93-7.14; p < 0.001). Withdrawal from randomized treatment occurred in 16.7 and 11.1% of participants receiving cenobamate and placebo, respectively (RR 1.34, 95% CI 0.85-2.09; p = 0.205). Treatment was discontinued due to AEs in 12.2 and 4.1% of the patients in the active and control arms (RR 2.27, 95% CI 1.08-4.79; p = 0.031). AEs were reported in 76.9 and 66.8% of the patients during treatment with cenobamate and placebo (RR 1.14, 95% CI 1.02-1.26; p = 0.021). The cenobamate-associated AEs included somnolence, dizziness, fatigue, balance disorder, and diplopia. CONCLUSIONS Adjunctive cenobamate in adult patients with uncontrolled focal-onset seizures is associated with a greater reduction in seizure frequency and a higher rate of AEs than placebo.
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Klingenberg C, Mouslet G, Hjalgrim H, Gerstner T. A Survey on Cannabinoid Treatment of Pediatric Epilepsy Among Neuropediatricians in Scandinavia and Germany. Front Pediatr 2020; 8:416. [PMID: 32850532 PMCID: PMC7396558 DOI: 10.3389/fped.2020.00416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 06/16/2020] [Indexed: 11/13/2022] Open
Abstract
Objectives: There is an increasing interest in cannabinoid-based products for the treatment of refractory pediatric epilepsy. However, a licensed cannabidiol (CBD) product was first approved for use by the European regulatory authorities in 2019. We aimed to obtain knowledge about clinical experience and attitudes toward cannabinoid use for epilepsy treatment among neuropediatricians in Scandinavia and Germany in the era before a CBD-product was commercially licensed and available. Study design: An internet-based questionnaire (Survey Monkey) was distributed by email to members of neuropediatric societies in Sweden, Germany, Denmark, and Norway between February and April 2018. One reminder email was sent. Results: Eighty-six responded. Only 10 of 86 (12%) respondents had personal experience with off-label prescription of cannabinoid-based products, mainly for severe refractory pediatric epilepsies like Dravet syndrome and Lennox-Gastaut syndrome. However, 49 respondents (57%) had been exposed to relatives of patients that had requested or wanted to discuss cannabinoid therapy, and 32 (37%) respondents knew about cannabinoid self-medication. The knowledge regarding cannabinoid-based therapy among the respondents was overall limited. Main reasons for not prescribing cannabinoid-based therapy were concerns about law regulations and lack of an available product. Conclusion: Off-label cannabinoid-based therapy for pediatric epilepsy was not widely prescribed by neuropediatricians in Scandinavia and Germany in 2018.
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Affiliation(s)
- Claus Klingenberg
- Paediatric Research Group, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway.,Department of Paediatrics and Adolescent Medicine, University Hospital of North-Norway, Tromsø, Norway
| | - George Mouslet
- Paediatric Research Group, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
| | | | - Thorsten Gerstner
- Department of Child Neurology and Rehabilitation (HABU-A), Sørlandet Hospital, Arendal, Norway
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