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Espinosa-Jovel C, Riveros S, Acosta-Amaya A, García C. Use of artisanal and non-regulated cannabis-based products for the treatment of epilepsy in a low-income population. Epilepsy Behav 2024; 159:109942. [PMID: 39121749 DOI: 10.1016/j.yebeh.2024.109942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 07/05/2024] [Accepted: 07/07/2024] [Indexed: 08/12/2024]
Abstract
INTRODUCTION Several artisanal and non-regulated cannabis-based products used for the treatment of epilepsy are available and can be easily obtained. Many of these preparations lack proper quality validation and exhibit cannabinoid contents significantly different from those stated on their labels, along with the presence of potentially harmful compounds. This study aims to evaluate the frequency of use and prescription patterns of these products among patients with epilepsy from a low-income population. METHODS Observational and cross-sectional study. A survey was conducted on patients with epilepsy at a public hospital in Bogotá, Colombia. RESULTS A total of 380 patients were evaluated, with 10.3 % (n = 39) reporting the use of artisanal and non-regulated cannabis-based products for the treatment of epilepsy. Among these patients, 84.6 % (n = 33) used the product on their own initiative, without a medical recommendation. Only 7.7 % (n = 3) of the patients had a record of the consumption of these products in their medical history. Age (p = 0.002), type of therapeutic response (p = 0.01), number of previous antiseizure medications used (p < 0.01), and non-pharmacological treatment such as vagal nerve stimulation (p < 0.01) showed a statistically significant association with the utilization of these products. CONCLUSION One in ten patients with epilepsy has used artisanal and non-regulated cannabis-based products for the treatment of their condition. The majority of patients used these products on their own initiative, without a medical recommendation. The prevalence of consuming these products was higher among younger individuals with uncontrolled epilepsy, who had previously used multiple antiseizure medications and other non-pharmacological alternatives such as vagal nerve stimulation.
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Affiliation(s)
- Camilo Espinosa-Jovel
- Epilepsy Program, Hospital de Kennedy, Subred de Servicios de Salud Sur Occidente, Bogotá, Colombia; Neurology Posgraduate Program, Universidad de la Sabana, Chía, Colombia.
| | - Sandra Riveros
- Epilepsy Program, Hospital de Kennedy, Subred de Servicios de Salud Sur Occidente, Bogotá, Colombia; Neurology Posgraduate Program, Universidad de la Sabana, Chía, Colombia
| | - Angela Acosta-Amaya
- Epilepsy Program, Hospital de Kennedy, Subred de Servicios de Salud Sur Occidente, Bogotá, Colombia
| | - Camila García
- Neurology Posgraduate Program, Universidad de la Sabana, Chía, Colombia
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2
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Mulla SA, Patil A, Mali S, Jain AK, Jaiswal H, Sawant HR, Arvind R, Singh S. Unleashing the therapeutic role of cannabidiol in dentistry. J Oral Biol Craniofac Res 2024; 14:649-654. [PMID: 39296277 PMCID: PMC11409039 DOI: 10.1016/j.jobcr.2024.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2024] [Accepted: 09/02/2024] [Indexed: 09/21/2024] Open
Abstract
Cannabidiol (CBD) found in Cannabis sativa is a non-psychoactive compound which is capable of binding to CB1 and CB2 receptors. CBD has recently gained interest in dentistry although it has not been explored sufficiently yet. The therapeutic effects of CBD include anti-inflammatory, analgesic, antioxidant, biological and osteoinductive properties. The aim of this review is to highlight these effects with respect to various oral conditions and shed light on the current limitations and prospects for the use of CBD in maintaining oral health.
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Affiliation(s)
- Sayem Anwarhussain Mulla
- Department of Dentistry, Bharati Vidyapeeth (Deemed to be University), Dental College and Hospital, Navi Mumbai, Maharashtra, India, 400614
| | - Amit Patil
- Department of Conservative Dentistry and Endodontics, Bharati Vidyapeeth (Deemed to be University), Dental College and Hospital, Navi Mumbai, Maharashtra, India, 400614
| | - Sheetal Mali
- Department of Conservative Dentistry and Endodontics, Bharati Vidyapeeth (Deemed to be University), Dental College and Hospital, Navi Mumbai, Maharashtra, India, 400614
| | - Ashish K Jain
- Department of Conservative Dentistry and Endodontics, Bharati Vidyapeeth (Deemed to be University), Dental College and Hospital, Navi Mumbai, Maharashtra, India, 400614
| | - Himmat Jaiswal
- Department of Conservative Dentistry and Endodontics, Bharati Vidyapeeth (Deemed to be University), Dental College and Hospital, Navi Mumbai, Maharashtra, India, 400614
| | - Hitesh Ramdas Sawant
- Department of Orthodontics and Dentofacial Orthopaedics, Bharati Vidyapeeth (Deemed to be University), Dental College and Hospital, Navi Mumbai, Maharashtra, India, 400614
| | - Ritvi Arvind
- Department of Conservative Dentistry and Endodontics, Bharati Vidyapeeth (Deemed to be University), Dental College and Hospital, Navi Mumbai, Maharashtra, India, 400614
| | - Shruti Singh
- Department of Dentistry, Bharati Vidyapeeth (Deemed to be University), Dental College and Hospital, Navi Mumbai, Maharashtra, India, 400614
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Giorgi S, Auvin S, Schoonjans AS, Turón E, Sánchez-Miranda I, Gil-Nagel A, Lagae L, Aibar JÁ. A tool for Dravet syndrome-associated neuropsychiatric comorbidities evaluation (DANCE). Epilepsy Behav 2024; 158:109958. [PMID: 39067307 DOI: 10.1016/j.yebeh.2024.109958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 07/19/2024] [Accepted: 07/19/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Dravet syndrome (DS) is a rare and severe form of epilepsy that begins in infancy, which is primarily caused by pathogenic variants in the SCN1A gene. DS is characterized by prolonged and frequent drug-resistant seizures, as well as developmental delays and behavioral problems. The identification of these comorbidities is based on clinical interview and relies on healthcare professionals (HCPs) experience. METHODS We assembled a group of expert HCPs and caregivers to create a screening checklist for assessing DS-Associated Neuropsychiatric Comorbidities (DANC). The checklist includes questions related to cognitive and psychiatric domains, motor skills, and the impact of DS on families' daily lives. We administered the checklist to 24 caregivers of DS patients from Belgium, France, and Spain. After piloting, we obtained feedback from expert HCPs and caregivers to refine the checklist. RESULTS DS patients showed a wide array of neuropsychiatric symptoms related to DS. The most common cognitive domains reported were attention difficulties and multitasking problems (18/24 caregivers), and impulsivity (17/24), while the most common psychiatric symptoms were temper tantrums (14/24), mood swings (13/24) and autism spectrum disorder (12/24). Balance and coordination problem have been reported in almost all patients with a statement of only 4/23 with complete mobility. Most patients were dependent on others for self-care and eating, and presented sleeping disturbances. Caregivers reported high levels of stress in the family unit, both between siblings and parents. Results show that the main concerns of parents were the behavior and the cognition of the person with DS. The quantitative feedback results showed good-to-very good scores on usefulness, ease of completion, clarity and comprehensiveness of the checklist. CONCLUSIONS This pilot study suggests that the DANCE checklist could be a useful screening tool in daily practice for neuropsychiatric comorbidities facilitating their diagnosis and treatment, and empowering both caregivers and patients.
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Affiliation(s)
| | - Stéphane Auvin
- Université Paris Cité, INSERM NeuroDiderot, Paris, France; APHP, Robert Debré University Hospital, Pediatric Neurology Department, CRMR epilepsies rares, EpiCare member, Paris, France; Institut Universitaire de France (IUF), Paris, France
| | | | - Eulalia Turón
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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Riva A, D'Onofrio G, Pisati A, Roberti R, Amadori E, Bosch F, de Souza CFM, Thomas A, Russo E, Striano P, Bayat A. Cannabidiol Add-On in Glycosylphosphatidylinositol-Related Drug-Resistant Epilepsy. Cannabis Cannabinoid Res 2024; 9:990-995. [PMID: 36862522 DOI: 10.1089/can.2022.0255] [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: 03/03/2023] Open
Abstract
Background: Glycosylphosphatidylinositol-anchored protein deficiencies (GPI-ADs) are commonly associated with drug-resistant epilepsy (DRE). Cannabidiol (CBD) is approved for the adjunctive treatment of seizures in Dravet/Lennox-Gastaut Syndromes and Tuberous Sclerosis Complex. We report on the efficacy and safety of CBD for the treatment of DRE in patients with genetically proven GPI-AD. Patients and Methods: Patients received add-on treatment with purified GW-pharma CBD (Epidyolex®). Efficacy endpoints were the percentage of patients with ≥50% (responders) or >25<50% (partial responders) reduction in monthly seizures from baseline and at 12 (M12) months of follow-up. Safety was evaluated through adverse events (AEs) monitoring. Results: Six patients (5 males) were enrolled. The median age at seizures onset was 5 months and the syndromic diagnosis was early infantile developmental and epileptic encephalopathy in 4 patients and focal non-lesional epilepsy or GEFS+ in one patient each. Five out of six (83%) patients were responders at M12, while one was a partial responder. No severe AEs were reported. Mean prescribed CBD dose was 17.85 mg/kg/day and median treatment duration is currently 27 months. Conclusions: In summary, off-label treatment with CBD was effective and safe in patients with DRE due to GPI-ADs.
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Affiliation(s)
- Antonella Riva
- 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
| | - Gianluca D'Onofrio
- 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
| | - Angelica Pisati
- Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto "Giannina Gaslini," Genoa, Italy
| | - Roberta Roberti
- Department of Science of Health, School of Medicine, University of Catanzaro, Catanzaro, Italy
| | - Elisabetta Amadori
- 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
| | | | | | | | - Emilio Russo
- Department of Science of Health, School of Medicine, University of Catanzaro, Catanzaro, 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
| | - Allan Bayat
- Department of Epilepsy Genetics and Personalized Medicine, Danish Epilepsy Center, Dianalund, Denmark
- Institute for Regional Health Services, University of Southern Denmark, Odense, Denmark
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Devinsky O, Hyland K, Loftus R, Nortvedt C, Nabbout R. Placebo response in patients with Dravet syndrome: Post-hoc analysis of two clinical trials. Epilepsy Behav 2024; 156:109805. [PMID: 38677101 DOI: 10.1016/j.yebeh.2024.109805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 04/18/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVE Dravet syndrome is a rare, early childhood-onset epileptic and developmental encephalopathy. Responses to placebo in clinical trials for epilepsy therapies range widely, but factors influencing placebo response remain poorly understood. This study explored placebo response and its effects on safety, efficacy, and quality of life outcomes in patients with Dravet syndrome. METHODS We performed exploratory post-hoc analyses of pooled data from placebo-treated patients from the GWPCARE 1B and GWPCARE 2 randomized controlled phase III trials, comparing cannabidiol and matched placebo in 2-18 year old Dravet syndrome patients. All patients had ≥4 convulsive seizures during a baseline period of 4 weeks. RESULTS 124 Dravet syndrome-treated patients were included in the analysis (2-5 years: n = 35; 6-12 years: n = 52; 13-18 years: n = 37). Convulsive seizures were experienced by all placebo group patients at all timepoints, with decreased median convulsive seizure frequency during the treatment period versus baseline; the number of convulsive seizure-free days was similar to baseline. Convulsive seizure frequency had a nominally significant positive correlation with age and a nominally significant negative correlation with body mass index. Most placebo-treated patients experienced a treatment-emergent adverse event; however, most resolved quickly, and serious adverse events were infrequent. Placebo treatment had very little effect on reported Caregiver Global Impression of Change outcomes versus baseline. INTERPRETATION Placebo had little impact on convulsive seizure-free days and Caregiver Global Impression of Change versus baseline, suggesting that these metrics may help differentiate placebo and active treatment effects in future studies. However, future research should further assess placebo responses to confirm these results.
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Affiliation(s)
- Orrin Devinsky
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | | | | | | | - Rima Nabbout
- Department of Pediatric Neurology, Necker Enfants Malades Hospital, APHP, Reference Centre for Rare Epilepsies and Member of the ERN EpiCARE, Imagine Institute UMR1163, Université Paris Cité, Paris, France
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Mannini E, Misirocchi F, Lazzari S, Balella G, Bottignole D, Frapporti M, Zinno L, Florindo I, Parrino L, Mutti C. Off-label use of cannabidiol in genetic epileptic and developmental encephalopathies: A case report. Epilepsy Behav Rep 2024; 27:100687. [PMID: 39040437 PMCID: PMC11261414 DOI: 10.1016/j.ebr.2024.100687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 06/14/2024] [Accepted: 06/18/2024] [Indexed: 07/24/2024] Open
Abstract
Developmental Epileptic encephalopathies (DEEs) are severe neurological conditions where cognitive functions appear modulated by both seizure and interictal epileptiform activity. Cannabidiol (CBD) has been shown to be highly effective in the treatment of drug-resistant seizures in patients with DEEs. Along with its antiseizure effects, CBD demonstrated clinical beneficial effects in patients' quality of life, sleep and numerous adaptive behaviors. However, based on the available phase III studies, the indications for this treatment have so far been restricted to Lennox-Gastaut syndrome (LGS), Dravet syndrome (DS) and tuberous sclerosis complex (TSC) by regulatory authorities. We present the case of a 30-year-old girl with a rare genetic DEE, experiencing relevant seizure frequency reduction together with striking improvement in sleep quality, mood, behavior, language and motor skills after introducing off-label CBD.
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Affiliation(s)
- Elisa Mannini
- Neurology Unit, Department of General and Specialized Medicine, Parma University Hospital, Parma, Italy
| | - Francesco Misirocchi
- Neurology Unit, Department of General and Specialized Medicine, Parma University Hospital, Parma, Italy
| | - Stefania Lazzari
- Neurology Unit, Department of General and Specialized Medicine, Parma University Hospital, Parma, Italy
| | - Giulia Balella
- Neurology Unit, Department of General and Specialized Medicine, Parma University Hospital, Parma, Italy
| | - Dario Bottignole
- Neurology Unit, Department of General and Specialized Medicine, Parma University Hospital, Parma, Italy
| | - Maddalena Frapporti
- Neurology Unit, Department of General and Specialized Medicine, Parma University Hospital, Parma, Italy
| | - Lucia Zinno
- Neurology Unit, Department of General and Specialized Medicine, Parma University Hospital, Parma, Italy
- Interdepartmental Centre for Sleep Medicine, University of Parma, Italy
| | - Irene Florindo
- Neurology Unit, Department of General and Specialized Medicine, Parma University Hospital, Parma, Italy
- Interdepartmental Centre for Sleep Medicine, University of Parma, Italy
| | - Liborio Parrino
- Neurology Unit, Department of General and Specialized Medicine, Parma University Hospital, Parma, Italy
- Sleep Disorders Center, Department of Medicine and Surgery, Parma University Hospital, Parma, Italy
- Interdepartmental Centre for Sleep Medicine, University of Parma, Italy
| | - Carlotta Mutti
- Neurology Unit, Department of General and Specialized Medicine, Parma University Hospital, Parma, Italy
- Sleep Disorders Center, Department of Medicine and Surgery, Parma University Hospital, Parma, Italy
- Interdepartmental Centre for Sleep Medicine, University of Parma, Italy
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Barker H, Ferraro MJ. Exploring the versatile roles of the endocannabinoid system and phytocannabinoids in modulating bacterial infections. Infect Immun 2024; 92:e0002024. [PMID: 38775488 PMCID: PMC11237442 DOI: 10.1128/iai.00020-24] [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] [Indexed: 06/12/2024] Open
Abstract
The endocannabinoid system (ECS), initially identified for its role in maintaining homeostasis, particularly in regulating brain function, has evolved into a complex orchestrator influencing various physiological processes beyond its original association with the nervous system. Notably, an expanding body of evidence emphasizes the ECS's crucial involvement in regulating immune responses. While the specific role of the ECS in bacterial infections remains under ongoing investigation, compelling indications suggest its active participation in host-pathogen interactions. Incorporating the ECS into the framework of bacterial pathogen infections introduces a layer of complexity to our understanding of its functions. While some studies propose the potential of cannabinoids to modulate bacterial function and immune responses, the outcomes inherently hinge on the specific infection and cannabinoid under consideration. Moreover, the bidirectional relationship between the ECS and the gut microbiota underscores the intricate interplay among diverse physiological processes. The ECS extends its influence far beyond its initial discovery, emerging as a promising therapeutic target across a spectrum of medical conditions, encompassing bacterial infections, dysbiosis, and sepsis. This review comprehensively explores the complex roles of the ECS in the modulation of bacteria, the host's response to bacterial infections, and the dynamics of the microbiome. Special emphasis is placed on the roles of cannabinoid receptor types 1 and 2, whose signaling intricately influences immune cell function in microbe-host interactions.
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Affiliation(s)
- Hailey Barker
- Microbiology and Cell Science Department, IFAS, University of Florida, Gainesville, Florida, USA
| | - Mariola J. Ferraro
- Microbiology and Cell Science Department, IFAS, University of Florida, Gainesville, Florida, USA
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Sanil K, Almotairy A, Uttreja P, Ashour EA. Formulation Development and Evaluation of Cannabidiol Hot-Melt Extruded Solid Self-Emulsifying Drug Delivery System for Oral Applications. AAPS PharmSciTech 2024; 25:136. [PMID: 38862810 DOI: 10.1208/s12249-024-02857-z] [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: 02/27/2024] [Accepted: 05/30/2024] [Indexed: 06/13/2024] Open
Abstract
Cannabidiol (CBD) is a highly lipophilic compound with poor oral bioavailability, due to poor aqueous solubility and extensive pre-systemic metabolism. The aim of this study was to explore the potential of employing Hot Melt Extrusion (HME) technology for the continuous production of Self Emulsifying Drug Delivery Systems (SEDDS) to improve the solubility and in vitro dissolution performance of CBD. Accordingly, different placebos were processed through HME in order to obtain a lead CBD loaded solid SEDDS. Two SEDDS were prepared with sesame oil, Poloxamer 188, Gelucire®59/14, PEO N80 and Soluplus®. Moreover, Vitamin E was added as an antioxidant. The SEDDS formulations demonstrated emulsification times of 9.19 and 9.30 min for F1 and F2 respectively. The formed emulsions showed smaller droplet size ranging from 150-400 nm that could improve lymphatic uptake of CBD and reduce first pass metabolism. Both formulations showed significantly faster in vitro dissolution rate (90% for F1 and 83% for F2) compared to 14% for the pure CBD within the first hour, giving an enhanced release profile. The formulations were tested for stability over a 60-day time period at 4°C, 25°C, and 40°C. Formulation F1 was stable over the 60-day time-period at 4°C. Therefore, the continuous HME technology could replace conventional methods for processing SEDDS and improve the oral delivery of CBD for better therapeutic outcomes.
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Affiliation(s)
- Kavish Sanil
- Department of Pharmaceutics and Drug Delivery, School of Pharmacy, The University of Mississippi, University, Mississippi, 38677, USA
| | - Ahmed Almotairy
- Pharmaceutics and Pharmaceutical Technology Department, College of Pharmacy, Taibah University, Al Madinah AlMunawarah, 30001, Saudi Arabia
| | - Prateek Uttreja
- Department of Pharmaceutics and Drug Delivery, School of Pharmacy, The University of Mississippi, University, Mississippi, 38677, USA
| | - Eman A Ashour
- Department of Pharmaceutics and Drug Delivery, School of Pharmacy, The University of Mississippi, University, Mississippi, 38677, USA.
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Zhu K, Chen S, Qin X, Bai W, Hao J, Xu X, Guo H, Bai H, Yang Z, Wang S, Zhao Z, Ji T, Kong D, Zhang W. Exploring the therapeutic potential of cannabidiol for sleep deprivation-induced hyperalgesia. Neuropharmacology 2024; 249:109893. [PMID: 38428482 DOI: 10.1016/j.neuropharm.2024.109893] [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: 12/13/2023] [Revised: 02/21/2024] [Accepted: 02/26/2024] [Indexed: 03/03/2024]
Abstract
Hyperalgesia resulting from sleep deprivation (SD) poses a significant a global public health challenge with limited treatment options. The nucleus accumbens (NAc) plays a crucial role in the modulation of pain and sleep, with its activity regulated by two distinct types of medium spiny neurons (MSNs) expressing dopamine 1 or dopamine 2 (D1-or D2) receptors (referred to as D1-MSNs and D2-MSNs, respectively). However, the specific involvement of the NAc in SD-induced hyperalgesia remains uncertain. Cannabidiol (CBD), a nonpsychoactive phytocannabinoid, has demonstrated analgesic effects in clinical and preclinical studies. Nevertheless, its potency in addressing this particular issue remains to be determined. Here, we report that SD induced a pronounced pronociceptive effect attributed to the heightened intrinsic excitability of D2-MSNs within the NAc in Male C57BL/6N mice. CBD (30 mg/kg, i.p.) exhibited an anti-hyperalgesic effect. CBD significantly improved the thresholds for thermal and mechanical pain and increased wakefulness by reducing delta power. Additionally, CBD inhibited the intrinsic excitability of D2-MSNs both in vitro and in vivo. Bilateral microinjection of the selective D2 receptor antagonist raclopride into the NAc partially reversed the antinociceptive effect of CBD. Thus, these findings strongly suggested that SD activates NAc D2-MSNs, contributing heightened to pain sensitivity. CBD exhibits antinociceptive effects by activating D2R, thereby inhibiting the excitability of D2-MSNs and promoting wakefulness under SD conditions.
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Affiliation(s)
- Kangsheng Zhu
- Department of Pharmacology of Chinese Materia Medica, Institution of Chinese Integrative Medicine, School of Chinese Integrative Medicine, The Key Laboratory of Neural and Vascular Biology, Ministry of Education, Hebei Medical University, Research Unit of Digestive Tract Microecosystem Pharmacology and Toxicology, Chinese Academy of Medical Sciences, Shijiazhuang, Hebei, 050017, China; Department of Anesthesiology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050011, China
| | - Siruan Chen
- Department of Pharmacology of Chinese Materia Medica, Institution of Chinese Integrative Medicine, School of Chinese Integrative Medicine, The Key Laboratory of Neural and Vascular Biology, Ministry of Education, Hebei Medical University, Research Unit of Digestive Tract Microecosystem Pharmacology and Toxicology, Chinese Academy of Medical Sciences, Shijiazhuang, Hebei, 050017, China
| | - Xia Qin
- Department of Pharmacology of Chinese Materia Medica, Institution of Chinese Integrative Medicine, School of Chinese Integrative Medicine, The Key Laboratory of Neural and Vascular Biology, Ministry of Education, Hebei Medical University, Research Unit of Digestive Tract Microecosystem Pharmacology and Toxicology, Chinese Academy of Medical Sciences, Shijiazhuang, Hebei, 050017, China
| | - Wanjun Bai
- Department of Pharmacy, Hebei General Hospital, Shijiazhuang, Hebei, 050051, China
| | - Jie Hao
- Department of Pharmacology of Chinese Materia Medica, Institution of Chinese Integrative Medicine, School of Chinese Integrative Medicine, The Key Laboratory of Neural and Vascular Biology, Ministry of Education, Hebei Medical University, Research Unit of Digestive Tract Microecosystem Pharmacology and Toxicology, Chinese Academy of Medical Sciences, Shijiazhuang, Hebei, 050017, China
| | - Xiaolei Xu
- School of Nursing, Hebei Medical University, Shijiazhuang, Hebei, 050000, China
| | - Han Guo
- Department of Pharmacology of Chinese Materia Medica, Institution of Chinese Integrative Medicine, School of Chinese Integrative Medicine, The Key Laboratory of Neural and Vascular Biology, Ministry of Education, Hebei Medical University, Research Unit of Digestive Tract Microecosystem Pharmacology and Toxicology, Chinese Academy of Medical Sciences, Shijiazhuang, Hebei, 050017, China
| | - Hui Bai
- Department of Cardiac Ultrasound, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050017, China
| | - Zuxiao Yang
- Department of Pharmacology of Chinese Materia Medica, Institution of Chinese Integrative Medicine, School of Chinese Integrative Medicine, The Key Laboratory of Neural and Vascular Biology, Ministry of Education, Hebei Medical University, Research Unit of Digestive Tract Microecosystem Pharmacology and Toxicology, Chinese Academy of Medical Sciences, Shijiazhuang, Hebei, 050017, China
| | - Sheng Wang
- Hebei Key Laboratory of Neurophysiology, Shijiazhuang, Hebei, 050017, China
| | - Zongmao Zhao
- Department of Neurosurgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050011, China
| | - Tengfei Ji
- Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100050, China
| | - Dezhi Kong
- Department of Pharmacology of Chinese Materia Medica, Institution of Chinese Integrative Medicine, School of Chinese Integrative Medicine, The Key Laboratory of Neural and Vascular Biology, Ministry of Education, Hebei Medical University, Research Unit of Digestive Tract Microecosystem Pharmacology and Toxicology, Chinese Academy of Medical Sciences, Shijiazhuang, Hebei, 050017, China.
| | - Wei Zhang
- Department of Pharmacology of Chinese Materia Medica, Institution of Chinese Integrative Medicine, School of Chinese Integrative Medicine, The Key Laboratory of Neural and Vascular Biology, Ministry of Education, Hebei Medical University, Research Unit of Digestive Tract Microecosystem Pharmacology and Toxicology, Chinese Academy of Medical Sciences, Shijiazhuang, Hebei, 050017, China.
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Pathak S, Jeyabalan JB, Liu K, Cook P, Lange B, Kim S, Nadar R, Ward K, Watts Alexander CS, Kumar A, Dua K, Moore T, Govindasamy J, Dhanasekaran M. Assessing effects of Cannabis on various neuropathologies: A systematic review. J Ayurveda Integr Med 2024; 15:100911. [PMID: 38876946 PMCID: PMC11282377 DOI: 10.1016/j.jaim.2024.100911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 01/12/2024] [Accepted: 02/19/2024] [Indexed: 06/16/2024] Open
Abstract
Natural bioactives possess a wide range of chemical structures that can exert a plethora of pharmacological and toxicological actions, resulting in neuroprotection or neurotoxicity. These pharmacodynamic properties can positively or negatively impact human and animal global healthcare. Remarkably, Ayurvedic botanical Cannabis has been used worldwide by different ethnicities and religions for spiritual, commercial, recreational, nutraceutical, cosmeceutical, and medicinal purposes for centuries. Cannabis-based congeners have been approved by the United States of America's (USA) Food & Drug Administration (FDA) and other global law agencies for various therapeutic purposes. Surprisingly, the strict laws associated with possessing cannabis products have been mitigated in multiple states in the USA and across the globe for recreational use. This has consequently led to a radical escalation of exposure to cannabis-related substances of abuse. However, there is a lacuna in the literature on the acute and chronic effects of Cannabis and its congeners on various neuropathologies. Moreover, in the post-COVID era, there has been a drastic increase in the incidence and prevalence of numerous neuropathologies, leading to increased morbidity and mortality. There is an impending necessity for a safe, economically viable, multipotent, natural bioactive to prevent and treat various neuropathologies. The ayurvedic herb, Cannabis is one of the oldest botanicals known to humans and has been widely used. However, the comprehensive effect of Cannabis on various neuropathologies is not well established. Hence, this review presents effects of Cannabis on various neuropathologies.
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Affiliation(s)
- Suhrud Pathak
- Harrison College of Pharmacy, Auburn University, Auburn, AL, 36849, USA
| | - Jeyaram Bharathi Jeyabalan
- Harrison College of Pharmacy, Auburn University, Auburn, AL, 36849, USA; Department of Pharmacology, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Nilgiris, Ooty, Tamil Nadu, 643 001, India
| | - Keyi Liu
- Harrison College of Pharmacy, Auburn University, Auburn, AL, 36849, USA
| | - Preston Cook
- Harrison College of Pharmacy, Auburn University, Auburn, AL, 36849, USA
| | - Bennett Lange
- Harrison College of Pharmacy, Auburn University, Auburn, AL, 36849, USA
| | - Shannon Kim
- Harrison College of Pharmacy, Auburn University, Auburn, AL, 36849, USA
| | - Rishi Nadar
- Harrison College of Pharmacy, Auburn University, Auburn, AL, 36849, USA
| | - Kiersten Ward
- Harrison College of Pharmacy, Auburn University, Auburn, AL, 36849, USA
| | | | - Ashwani Kumar
- Patanjali Herbal Research Department, Patanjali Research Foundation, Haridwar, 249405, India
| | - Kamal Dua
- Discipline of Pharmacy, Graduate School of Health, University of Technology Sydney, Ultimo, NSW, Australia; Faculty of Health, Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Ultimo, NSW, Australia
| | - Timothy Moore
- Harrison College of Pharmacy, Auburn University, Auburn, AL, 36849, USA
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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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12
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Matricardi S, Scorrano G, Prezioso G, Burchiani B, Di Cara G, Striano P, Chiarelli F, Verrotti A. The latest advances in the pharmacological management of focal epilepsies in children: a narrative review. Expert Rev Neurother 2024; 24:371-381. [PMID: 38433525 DOI: 10.1080/14737175.2024.2326606] [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: 01/22/2024] [Accepted: 02/29/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Focal epilepsy constitutes the most common epilepsy in children, and medical treatment represents the first-line therapy in this condition. The main goal of medical treatment for children and adolescents with epilepsy is the achievement of seizure freedom or, in drug-resistant epilepsies, a significant seizure reduction, both minimizing antiseizure medications (ASM)-related adverse events, thus improving the patient's quality of life. However, up to 20-40% of pediatric epilepsies are refractory to drug treatments. New ASMs came to light in the pediatric landscape, improving the drug profile compared to that of the preexisting ones. Clinicians should consider several factors during the drug choice process, including patient and medication-specific characteristics. AREAS COVERED This narrative review aims to summarize the latest evidence on the effectiveness and tolerability of the newest ASMs administered as monotherapy or adjunctive therapy in pediatric epilepsies with focal onset seizures, providing a practical appraisal based on the existing evidence. EXPERT OPINION The latest ASMs have the potential to be effective in the pharmacological management of focal onset seizures in children, and treatment choice should consider several drug- and epilepsy-related factors. Future treatments should be increasingly personalized and targeted on patient-specific pathways. Future research should focus on discovering new chemical compounds and repurposing medications used for other indications.
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Affiliation(s)
- Sara Matricardi
- Department of Paediatrics, University of Chieti, Chieti, Italy
| | | | | | | | - Giuseppe Di Cara
- Department of Paediatrics, University of Perugia, Perugia, Italy
| | - Pasquale Striano
- Paediatric Neurology and Muscular Disease Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | | | - Alberto Verrotti
- Department of Paediatrics, University of Perugia, Perugia, Italy
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Chico SFV, Diaz DAM, Contreras-Puentes N. Use of cannabidiol in the treatment of drug-refractory epilepsy in children and young adults: A systematic review. J Neurosci Rural Pract 2024; 15:203-210. [PMID: 38746511 PMCID: PMC11090527 DOI: 10.25259/jnrp_618_2023] [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: 12/04/2023] [Accepted: 02/16/2024] [Indexed: 05/16/2024] Open
Abstract
Objectives Epilepsy poses a significant challenge in pediatric and adolescent populations, impacting not only seizures but also psychological and cognitive comorbidities, leading to higher mortality rates than the general population. Drug-refractory epilepsy, resistant to conventional treatments, affects a range of 7-20% of pediatric patients. The search for alternative therapies has led to exploring the therapeutic potential of Cannabis sativa L. compounds, particularly cannabidiol (CBD). Examine the use of CBD for treating drug-refractory epilepsy in children and young adults, summarizing existing evidence on its efficacy. Materials and Methods A systematic review, following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, assessed studies from 2018 to 2023, focusing on CBD's efficacy and safety for treatment-resistant epilepsy in pediatric and juvenile populations. The search spanned seven databases, and the studies underwent rigorous screening and data extraction. Results Out of 6351 identified articles, eight were selected for review. The included studies reported positive outcomes, with CBD leading to a reduction in seizure frequency ranging from 50% to complete seizure freedom. Adverse effects were mostly mild and reversible, including drowsiness, diarrhea, and loss of appetite. Conclusion The CBD emerges as a promising tool for refractory epilepsy in pediatric patients, showing efficacy in reducing seizure frequency and improving overall quality of life. Despite mild and reversible adverse effects, CBD's benefits outweigh the risks. However, more research on long-term effects is needed to fully understand its implications.
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14
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Patel S, Maney K, Morris L, Papadopoulou MT, Prange L, Boggs A, Hunanyan A, Megvinov A, Vavassori R, Panagiotakaki E, Mikati MA. Real life retrospective study of cannabidiol therapy in alternating hemiplegia of childhood. Eur J Paediatr Neurol 2024; 49:55-59. [PMID: 38367370 DOI: 10.1016/j.ejpn.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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 01/15/2024] [Accepted: 02/06/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND Many alternating hemiplegia of childhood (AHC) patients have received Cannabidiol (CBD) but, to our knowledge, there are no published data available. GOALS Test the hypothesis that CBD has favorable effects on AHC spells. METHODS Retrospective review of available data of AHC patients who received CBD. Primary analysis: Clinical Global Impression Scale of Improvement (CGI-I) score for response of AHC spells to CBD with calculation of 95% confidence interval (CI) for rejection of the null hypothesis. Secondary analyses, performed to achieve an understanding of the effect of CBD as compared to flunarizine, were CGI-I scores of 1) epileptic seizures to CBD, 2) AHC spells to flunarizine, 3) epileptic seizures to flunarizine. Also, Mann-Whitney test was done for comparison of CGI-I scores of CBD and flunarizine to both AHC spells and seizures. RESULTS We studied 16 AHC patients seen at Duke University and University of Lyon. CI of CGI-I scores for AHC spells in response to CBD and to flunarizine, each separately, indicated a positive response to each of these two medications: neither overlapped with the null hypothesis score, 4, indicating significant positive responses with p < 0.05 for both. These two scores also did not differ (p = 0.84) suggesting similar efficacy of both: CBD score was 2 ± 1.1 with a 95% CI of 1.5-2.6 and flunarizine score was 2.3 ± 1.3 with a 95% CI of 1.7-3.1. In patients who had seizures, CI calculations indicated a positive effect of CBD on seizure CGI scores but not of flunarizine on seizure scores. CBD was well tolerated with no patients discontinuing it due to side effects and with some reporting positive behavioral changes. CONCLUSION Our study indicates a real-life positive effect of CBD on AHC type spells.
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Affiliation(s)
- Shital Patel
- Duke University Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Durham, NC, USA
| | - Kayli Maney
- Duke University Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Durham, NC, USA
| | - Lauren Morris
- Duke University Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Durham, NC, USA
| | - Maria T Papadopoulou
- Department of Pediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, Member of the ERN EpiCARE, University Hospitals of Lyon (HCL), Lyon, France
| | - Lyndsey Prange
- Duke University Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Durham, NC, USA
| | - April Boggs
- Duke University Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Durham, NC, USA
| | - Arsen Hunanyan
- Duke University Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Durham, NC, USA
| | - Andrey Megvinov
- Euro Mediterranean Institute of Science and Technology I.E.ME.S.T., Palermo, Italy
| | - Rosaria Vavassori
- Euro Mediterranean Institute of Science and Technology I.E.ME.S.T., Palermo, Italy; Association AHC18+ e.V., Member of the EPAG of ERN EpiCARE, Germany
| | - Eleni Panagiotakaki
- Department of Pediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, Member of the ERN EpiCARE, University Hospitals of Lyon (HCL), Lyon, France
| | - Mohamad A Mikati
- Duke University Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Durham, NC, USA.
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15
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Desnous B, Beretti T, Muller N, Neveu J, Villeneuve N, Lépine A, Daquin G, Milh M. Efficacy and tolerance of cannabidiol in the treatment of epilepsy in patients with Rett syndrome. Epilepsia Open 2024; 9:397-403. [PMID: 37485779 PMCID: PMC10839357 DOI: 10.1002/epi4.12796] [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: 04/04/2023] [Accepted: 07/20/2023] [Indexed: 07/25/2023] Open
Abstract
We aim to assess the efficacy and tolerance of cannabidiol as adjunctive therapy for Rett syndrome (RTT) patients with epilepsy. We conducted a longitudinal observational study through a monocentric cohort of 46 patients with RTT. Patients were recruited from March 2020 to October 2022 and were treated with Epidyolex® (cannabidiol, CBD, 100 mg/mL oral solution). In our cohort, 26 patients had associated epilepsy (26/46 [56%]), and 10/26 (38%) were treated with CBD, in combination with clobazam in 50% of cases. The median dose at their last follow-up was 15 mg/kg/day. The median treatment duration was 13 months (range: 1-32 months). CBD reduced the incidence of seizures in seven out of 10 patients (70%) with one seizure-free patient, two patients with a reduction of seizures of more than 75%, and four patients with a decrease of more than 50%. No aggravation of symptoms or adverse effects were observed. Only one patient experienced a transitory drooling and somnolence episode at the CBD initiation. Half of the patients showed a reduction in agitation and/or anxiety attacks, and an improvement in spasticity was reported in 4/10 (40%) of patients. CBD appears to have potential therapeutic value for the treatment of drug-resistant epilepsy in Rett syndrome. CBD is well tolerated and, when used in combination with clobazam, may increase the effectiveness of clobazam alone.
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Affiliation(s)
- Béatrice Desnous
- Pediatric Neurology DepartmentTimone Enfant, APHMMarseilleFrance
| | - Thibault Beretti
- Pediatric Neurology DepartmentTimone Enfant, APHMMarseilleFrance
| | - Nathan Muller
- Pediatric Neurology DepartmentTimone Enfant, APHMMarseilleFrance
| | | | | | - Anne Lépine
- Pediatric Neurology DepartmentTimone Enfant, APHMMarseilleFrance
| | - Géraldine Daquin
- Epileptology and Cerebral Rhythmology DepartmentTimone Adulte, APHMMarseilleFrance
| | - Mathieu Milh
- Pediatric Neurology DepartmentTimone Enfant, APHMMarseilleFrance
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16
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Reyes Valenzuela G, Gallo A, Calvo A, Chacón S, Fasulo L, Galicchio S, Adi J, Fortini PS, Caraballo R. Purified cannabidiol as add-on therapy in children with treatment-resistant infantile epileptic spasms syndrome. Seizure 2024; 115:94-99. [PMID: 38237316 DOI: 10.1016/j.seizure.2024.01.010] [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: 11/02/2023] [Revised: 01/08/2024] [Accepted: 01/14/2024] [Indexed: 02/17/2024] Open
Abstract
OBJECTIVE The aim of this study was to assess efficacy, safety, and tolerability of highly purified cannabidiol oil (CBD) as add-on therapy for the treatment of a series of patients with infantile epileptic spasms syndrome (IESS) who were resistant to antiseizure medications and ketogenic dietary therapy. MATERIAL AND METHODS We conducted a retrospective analysis of the medical records of 28 infants with treatment-resistant IESS aged 6 to 21 months who received highly purified CBD between July 2021 and June 2023. Data were collected on neurological examinations, EEG, Video-EEG and polygraphic recordings, imaging studies, laboratory testing, and seizure frequency, type, and duration, and adverse effects. As the primary outcome, a reduction of frequency of epileptic spasms (ES) was assessed. ES freedom was considered after a minimal time of 1 month without ES. RESULTS Sixteen male and 12 female patients, aged 6-21 months, who received CBD for treatment-resistant IESS were included. The etiology was structural in 10, Down syndrome in seven, genetic in nine, and unknown in two. Initial CBD dose was 2 mg/kg/day, which was uptitrated to a median dose of 25 mg/kg/day (range, 2-50). Prior to CBD initiation, patients had a median of 69 ES in clusters per day (range, 41-75) and of 10 focal seizures per week (range, 7-13). After a mean and median follow-up of 15 and 12.5 months (range, 6-26 months), seven patients were ES free and 12 had a >50 % ES reduction. Five of seven patients (71 %) with Down syndrome and 3/5 (60 %) with cerebral palsy responded well. Adverse effects were mild. EEG improvements correlated with ES reductions. CONCLUSION In this study evaluating the use of CBD in children with IESS, 19/28 (67.8 %) had a more than 50 % ES reduction with good tolerability.
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Affiliation(s)
- Gabriela Reyes Valenzuela
- Department of Neurology, Hospital de Pediatría Juan P Garrahan, Combate de los Pozos, Buenos Aires 1881 Argentina
| | - Adolfo Gallo
- Department of Neurology, Hospital de Pediatría Juan P Garrahan, Combate de los Pozos, Buenos Aires 1881 Argentina
| | - Agustin Calvo
- Department of Pediatric Neurology, Hospital Regional de Comodoro Rivadavia, Argentina
| | | | - Lorena Fasulo
- Department of Neurology, Clinica San Lucas, Neuquen, Argentina
| | | | - Javier Adi
- Department of Pediatric Neurology, Hospital Notti, Mendoza, Argentina
| | - Pablo Sebastian Fortini
- Department of Neurology, Hospital de Pediatría Juan P Garrahan, Combate de los Pozos, Buenos Aires 1881 Argentina
| | - Roberto Caraballo
- Department of Neurology, Hospital de Pediatría Juan P Garrahan, Combate de los Pozos, Buenos Aires 1881 Argentina.
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17
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Hidding U, Mainka T, Buhmann C. Therapeutic use of medical Cannabis in neurological diseases: a clinical update. J Neural Transm (Vienna) 2024; 131:117-126. [PMID: 38015317 PMCID: PMC10791790 DOI: 10.1007/s00702-023-02719-1] [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: 09/10/2023] [Accepted: 10/31/2023] [Indexed: 11/29/2023]
Abstract
The use of medical Cannabis has increased in recent years due to changing legal circumstances in many countries. Approval exists only for a few neurological conditions such as rare forms of epilepsy or spasticity in multiple sclerosis. Beyond that, however, medical Cannabis is used for a wide range of neurological conditions and symptoms. In Germany, in parallel with new legislation that has simplified the prescription of medical Cannabis, an accompanying survey has been implemented for which initial data are now available. In this context, our review provides an overview of the evidence for the therapeutic use of medical Cannabis in neurology, the potential benefits, and side effects.
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Affiliation(s)
- Ute Hidding
- Department of Neurology, University Clinic Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Tina Mainka
- Department of Neurology and Experimental Neurology at the Charité, Charitéplatz 1, 10117, Berlin, Germany
- Berlin Institute of Health at Charité-BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Charitéplatz 1, 10117, Berlin, Germany
| | - Carsten Buhmann
- Department of Neurology, University Clinic Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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18
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López-Moreno Y, Cabezudo-García P, Ciano-Petersen NL, García-Martín G, Serrano-Castro PJ. Epileptic and neurodevelopmental encephalopathy associated to SYNGAP1 mutation: Description of a case and treatment response to cannabidiol. Neurologia 2024; 39:101-103. [PMID: 38056595 DOI: 10.1016/j.nrleng.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 01/01/2023] [Indexed: 12/08/2023] Open
Affiliation(s)
- Y López-Moreno
- Instituto de Investigación Biomédica de Málaga - IBIMA, Málaga, Spain.
| | - P Cabezudo-García
- Instituto de Investigación Biomédica de Málaga - IBIMA, Málaga, Spain; Red Andaluza de Investigación Clínica y Traslacional en Neurología (NeuroRECA), Málaga, Spain; Servicio de Neurología, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - N L Ciano-Petersen
- Instituto de Investigación Biomédica de Málaga - IBIMA, Málaga, Spain; Red Andaluza de Investigación Clínica y Traslacional en Neurología (NeuroRECA), Málaga, Spain; Servicio de Neurología, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - G García-Martín
- Instituto de Investigación Biomédica de Málaga - IBIMA, Málaga, Spain; Red Andaluza de Investigación Clínica y Traslacional en Neurología (NeuroRECA), Málaga, Spain; Servicio de Neurología, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - P J Serrano-Castro
- Instituto de Investigación Biomédica de Málaga - IBIMA, Málaga, Spain; Red Andaluza de Investigación Clínica y Traslacional en Neurología (NeuroRECA), Málaga, Spain; Servicio de Neurología, Hospital Regional Universitario de Málaga, Málaga, Spain
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19
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Maldonado C, Peyraube R, Fagiolino P, Oricchio F, Cuñetti L, Vázquez M. Human Data on Pharmacokinetic Interactions of Cannabinoids: A Narrative Review. Curr Pharm Des 2024; 30:241-254. [PMID: 38288797 DOI: 10.2174/0113816128288510240113170116] [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: 11/22/2023] [Accepted: 01/02/2024] [Indexed: 05/08/2024]
Abstract
Concomitant use of cannabinoids with other drugs may result in pharmacokinetic drug-drug interactions, mainly due to the mechanism involving Phase I and Phase II enzymes and/or efflux transporters. Cannabinoids are not only substrates but also inhibitors or inducers of some of these enzymes and/or transporters. This narrative review aims to provide the available information reported in the literature regarding human data on the pharmacokinetic interactions of cannabinoids with other medications. A search on Pubmed/Medline, Google Scholar, and Cochrane Library was performed. Some studies were identified with Google search. Additional articles of interest were obtained through cross-referencing of published literature. All original research papers discussing interactions between cannabinoids, used for medical or recreational/adult-use purposes, and other medications in humans were included. Thirty-two studies with medicinal or recreational/adult-use cannabis were identified (seventeen case reports/series, thirteen clinical trials, and two retrospective analyses). In three of these studies, a bidirectional pharmacokinetic drug-drug interaction was reported. In the rest of the studies, cannabinoids were the perpetrators, as in most of them, concentrations of cannabinoids were not measured. In light of the widespread use of prescribed and non-prescribed cannabinoids with other medications, pharmacokinetic interactions are likely to occur. Physicians should be aware of these potential interactions and closely monitor drug levels and/or responses. The existing literature regarding pharmacokinetic interactions is limited, and for some drugs, studies have relatively small cohorts or are only case reports. Therefore, there is a need for high-quality pharmacological studies on cannabinoid-drug interactions.
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Affiliation(s)
- Cecilia Maldonado
- Department of Pharmaceutical Sciences, Faculty of Chemistry, Universidad de la República, Montevideo, Uruguay
| | - Raquel Peyraube
- Instituto de Investigaciones Biológicas Clemente Estable - MEC, Montevideo, Uruguay
| | - Pietro Fagiolino
- Department of Pharmaceutical Sciences, Faculty of Chemistry, Universidad de la República, Montevideo, Uruguay
| | - Florencia Oricchio
- Department of Pharmaceutical Sciences, Faculty of Chemistry, Universidad de la República, Montevideo, Uruguay
| | - Leticia Cuñetti
- Kidney Transplant Unit, Nephrology and Urology Institute, Montevideo, Uruguay
| | - Marta Vázquez
- Department of Pharmaceutical Sciences, Faculty of Chemistry, Universidad de la República, Montevideo, Uruguay
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20
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Martínez-Aguirre C, Márquez LA, Santiago-Castañeda CL, Carmona-Cruz F, Nuñez-Lumbreras MDLA, Martínez-Rojas VA, Alonso-Vanegas M, Aguado-Carrillo G, Gómez-Víquez NL, Galván EJ, Cuéllar-Herrera M, Rocha L. Cannabidiol Modifies the Glutamate Over-Release in Brain Tissue of Patients and Rats with Epilepsy: A Pilot Study. Biomedicines 2023; 11:3237. [PMID: 38137458 PMCID: PMC10741033 DOI: 10.3390/biomedicines11123237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 11/15/2023] [Accepted: 11/20/2023] [Indexed: 12/24/2023] Open
Abstract
Drug-resistant epilepsy (DRE) is associated with high extracellular levels of glutamate. Studies support the idea that cannabidiol (CBD) decreases glutamate over-release. This study focused on investigating whether CBD reduces the evoked glutamate release in cortical synaptic terminals obtained from patients with DRE as well as in a preclinical model of epilepsy. Synaptic terminals (synaptosomes) were obtained from the epileptic neocortex of patients with drug-resistant temporal lobe epilepsy (DR-TLE, n = 10) or drug-resistant extratemporal lobe epilepsy (DR-ETLE, n = 10) submitted to epilepsy surgery. Synaptosomes highly purified by Percoll-sucrose density gradient were characterized by confocal microscopy and Western blot. Synaptosomes were used to estimate the high KCl (33 mM)-evoked glutamate release in the presence of CBD at different concentrations. Our results revealed responsive tissue obtained from seven patients with DR-TLE and seven patients with DR-ETLE. Responsive tissue showed lower glutamate release (p < 0.05) when incubated with CBD at low concentrations (less than 100 µM) but not at higher concentrations. Tissue that was non-responsive to CBD (DR-TLE, n = 3 and DR-ELTE, n = 3) showed high glutamate release despite CBD exposure at different concentrations. Simultaneously, a block of the human epileptic neocortex was used to determine its viability through whole-cell and extracellular electrophysiological recordings. The electrophysiological evaluations supported that the responsive and non-responsive human epileptic neocortices used in the present study exhibited proper neuronal viability and stability to acquire electrophysiological responses. We also investigated whether the subchronic administration of CBD could reduce glutamate over-release in a preclinical model of temporal lobe epilepsy. Administration of CBD (200 mg/kg, p.o. every 24 h for 7 days) to rats with lithium-pilocarpine-evoked spontaneous recurrent seizures reduced glutamate over-release in the hippocampus. The present study revealed that acute exposure to low concentrations of CBD can reduce the glutamate over-release in synaptic terminals obtained from some patients with DRE. This effect is also evident when applied subchronically in rats with spontaneous recurrent seizures. An important finding was the identification of a group of patients that were non-responsive to CBD effects. Future studies are essential to identify biomarkers of responsiveness to CBD to control DRE.
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Affiliation(s)
- Christopher Martínez-Aguirre
- Pharmacobiology Department, Center for Research and Advanced Studies, Mexico City 14330, Mexico; (C.M.-A.); (L.A.M.); (C.L.S.-C.); (F.C.-C.); (M.d.l.A.N.-L.); (V.A.M.-R.); (N.L.G.-V.); (E.J.G.)
| | - Luis Alfredo Márquez
- Pharmacobiology Department, Center for Research and Advanced Studies, Mexico City 14330, Mexico; (C.M.-A.); (L.A.M.); (C.L.S.-C.); (F.C.-C.); (M.d.l.A.N.-L.); (V.A.M.-R.); (N.L.G.-V.); (E.J.G.)
| | - Cindy Lizbeth Santiago-Castañeda
- Pharmacobiology Department, Center for Research and Advanced Studies, Mexico City 14330, Mexico; (C.M.-A.); (L.A.M.); (C.L.S.-C.); (F.C.-C.); (M.d.l.A.N.-L.); (V.A.M.-R.); (N.L.G.-V.); (E.J.G.)
| | - Francia Carmona-Cruz
- Pharmacobiology Department, Center for Research and Advanced Studies, Mexico City 14330, Mexico; (C.M.-A.); (L.A.M.); (C.L.S.-C.); (F.C.-C.); (M.d.l.A.N.-L.); (V.A.M.-R.); (N.L.G.-V.); (E.J.G.)
| | - Maria de los Angeles Nuñez-Lumbreras
- Pharmacobiology Department, Center for Research and Advanced Studies, Mexico City 14330, Mexico; (C.M.-A.); (L.A.M.); (C.L.S.-C.); (F.C.-C.); (M.d.l.A.N.-L.); (V.A.M.-R.); (N.L.G.-V.); (E.J.G.)
| | - Vladimir A. Martínez-Rojas
- Pharmacobiology Department, Center for Research and Advanced Studies, Mexico City 14330, Mexico; (C.M.-A.); (L.A.M.); (C.L.S.-C.); (F.C.-C.); (M.d.l.A.N.-L.); (V.A.M.-R.); (N.L.G.-V.); (E.J.G.)
- Center for Research on Aging, Center for Research and Advanced Studies, Mexico City 14330, Mexico
| | - Mario Alonso-Vanegas
- International Center for Epilepsy Surgery, HMG-Coyoacán Hospital, Mexico City 04380, Mexico;
| | - Gustavo Aguado-Carrillo
- Clinic of Epilepsy, General Hospital of México Dr. Eduardo Liceaga, Mexico City 06720, Mexico
| | - Norma L. Gómez-Víquez
- Pharmacobiology Department, Center for Research and Advanced Studies, Mexico City 14330, Mexico; (C.M.-A.); (L.A.M.); (C.L.S.-C.); (F.C.-C.); (M.d.l.A.N.-L.); (V.A.M.-R.); (N.L.G.-V.); (E.J.G.)
| | - Emilio J. Galván
- Pharmacobiology Department, Center for Research and Advanced Studies, Mexico City 14330, Mexico; (C.M.-A.); (L.A.M.); (C.L.S.-C.); (F.C.-C.); (M.d.l.A.N.-L.); (V.A.M.-R.); (N.L.G.-V.); (E.J.G.)
- Center for Research on Aging, Center for Research and Advanced Studies, Mexico City 14330, Mexico
| | - Manola Cuéllar-Herrera
- Clinic of Epilepsy, General Hospital of México Dr. Eduardo Liceaga, Mexico City 06720, Mexico
| | - Luisa Rocha
- Pharmacobiology Department, Center for Research and Advanced Studies, Mexico City 14330, Mexico; (C.M.-A.); (L.A.M.); (C.L.S.-C.); (F.C.-C.); (M.d.l.A.N.-L.); (V.A.M.-R.); (N.L.G.-V.); (E.J.G.)
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Espinosa-Jovel C, Riveros S, Bolaños-Almeida C, Salazar MR, Inga LC, Guío L. Real-world evidence on the use of cannabidiol for the treatment of drug resistant epilepsy not related to Lennox-Gastaut syndrome, Dravet syndrome or Tuberous Sclerosis Complex. Seizure 2023; 112:72-76. [PMID: 37769547 DOI: 10.1016/j.seizure.2023.09.015] [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: 07/09/2023] [Revised: 09/05/2023] [Accepted: 09/14/2023] [Indexed: 10/03/2023] Open
Abstract
INTRODUCTION Highly purified cannabidiol (CBD) has a broad spectrum of action and could be useful for the treatment of drug resistant epilepsy regardless of etiology or syndrome. MATERIALS AND METHODS Multicenter retrospective study that evaluated the efficacy and safety of CBD for the treatment of drug resistant epilepsy of different etiologies in patients >2 years of age. RESULTS Seventy-eight patients with a median age of 24 years and a wide spectrum of mainly structural and genetic etiologies were included. Patients were using a median of 3 antiseizure drugs (IQR=2-4) and had a median of 30 monthly seizures (IQR=12-100) before starting CBD. The median treatment time with CBD was 14 months (IQR=10-17). The efficacy analysis at the last available visit showed that mean percent reduction in seizures, ≥50% reduction in seizure frequency and seizure freedom was 67.8%, 68.8% and 11.5% respectively. We found no significant impact of concomitant clobazam use on the efficacy and safety of CBD. In the safety analysis, 28.2% (n = 22) of patients presented adverse events related to CBD and drug-retention rate was 78.2%. CONCLUSIONS In a real-world setting, highly purified CBD has been shown to be safe and effective for the treatment of drug resistant epilepsy not related to Lennox-Gastaut syndrome, Dravet syndrome or Tuberous Sclerosis Complex. Based on these findings, highly purified CBD should be considered as an adjuvant therapy for drug resistant epilepsy, regardless of its underlying cause or specific syndrome. Nevertheless, this assumption should be validated through further controlled trials.
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Affiliation(s)
- Camilo Espinosa-Jovel
- Epilepsy Program and Neurology Department, Subred de Servicios de Salud Sur Occidente, Hospital Occidente de Kennedy, Av. 1 de mayo #40B-54, Bogotá, Colombia; Neurology Posgraduate Program, Universidad de la Sabana, Chía, Colombia.
| | - Sandra Riveros
- Epilepsy Program and Neurology Department, Subred de Servicios de Salud Sur Occidente, Hospital Occidente de Kennedy, Av. 1 de mayo #40B-54, Bogotá, Colombia; Neurology Posgraduate Program, Universidad de la Sabana, Chía, Colombia
| | | | - Mateo Ramírez Salazar
- Pediatric Neurology Posgraduate Program, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Leidy Ceballos Inga
- Pediatric Neurology Posgraduate Program, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Laura Guío
- Epilepsy Program, HOMI fundación, Bogotá, Colombia
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22
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Padoan F, Colombrino C, Sciorio F, Piacentini G, Gaudino R, Pietrobelli A, Pecoraro L. Concerns Related to the Consequences of Pediatric Cannabis Use: A 360-Degree View. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1721. [PMID: 38002812 PMCID: PMC10670833 DOI: 10.3390/children10111721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/17/2023] [Accepted: 10/22/2023] [Indexed: 11/26/2023]
Abstract
Cannabis, a plant known for its recreational use, has gained global attention due to its widespread use and addiction potential. Derived from the Cannabis sativa plant, it contains a rich array of phytochemicals concentrated in resin-rich trichomes. The main cannabinoids, delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD), interact with CB1 and CB2 receptors, influencing various physiological processes. Particularly concerning is its prevalence among adolescents, often driven by the need for social connection and anxiety alleviation. This paper provides a comprehensive overview of cannabis use, its effects, and potential health risks, especially in adolescent consumption. It covers short-term and long-term effects on different body systems and mental health and highlights the need for informed decision making and public health initiatives, particularly regarding adolescent cannabis use.
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Affiliation(s)
| | | | | | | | | | | | - Luca Pecoraro
- Pediatric Unit, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, 37126 Verona, Italy
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23
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Portela R, Mota DM, Ferreira PJG, Lula MD, Reis BB, Oliveira HND, Ruas CM. [Judicialization of cannabidiol-based products in Brazil: an analysis from 2019 to 2022]. CAD SAUDE PUBLICA 2023; 39:e00024723. [PMID: 37820230 PMCID: PMC10566558 DOI: 10.1590/0102-311xpt024723] [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: 02/09/2023] [Revised: 05/24/2023] [Accepted: 06/02/2023] [Indexed: 10/13/2023] Open
Abstract
The study analyzed the lawsuits of patients who requested cannabidiol (CBD)-based products from the Brazilian Unified National Health System during the period from 2019 to 2022, describing sociodemographic, clinical, and legal characteristics. This is a cross-sectional study composed of the evaluation of the technical notes issued by the Center for Technical Support of the Judiciary (NatJus), which supports judicial decisions. The data were obtained from the e-NatJus system, of the Brazilian Ministry of Justice, using web scraping techniques. Logistic regression was used to estimate odds ratios with 95% confidence intervals. We analyzed 1,115 technical notes of the CBD plaintiffs, of which 54.7% of the male patients, with a mean age of 18.4 years, mostly from the South Region of the country (38.8%), and 49.6% sought treatment for epilepsy. Regarding the actions with favorable opinions, 28.8% had no scientific evidence, 26.5% pleaded for products without registration with the Brazilian Health Regulatory Agency, and 25.3% of those that had registration were not in compliance with the therapeutic indication. Patients from the Northeast Region had a chance of a favorable opinion increased by 3.0 times and those diagnosed with epilepsy by 2.3. The expert opinions that supported the magistrates for the judicial decisions regarding the demands of patients for cannabidiol-based products in Brazil were mostly in accordance with scientific evidence, denoting the importance of NatJus in the qualification of access to medicinal products in the country.
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Affiliation(s)
- Ronaldo Portela
- Faculdade de Farmácia, Universidade Federal de Minas Gerais, Belo Horizonte, Brasil
| | | | | | - Mariana Dias Lula
- Faculdade de Farmácia, Universidade Federal de Minas Gerais, Belo Horizonte, Brasil
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24
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Vicino W, Muccioli L, Pondrelli F, Licchetta L, Stipa C, Mostacci B, Vito LD, Ferri L, Cancellerini C, Sold M, Tinuper P, Bisulli F. Real-world experience with cannabidiol as add-on treatment in drug-resistant epilepsy. Seizure 2023; 111:39-41. [PMID: 37506564 DOI: 10.1016/j.seizure.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
PURPOSE To evaluate the efficacy and safety of cannabidiol (CBD) for the treatment of epilepsy in a real-world setting. METHODS In this retrospective observational study, we included PwE with epilepsy who received a prescription for CBD between 01.03.2019 and 30.11.2022 and had a follow-up period ≥ 3 months. Participants were evaluated at baseline and after 3, 6, and 12 months. "Responders" were defined as individuals experiencing a reduction in seizure frequency > 30% but < 80% compared to baseline, while "super responders" were those with a reduction ≥ 80%. Adverse events were recorded to assess safety. RESULTS Forty-two PwE were included (mean age 36.1 ± 10.9 years; 14 females). In 24 patients CBD was prescribed on-label (Lennox-Gastaut syndrome, n = 18; Dravet syndrome, n = 5; tuberous sclerosis, n = 1), while 18 patients were treated off-label (ring chromosome 20 syndrome, n = 1; ring chromosome 17 syndrome, n = 1; Lafora disease, n = 3; Unverricht-Lundborg disease, n = 1; polymicrogyria, n = 2; febrile infection-related epilepsy syndrome, n = 1; non-lesional focal epilepsy, n = 2; developmental and/or epileptic encephalopathy of unknown etiology n = 6). The mean number of concomitant antiseizure medications was 3.4 (≥2 for all patients). At 3 months, 10 subjects (23%) were "responders" and 12 (29%) were "super-responders". Efficacy was sustained at 6 and 12 months of follow-up. Twenty-two patients (52.3%) developed AEs, with drowsiness (36.5%) and diarrhea (9.8%) being the most common. The retention rate was 85.7%, 78.6%, and 71.4% at 3, 6, and 12 months, respectively. CONCLUSIONS In this monocentric real-world study, CBD was a safe and effective therapeutic option for highly drug-resistant patients, leading to a dramatic reduction in seizure frequency in over one-fourth of them, including off-label indications.
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Affiliation(s)
- Walter Vicino
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Lorenzo Muccioli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.
| | - Federica Pondrelli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Laura Licchetta
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Full Member of the European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy
| | - Carlotta Stipa
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Full Member of the European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy
| | - Barbara Mostacci
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Full Member of the European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy
| | - Lidia Di Vito
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Full Member of the European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy
| | - Lorenzo Ferri
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, Full Member of the European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy
| | - Chiara Cancellerini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Full Member of the European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy
| | - Martina Sold
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Full Member of the European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy
| | - Paolo Tinuper
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Francesca Bisulli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, Full Member of the European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy
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25
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Ghosh S, Sinha JK, Ghosh S, Sharma H, Bhaskar R, Narayanan KB. A Comprehensive Review of Emerging Trends and Innovative Therapies in Epilepsy Management. Brain Sci 2023; 13:1305. [PMID: 37759906 PMCID: PMC10527076 DOI: 10.3390/brainsci13091305] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/09/2023] [Accepted: 09/10/2023] [Indexed: 09/29/2023] Open
Abstract
Epilepsy is a complex neurological disorder affecting millions worldwide, with a substantial number of patients facing drug-resistant epilepsy. This comprehensive review explores innovative therapies for epilepsy management, focusing on their principles, clinical evidence, and potential applications. Traditional antiseizure medications (ASMs) form the cornerstone of epilepsy treatment, but their limitations necessitate alternative approaches. The review delves into cutting-edge therapies such as responsive neurostimulation (RNS), vagus nerve stimulation (VNS), and deep brain stimulation (DBS), highlighting their mechanisms of action and promising clinical outcomes. Additionally, the potential of gene therapies and optogenetics in epilepsy research is discussed, revealing groundbreaking findings that shed light on seizure mechanisms. Insights into cannabidiol (CBD) and the ketogenic diet as adjunctive therapies further broaden the spectrum of epilepsy management. Challenges in achieving seizure control with traditional therapies, including treatment resistance and individual variability, are addressed. The importance of staying updated with emerging trends in epilepsy management is emphasized, along with the hope for improved therapeutic options. Future research directions, such as combining therapies, AI applications, and non-invasive optogenetics, hold promise for personalized and effective epilepsy treatment. As the field advances, collaboration among researchers of natural and synthetic biochemistry, clinicians from different streams and various forms of medicine, and patients will drive progress toward better seizure control and a higher quality of life for individuals living with epilepsy.
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Affiliation(s)
- Shampa Ghosh
- GloNeuro, Sector 107, Vishwakarma Road, Noida 201301, India
- ICMR—National Institute of Nutrition, Tarnaka, Hyderabad 500007, India
| | | | - Soumya Ghosh
- GloNeuro, Sector 107, Vishwakarma Road, Noida 201301, India
| | | | - Rakesh Bhaskar
- School of Chemical Engineering, Yeungnam University, 280 Daehak-Ro, Gyeongsan, Gyeongbuk 38541, Republic of Korea
| | - Kannan Badri Narayanan
- School of Chemical Engineering, Yeungnam University, 280 Daehak-Ro, Gyeongsan, Gyeongbuk 38541, Republic of Korea
- Research Institute of Cell Culture, Yeungnam University, 280 Daehak-Ro, Gyeongsan, Gyeongbuk 38541, Republic of Korea
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26
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Flamini RJ, Comi AM, Bebin EM, Chez MG, Clark G, Devinsky O, Hussain SA, Lyons PD, Patel AD, Rosengard JL, Sahebkar F, Segal E, Seltzer L, Szaflarski JP, Weinstock A. Efficacy of cannabidiol in convulsive and nonconvulsive seizure types associated with treatment-resistant epilepsies in the Expanded Access Program. Epilepsia 2023; 64:e156-e163. [PMID: 37243404 DOI: 10.1111/epi.17665] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 05/19/2023] [Accepted: 05/23/2023] [Indexed: 05/28/2023]
Abstract
The cannabidiol (CBD) Expanded Access Program (EAP), initiated in 2014, provided CBD (Epidiolex) to patients with treatment-resistant epilepsy (TRE). In the final pooled analysis of 892 patients treated through January 2019 (median exposure = 694 days), CBD treatment was associated with a 46%-66% reduction in median monthly total (convulsive plus nonconvulsive) seizure frequency. CBD was well tolerated, and adverse events were consistent with previous findings. We used pooled EAP data to investigate the effectiveness of add-on CBD therapy for individual convulsive seizure types (clonic, tonic, tonic-clonic, atonic, focal to bilateral tonic-clonic), nonconvulsive seizure types (focal with and without impaired consciousness, absence [typical and atypical], myoclonic, myoclonic absence), and epileptic spasms. CBD treatment was associated with a reduction in the frequency of convulsive seizure types (median percentage reduction = 47%-100%), and nonconvulsive seizure types and epileptic spasms (median percentage reduction = 50%-100%) across visit intervals through 144 weeks of treatment. Approximately 50% of patients had ≥50% reduction in convulsive and nonconvulsive seizure types and epileptic spasms at nearly all intervals. These results show a favorable effect of long-term CBD use in patients with TRE, who may experience various convulsive and nonconvulsive seizure types. Future controlled trials are needed to confirm these findings.
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Affiliation(s)
| | - Anne M Comi
- Kennedy Krieger Institute, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - E Martina Bebin
- University of Alabama School of Medicine, Birmingham, Alabama, USA
| | | | - Gary Clark
- Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Orrin Devinsky
- NYU Langone Comprehensive Epilepsy Center, New York, New York, USA
| | - Shaun A Hussain
- David Geffen School of Medicine and UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - Paul D Lyons
- Virginia Comprehensive Epilepsy Program, Winchester, Virginia, USA
| | - Anup D Patel
- Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Jillian L Rosengard
- Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Eric Segal
- Northeast Region Epilepsy Group, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Laurie Seltzer
- University of Rochester Medical Center, Rochester, Minnesota, USA
| | | | - Arie Weinstock
- University at Buffalo and Oishei Children's Hospital, Buffalo, New York, USA
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27
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Ebadi SR, Saleki K, Adl Parvar T, Rahimi N, Aghamollaii V, Ranji S, Tafakhori A. The effect of cannabidiol on seizure features and quality of life in drug-resistant frontal lobe epilepsy patients: a triple-blind controlled trial. Front Neurol 2023; 14:1143783. [PMID: 37470002 PMCID: PMC10352113 DOI: 10.3389/fneur.2023.1143783] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 05/09/2023] [Indexed: 07/21/2023] Open
Abstract
Background Treatment-resistant epileptic seizures are associated with reduced quality of life (QoL). As polypharmacy with routine antiseizure medications has many side effects, novel add-on treatments are necessary. Recent research showed the efficacy of add-on therapy by cannabidiol (CBD) on refractory epilepsy. We attempted to extend data on the efficacy and safety profile of CBD in patients with frontal lobe treatment-resistant epilepsy. Methods A total of 27 patients were recruited into two CBD (n = 12) and placebo (n = 15) groups. The CBD group received a highly purified liposomal preparation of the drug in addition to routine antiseizure medications. The placebo group only received antiseizure medications. This experiment followed a triple-blinding protocol. Outcome measures were seizure frequency, the Chalfont seizure severity scale (CSSS), and the quality of life questionnaire score (QOLIE-31) assessed at baseline, 4 weeks, and 8 weeks. Results At 4 weeks, results indicated that a higher fraction of patients in the CBD group (66.67%) showed improvement in seizure, compared to the placebo group (20.00%). Before-after comparison revealed that CBD, unlike routine ADEs, was effective in reducing the occurrence of seizures at the study's final timepoint [mean difference 45.58, 95% CI (8.987 to 82.18), p = 0.009]. Seizure severity was not affected by study groups or time intervals (repeated-measures ANOVA p > 0.05). Post-hoc tests found that the QoLI-31 score was improved at 8 weeks compared to baseline [mean diff. -5.031, 95% CI (-9.729 to -0.3328), p = 0.032]. The difference in cases who experienced enhanced QoL was meaningful between the CBD and placebo groups at 8 weeks [RR: 2.160, 95% CI (1.148 to 4.741), p = 0.018] but not at 4 weeks (p = 0.653). A positive finding for QoL improvement was associated with a positive finding for seizure frequency reduction [r = 0.638, 95% CI (0.296 to 0.835), p = 0.001]. Interestingly, limiting the correlation analysis to cases receiving CBD indicated that QoL improvement was not linked with seizure parameters such as severity and frequency (p > 0.05). Conclusion The present study suggests the benefit of a purified and highly efficient preparation of CBD for seizure frequency reduction and improvement of QoL in refractory frontal lobe epilepsy. Further study with longer follow-ups and larger sample size is advised. Clinical trial registration https://www.irct.ir/trial/56790, identifier: IRCT20210608051515N1.
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Affiliation(s)
- Seyyed Reza Ebadi
- Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Kiarash Saleki
- School of Management and Medical Education, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Student Research Committee, Babol University of Medical Sciences, Babol, Iran
- USERN Office, Babol University of Medical Sciences, Babol, Iran
| | - Tanin Adl Parvar
- Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Negin Rahimi
- Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Vajiheh Aghamollaii
- Cognitive Neurology and Neuropsychiatry Division, Tehran University of Medical Sciences, Tehran, Iran
- Department of Neurology, Roozbeh Psychiatric Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Sara Ranji
- Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Abbas Tafakhori
- Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
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28
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Kumric M, Dujic G, Vrdoljak J, Supe-Domic D, Bilopavlovic N, Dolic K, Dujic Z, Bozic J. Effects of CBD supplementation on ambulatory blood pressure and serum urotensin-II concentrations in Caucasian patients with essential hypertension: A sub-analysis of the HYPER-H21-4 trial. Biomed Pharmacother 2023; 164:115016. [PMID: 37321059 DOI: 10.1016/j.biopha.2023.115016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 06/08/2023] [Accepted: 06/11/2023] [Indexed: 06/17/2023] Open
Abstract
HYPER-H21-4 was a randomized crossover trial that aimed to determine if cannabidiol (CBD), a non-intoxicating constituent of cannabis, has relevant effects on blood pressure and vascular health in patients with essential hypertension. In the present sub-analysis, we aimed to elucidate whether serum urotensin-II concentrations may reflect hemodynamic changes caused by oral supplementation with CBD. The sub-analysis of this randomized crossover study included 51 patients with mild to moderate hypertension that received CBD for five weeks, and placebo for five weeks. After five weeks of oral CBD supplementation, but not placebo, serum urotensin concentrations reduced significantly in comparison to baseline (3.31 ± 1.46 ng/mL vs. 2.08 ± 0.91 ng/mL, P < 0.001). Following the five weeks of CBD supplementation, the magnitude of reduction in 24 h mean arterial pressure (MAP) positively correlated with the extent of change in serum urotensin levels (r = 0.412, P = 0.003); this association was independent of age, sex, BMI and previous antihypertensive treatment (β ± standard error, 0.023 ± 0.009, P = 0.009). No correlation was present in the placebo condition (r = -0.132, P = 0.357). In summary, potent vasoconstrictor urotensin seems to be implicated in CBD-mediated reduction in blood pressure, although further research is needed to confirm these notions.
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Affiliation(s)
- Marko Kumric
- Department of Pathophysiology, University of Split School of Medicine, 21000 Split, Croatia.
| | - Goran Dujic
- Clinical Department of Diagnostic and Interventional Radiology, University Hospital of Split, 21000 Split, Croatia.
| | - Josip Vrdoljak
- Department of Pathophysiology, University of Split School of Medicine, 21000 Split, Croatia.
| | - Daniela Supe-Domic
- Department of Health Studies, University of Split, 21000 Split, Croatia; Department of Medical Laboratory Diagnostics, University Hospital of Split, 21000 Split, Croatia.
| | - Nada Bilopavlovic
- Department of Medical Laboratory Diagnostics, University Hospital of Split, 21000 Split, Croatia
| | - Kresimir Dolic
- Clinical Department of Diagnostic and Interventional Radiology, University Hospital of Split, 21000 Split, Croatia.
| | - Zeljko Dujic
- Department of Integrative Physiology, University of Split School of Medicine, 21000 Split, Croatia.
| | - Josko Bozic
- Department of Pathophysiology, University of Split School of Medicine, 21000 Split, Croatia.
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29
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Bellocchio L, Patano A, Inchingolo AD, Inchingolo F, Dipalma G, Isacco CG, de Ruvo E, Rapone B, Mancini A, Lorusso F, Scarano A, Malcangi G, Inchingolo AM. Cannabidiol for Oral Health: A New Promising Therapeutical Tool in Dentistry. Int J Mol Sci 2023; 24:ijms24119693. [PMID: 37298644 DOI: 10.3390/ijms24119693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 05/30/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023] Open
Abstract
The medical use of cannabis has a very long history. Although many substances called cannabinoids are present in cannabis, Δ9tetrahydrocannabinol (Δ9-THC), cannabidiol (CBD) and cannabinol (CBN) are the three main cannabinoids that are most present and described. CBD itself is not responsible for the psychotropic effects of cannabis, since it does not produce the typical behavioral effects associated with the consumption of this drug. CBD has recently gained growing attention in modern society and seems to be increasingly explored in dentistry. Several subjective findings suggest some therapeutic effects of CBD that are strongly supported by research evidence. However, there is a plethora of data regarding CBD's mechanism of action and therapeutic potential, which are in many cases contradictory. We will first provide an overview of the scientific evidence on the molecular mechanism of CBD's action. Furthermore, we will map the recent developments regarding the possible oral benefits of CBD. In summary, we will highlight CBD's promising biological features for its application in dentistry, despite exiting patents that suggest the current compositions for oral care as the main interest of the industry.
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Affiliation(s)
- Luigi Bellocchio
- INSERM, U1215 NeuroCentre Magendie, Endocannabinoids and Neuroadaptation, University of Bordeaux, 33063 Bordeaux, France
| | - Assunta Patano
- Department of Interdisciplinary Medicine, University of Study "Aldo Moro", 70124 Bari, Italy
| | | | - Francesco Inchingolo
- Department of Interdisciplinary Medicine, University of Study "Aldo Moro", 70124 Bari, Italy
| | - Gianna Dipalma
- Department of Interdisciplinary Medicine, University of Study "Aldo Moro", 70124 Bari, Italy
| | - Ciro Gargiulo Isacco
- Department of Interdisciplinary Medicine, University of Study "Aldo Moro", 70124 Bari, Italy
| | - Elisabetta de Ruvo
- Department of Interdisciplinary Medicine, University of Study "Aldo Moro", 70124 Bari, Italy
| | - Biagio Rapone
- Department of Interdisciplinary Medicine, University of Study "Aldo Moro", 70124 Bari, Italy
| | - Antonio Mancini
- Department of Interdisciplinary Medicine, University of Study "Aldo Moro", 70124 Bari, Italy
| | - Felice Lorusso
- Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, 66100 Chieti, Italy
| | - Antonio Scarano
- Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, 66100 Chieti, Italy
| | - Giuseppina Malcangi
- Department of Interdisciplinary Medicine, University of Study "Aldo Moro", 70124 Bari, Italy
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Kochen S, Villanueva M, Bayarres L, Daza-Restrepo A, Gonzalez Martinez S, Oddo S. Cannabidiol as an adjuvant treatment in adults with drug-resistant focal epilepsy. Epilepsy Behav 2023; 144:109210. [PMID: 37196452 DOI: 10.1016/j.yebeh.2023.109210] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/30/2023] [Accepted: 04/01/2023] [Indexed: 05/19/2023]
Abstract
Cannabidiol oil (CBD) has been approved as an anti-seizure medication for the treatment of uncommon types of epilepsy, occurring in children: Dravet syndrome, Lennox-Gastaut syndrome, and Tuberous Sclerosis Complex. There are few publications in relation to use the CBD in adult patients with focal drug-resistant epilepsy. The objective of this study was to evaluate the efficacy, tolerability, safety, and quality of life, of adjuvant treatment with CBD, in adult patients with drug-resistant focal epilepsy for at least 6 months. An open, observational, prospective cohort study was conducted using a before-after design (time series) in adult patients undergoing outpatient follow-up in a public hospital in Buenos Aires, Argentina. From a total of 44 patients, 5% of patients were seizure-free, 32% of patients reduced more than 80% of their seizures and 87% of patients reduced 50% of their monthly seizures. Eleven percent presented a decrease of less than 50% in seizure frequency. The average final dose was 335 mg/d orally administered. Thirty-four percent of patients reported mild adverse events and no patient reported severe adverse effects. At the end of the study, we found in most patients a significant improvement in the quality of life, in all the items evaluated. Adjuvant treatment with CBD in adult patients with drug-resistant focal epilepsy was effective, safe, well tolerated, and associated with a significant improvement in their quality of life.
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Affiliation(s)
- Silvia Kochen
- Neurosciences and Complex Systems Unit (ENyS), Epilepsy Unit, Hospital El Cruce "Nestor Kirchner". CONICET. National University Arturo Jauretche (UNAJ), F. Varela, Prov. Buenos Aires, Argentina
| | - Manuela Villanueva
- Neurosciences and Complex Systems Unit (ENyS), Epilepsy Unit, Hospital El Cruce "Nestor Kirchner". CONICET. National University Arturo Jauretche (UNAJ), F. Varela, Prov. Buenos Aires, Argentina
| | - Liliana Bayarres
- Neurosciences and Complex Systems Unit (ENyS), Epilepsy Unit, Hospital El Cruce "Nestor Kirchner". CONICET. National University Arturo Jauretche (UNAJ), F. Varela, Prov. Buenos Aires, Argentina
| | - Anilu Daza-Restrepo
- Neurosciences and Complex Systems Unit (ENyS), Epilepsy Unit, Hospital El Cruce "Nestor Kirchner". CONICET. National University Arturo Jauretche (UNAJ), F. Varela, Prov. Buenos Aires, Argentina
| | - Silvia Gonzalez Martinez
- Neurosciences and Complex Systems Unit (ENyS), Epilepsy Unit, Hospital El Cruce "Nestor Kirchner". CONICET. National University Arturo Jauretche (UNAJ), F. Varela, Prov. Buenos Aires, Argentina
| | - Silvia Oddo
- Neurosciences and Complex Systems Unit (ENyS), Epilepsy Unit, Hospital El Cruce "Nestor Kirchner". CONICET. National University Arturo Jauretche (UNAJ), F. Varela, Prov. Buenos Aires, Argentina.
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Lu H, Wang Q, Jiang X, Zhao Y, He M, Wei M. The Potential Mechanism of Cannabidiol (CBD) Treatment of Epilepsy in Pentetrazol (PTZ) Kindling Mice Uncovered by Multi-Omics Analysis. Molecules 2023; 28:molecules28062805. [PMID: 36985783 PMCID: PMC10056192 DOI: 10.3390/molecules28062805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/05/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
Cannabidiol (CBD) is the main active ingredient in the cannabis plant used for treating epilepsy and related diseases. However, how CBD ameliorates epilepsy and its effect on the hippocampus remains unknown. Herein, we evaluated how CBD ameliorates seizure degree in pentylenetetrazol (PTZ) induced epilepsy mice after being exposed to CBD (10 mg/kg p.o). In addition, transcriptome and metabolomic analysis were performed on the hippocampus. Our results suggested that CBD could alleviate PTZ-induced seizure, of which the NPTX2, Gprc5c, Lipg, and Stc2 genes were significantly down-regulated in mice after being exposed to PTZ. Transcriptome analysis showed 97 differently expressed genes (CBD) and the PTZ groups. Metabonomic analysis revealed that compared with the PTZ group, 41 up-regulated and 67 down-regulated metabolites were identified in the hippocampus of epileptic mice exposed to CBD. The correlation analysis for transcriptome and metabolome showed that (±) 15-HETE and carnitine C6:0 were at the core of the network and were involved in the positive or negative regulation of the related genes after being treated with CBD. In conclusion, CBD ameliorates epilepsy by acting on the metabolism, calcium signaling pathway, and tuberculosis pathways in the hippocampus. Our study provided a practical basis for the therapeutic potential of treating epilepsy using CBD.
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Affiliation(s)
- Hongyuan Lu
- Department of Pharmacology, School of Pharmacy, China Medical University, Shenyang 110122, China
| | - Qinbiao Wang
- Department of Pharmacology, School of Pharmacy, China Medical University, Shenyang 110122, China
| | - Xiaowen Jiang
- School of Traditional Chinese Materia Medica, Shenyang Pharmaceutical University, Shenyang 110016, China
| | - Yanyun Zhao
- Department of Pharmacology, School of Pharmacy, China Medical University, Shenyang 110122, China
| | - Miao He
- Department of Pharmacology, School of Pharmacy, China Medical University, Shenyang 110122, China
| | - Minjie Wei
- Department of Pharmacology, School of Pharmacy, China Medical University, Shenyang 110122, China
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Erridge S, Holvey C, Coomber R, Hoare J, Khan S, Platt MW, Rucker JJ, Weatherall MW, Beri S, Sodergren MH. Clinical Outcome Data of Children Treated with Cannabis-Based Medicinal Products for Treatment Resistant Epilepsy - Analysis from the UK Medical Cannabis Registry. Neuropediatrics 2023; 54:174-181. [PMID: 36539215 PMCID: PMC10166640 DOI: 10.1055/a-2002-2119] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND There is a paucity of high-quality evidence of the efficacy and safety of cannabis-based medicinal products in treatment of treatment-resistant epilepsy (TRE) in children. METHODS A case series of children (<18 years old) with TRE from the UK Medical Cannabis Registry was analyzed. Primary outcomes were ≥50% reduction in seizure frequency, changes in the Impact of Pediatric Epilepsy Score (IPES), and incidence of adverse events. RESULTS Thirty-five patients were included in the analysis. Patients were prescribed during their treatment with the following: CBD isolate oils (n = 19), CBD broad-spectrum oils (n = 17), and CBD/Δ9-THC combination therapy (n = 17). Twenty-three (65.7%) patients achieved a ≥50% reduction in seizure frequency. 94.1% (n = 16) of patients treated with CBD and Δ9-THC observed a ≥50% reduction in seizure frequency compared to 31.6% (n = 6) and 17.6% (n = 3) of patients treated with CBD isolates and broad-spectrum CBD products, respectively (p< 0.001). Twenty-six (74.3%) adverse events were reported by 16 patients (45.7%). The majority of these were mild (n = 12; 34.2%) and moderate (n = 10; 28.6%). CONCLUSION The results of this study demonstrate a positive signal of improved seizure frequency in children treated with Cannabis-based medicinal products (CBMPs) for TRE. Moreover, the results suggest that CBMPs are well-tolerated in the short term. The limitations mean causation cannot be determined in this open-label, case series.
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Affiliation(s)
- Simon Erridge
- Department of Surgery & Cancer, Imperial College London, London, United Kingdom.,Department of Medicine, Sapphire Medical Clinics, London, United Kingdom
| | - Carl Holvey
- Department of Medicine, Sapphire Medical Clinics, London, United Kingdom
| | - Ross Coomber
- Department of Medicine, Sapphire Medical Clinics, London, United Kingdom.,Department of Trauma & Orthopaedics, St Georges NHS Healthcare Trust, London, United Kingdom
| | - Jonathan Hoare
- Department of Surgery & Cancer, Imperial College London, London, United Kingdom.,Department of Medicine, Sapphire Medical Clinics, London, United Kingdom
| | - Shaheen Khan
- Department of Medicine, Sapphire Medical Clinics, London, United Kingdom.,Department of Palliative Medicine, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Michael W Platt
- Department of Surgery & Cancer, Imperial College London, London, United Kingdom.,Department of Medicine, Sapphire Medical Clinics, London, United Kingdom
| | - James J Rucker
- Department of Medicine, Sapphire Medical Clinics, London, United Kingdom.,Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, Kings College London, London, United Kingdom.,Centre for Affective Disorders, South London & Maudsley NHS Foundation Trust, London, United Kingdom
| | - Mark W Weatherall
- Department of Medicine, Sapphire Medical Clinics, London, United Kingdom.,Department of Neurology, Buckinghamshire Healthcare NHS Trust, Amersham, United Kingdom
| | - Sushil Beri
- Department of Surgery & Cancer, Imperial College London, London, United Kingdom.,Department of Medicine, Sapphire Medical Clinics, London, United Kingdom
| | - Mikael H Sodergren
- Department of Surgery & Cancer, Imperial College London, London, United Kingdom.,Department of Medicine, Sapphire Medical Clinics, London, United Kingdom
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Klatzkow S, Davis G, Shmalberg J, Gallastegui A, Miscioscia E, Tarricone J, Elam L, Johnson MD, Leonard KM, Wakshlag JJ. Evaluation of the efficacy of a cannabidiol and cannabidiolic acid rich hemp extract for pain in dogs following a tibial plateau leveling osteotomy. Front Vet Sci 2023; 9:1036056. [PMID: 36686184 PMCID: PMC9846637 DOI: 10.3389/fvets.2022.1036056] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 11/28/2022] [Indexed: 01/06/2023] Open
Abstract
Objective To determine the impact of a cannabidiol (CBD) and cannabidiolic acid (CBDA) rich hemp product on acute post-operative pain in dogs following a tibial plateau leveling osteotomy (TPLO), and to evaluate for changes in early bone healing, serum chemistry profiles, and complete blood counts. Methods In this randomized, placebo controlled, blinded clinical trial, 44 client-owned dogs were assigned to receive either a CBD/CBDA product dosed at 2-2.5 mg/kg PO every 12 h or a placebo for 4 weeks following a TPLO. Variables evaluated before (week 0), and at 2 and 4 weeks post-operatively included standardized veterinary assessments for pain score, weight-bearing, and lameness, the Canine Brief Pain Inventory (pain interference score-PIS, pain severity score-PSS), and serum biochemistry. Complete blood counts were performed at weeks 0 and 4. Additionally, orthogonal radiographs evaluating the degree of healing were taken at week 4. A mixed model analysis, analyzing changes of variables of interest from enrollment baseline to all other time points was utilized, with a p-value ≤ 0.05 considered significant. Results Of the 44 enrolled patients, 3 were lost to follow up and excluded from analysis. No significant differences were noted between placebo (n = 19) and CBD/CBDA (n = 22) groups at any point in pain score, degree of lameness, degree of weight-bearing, PIS, PSS, or radiographic healing of the osteotomy. A significant finding of elevation of ALP above normal reference range in the treatment group was identified (p = 0.02) and eosinophil count was affected by treatment (p = 0.01), increasing from baseline in placebo and decreasing in treatment groups. Finally, a significant difference (p = 0.03) was noted at 2 weeks post-operatively where 4 patients in the placebo group and no treatment patients received trazodone to facilitate activity restrictions. Clinical significance Use of a CBD/CBDA rich hemp product dosed at 2-2.5 mg/kg PO every 12 h did not have a significant impact on pain or delay early bone healing. A statistically significant increase in ALP, decrease in eosinophils, and reduced use of trazodone was identified in the treatment group.
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Affiliation(s)
- Sarah Klatzkow
- Department of Small Animal Surgery, Red Bank Veterinary Hospital, Tinton Falls, NJ, United States
| | - Garrett Davis
- Department of Small Animal Surgery, Red Bank Veterinary Hospital, Tinton Falls, NJ, United States
| | - Justin Shmalberg
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL, United States
| | - Aitor Gallastegui
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL, United States
| | - Erin Miscioscia
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL, United States
| | - Jason Tarricone
- Department of Small Animal Surgery, Red Bank Veterinary Hospital, Tinton Falls, NJ, United States
| | - Lindsay Elam
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL, United States
| | - Matthew D. Johnson
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL, United States
| | - Katelyn M. Leonard
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL, United States
| | - Joseph J. Wakshlag
- Department of Clinical Sciences, Cornell College of Veterinary Medicine, Ithaca, NY, United States
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Sciaccaluga M, Ruffolo G, Palma E, Costa C. Traditional and Innovative Anti-seizure Medications Targeting Key Physiopathological Mechanisms: Focus on Neurodevelopment and Neurodegeneration. Curr Neuropharmacol 2023; 21:1736-1754. [PMID: 37143270 PMCID: PMC10514539 DOI: 10.2174/1570159x21666230504160948] [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: 09/03/2022] [Revised: 03/23/2023] [Accepted: 03/29/2023] [Indexed: 05/06/2023] Open
Abstract
Despite the wide range of compounds currently available to treat epilepsy, there is still no drug that directly tackles the physiopathological mechanisms underlying its development. Indeed, antiseizure medications attempt to prevent seizures but are inefficacious in counteracting or rescuing the physiopathological phenomena that underlie their onset and recurrence, and hence do not cure epilepsy. Classically, the altered excitation/inhibition balance is postulated as the mechanism underlying epileptogenesis and seizure generation. This oversimplification, however, does not account for deficits in homeostatic plasticity resulting from either insufficient or excessive compensatory mechanisms in response to a change in network activity. In this respect, both neurodevelopmental epilepsies and those associated with neurodegeneration may share common underlying mechanisms that still need to be fully elucidated. The understanding of these molecular mechanisms shed light on the identification of new classes of drugs able not only to suppress seizures, but also to present potential antiepileptogenic effects or "disease-modifying" properties.
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Affiliation(s)
- Miriam Sciaccaluga
- Section of Neurology, S.M. della Misericordia Hospital, Department of Medicine and Surgery, University of Perugia, Piazzale Gambuli 1, Perugia, 06129, Italy
| | - Gabriele Ruffolo
- Department of Physiology and Pharmacology, Istituto Pasteur—Fondazione Cenci Bolognetti, University of Rome, Sapienza, Rome, 00185, Italy
- IRCCS San Raffaele Roma, Rome, 00166, Italy
| | - Eleonora Palma
- Department of Physiology and Pharmacology, Istituto Pasteur—Fondazione Cenci Bolognetti, University of Rome, Sapienza, Rome, 00185, Italy
- IRCCS San Raffaele Roma, Rome, 00166, Italy
| | - Cinzia Costa
- Section of Neurology, S.M. della Misericordia Hospital, Department of Medicine and Surgery, University of Perugia, Piazzale Gambuli 1, Perugia, 06129, Italy
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Efficacy and safety of traditional Chinese medicine for the treatment of epilepsy: A updated meta-analysis of randomized controlled trials. Epilepsy Res 2023; 189:107075. [PMID: 36603453 DOI: 10.1016/j.eplepsyres.2022.107075] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/13/2022] [Accepted: 12/30/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of Traditional Chinese Medicine (TCM) in the treatment of epilepsy. METHODS A comprehensive search of the database in both Chinese and English was performed. Data from the selected studies were extracted and analyzed independently by two authors. RESULTS 30 randomized controlled trials (RCTs) were included in the meta-analysis with a total of 2471 patients. Among them, 4 trials (n = 235) focused on TCM monotherapy, while the other 26 trials (n = 2236) assessed the benefit of TCM as an add-on therapy to antiseizure medications (ASMs). For the efficacy, the meta-analysis found (1) The effective rate in TCM monotherapy group was higher than that in control group (OR = 4.92, 95 % CI: 2.29-10.57, Z = 4.08, P 0.0001); (2) The add-on of TCM also increased the effective rate (OR = 3.37, 95 % CI: 2.65-4.30, Z = 9.85, P 0.00001) and seizure freedom rate (OR = 1.93, 95 % CI: 1.53-2.44, Z = 5.58, P 0.00001). In terms of safety, the add-on of TCM reduced the rate of total adverse events (OR = 0.46, 95 % CI: 0.31-0.67, Z = 3.96, P 0.0001) as well as adverse events of the gastrointestinal and nervous system. 26 different TCM prescriptions were used in these included RCTs. Among them, the 5 most frequently used herbs were Acorus tatarinowii (19 out of 26), Glycyrrhiza uralensis (13 out of 26), Gastrodia elata (12 out of 26), Pinellia ternata (11 out of 26) and Poria cocos (11 out of 26). CONCLUSION This study suggested that TCM may be a relatively efficacious and safe clinical strategy for the treatment of epilepsy. Several limitations still exist, such as the risk of bias in the included studies, the diversified composition of TCM prescriptions, and the relatively low quality of study design.
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Cannabis-based magistral formulation is highly effective as an adjuvant treatment in drug-resistant focal epilepsy in adult patients: an open-label prospective cohort study. Neurol Sci 2023; 44:297-304. [PMID: 36129615 DOI: 10.1007/s10072-022-06393-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 09/08/2022] [Indexed: 01/12/2023]
Abstract
INTRODUCTION The safety and efficacy of a formulation high in cannabidiol (CBD) and low in ∆9-tetrahydrocannabinol (THC) to treat drug-resistant epilepsy have been examined previously in children, but not in adult population. The aim of this study was to evaluate whether CBD-rich oil, as an add-on treatment to conventional antiepileptic drugs, was effective, safe, and well-tolerated in adults with drug-resistant focal epilepsy (DRFE). METHODS An open-label, prospective cohort, single-center in adult patients with DRFE, were receiving stable doses of antiepileptic drugs (AEDs). A cannabis based-magistral formulation (CBMF) (100 mg/ml CBD and THC <1.9 mg/ml) was administrated 0.1 ml sublingually every 12 hours, up-titrated weekly. The primary outcome was to establish a reduction in seizures frequency >50% at 12 weeks. Adverse-drug reactions monitoring was done. p-value <0.05 was statistically significant. RESULTS Between August 2020 and July 2022, 44 (38.6%) patients completed >3 months of follow-up. The median daily dose of CBD was 200 mg, that of THC was 4 mg, and that of CBD per kilogram of weight was 3.7 mg. The median number of seizures per month before CBD treatment was 11, and after CBD treatment was 2.5 (p<0.001). A reduction in seizures >50% at 12 week was achieved in 79.5% of the patients. The median percentage change in seizure frequency per month was 84.1% at 12 weeks. Five patients reported any adverse-drug reactions. CONCLUSION The CBMF is a highly effective and safety therapy to treat adult patients with DRFE. The reduction in seizures frequency is maintained over time.
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Yuan Y, Wu Q, Huo L, Wang H, Liu X. Case report: Alexander's disease with "head drop" as the main symptom and literature review. Front Neurol 2022; 13:1002527. [PMID: 36601294 PMCID: PMC9807021 DOI: 10.3389/fneur.2022.1002527] [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: 07/25/2022] [Accepted: 11/25/2022] [Indexed: 12/24/2022] Open
Abstract
Alexander's disease (AxD) is a rare autosomal dominant hereditary disorder that is caused by the mutations in the GFAP gene, which encodes the glial fibrillary acidic protein (GFAP). This neurogenerative disease has many clinical manifestations, and the onset of disease spans a wide range of ages, from newborns to children, adults, and even the elderly. An overaccumulation of the expression of GFAP has a close causal relationship with the pathogenesis of Alexander's disease. Usually, the disease has severe morbidity and high mortality, and can be divided into three distinct subgroups that are based on the age of clinical presentation: infantile (0-2 years), juvenile (2-13 years), and adult (>13 years). Children often present with epilepsy, macrocephaly, and psychomotor retardation, while adolescents and adults mainly present with muscle weakness, spasticity, and bulbar symptoms. Atonic seizures are a type of epilepsy that often appears in the Lennox-Gastaut syndrome and myoclonic-astatic epilepsy in early childhood; however, the prognosis is often poor. Atonic episodes are characterized by a sudden or frequent reduction in muscle tone that can be local (such as head, neck, or limb) or generalized. Here, we report a 4-year-old girl whose main symptoms were intermittent head drop movements, which could break the frontal frame and even bleed in severe conditions. A video-encephalography (VEEG) showed that the nodding movements were atonic seizures. A head magnetic resonance imaging (MRI) revealed abnormal signals in the bilateral paraventricular and bilateral subfrontal cortex. The gene detection analyses indicated that the GFAP gene exon 1 c.262 C>T was caused by a heterozygous mutation, as both her parents were of the wild-type. The girl had no other abnormal manifestations except atonic seizures. She could communicate normally and go to kindergarten. After an oral administration of sodium valproate, there were no atonic attacks. Although epilepsy is a common symptom of Alexander's disease, atonic seizures have not been reported to date. Therefore, we report a case of Alexander's disease with atonic seizures as the main symptom and provide a review of the literature.
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Zavala-Tecuapetla C, Luna-Munguia H, López-Meraz ML, Cuellar-Herrera M. Advances and Challenges of Cannabidiol as an Anti-Seizure Strategy: Preclinical Evidence. Int J Mol Sci 2022; 23:ijms232416181. [PMID: 36555823 PMCID: PMC9783044 DOI: 10.3390/ijms232416181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 11/24/2022] [Accepted: 12/16/2022] [Indexed: 12/23/2022] Open
Abstract
The use of Cannabis for medicinal purposes has been documented since ancient times, where one of its principal cannabinoids extracted from Cannabis sativa, cannabidiol (CBD), has emerged over the last few years as a promising molecule with anti-seizure potential. Here, we present an overview of recent literature pointing out CBD's pharmacological profile (solubility, metabolism, drug-drug interactions, etc.,), CBD's interactions with multiple molecular targets as well as advances in preclinical research concerning its anti-seizure effect on both acute seizure models and chronic models of epilepsy. We also highlight the recent attention that has been given to other natural cannabinoids and to synthetic derivatives of CBD as possible compounds with therapeutic anti-seizure potential. All the scientific research reviewed here encourages to continue to investigate the probable therapeutic efficacy of CBD and its related compounds not only in epilepsy but also and specially in drug-resistant epilepsy, since there is a dire need for new and effective drugs to treat this disease.
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Affiliation(s)
- Cecilia Zavala-Tecuapetla
- Laboratory of Physiology of Reticular Formation, National Institute of Neurology and Neurosurgery, Insurgentes Sur 3877, La Fama, Mexico City 14269, Mexico
- Correspondence:
| | - Hiram Luna-Munguia
- Departamento de Neurobiologia Conductual y Cognitiva, Instituto de Neurobiologia, Universidad Nacional Autonoma de Mexico, Campus UNAM-Juriquilla, Queretaro 76230, Mexico
| | - María-Leonor López-Meraz
- Instituto de Investigaciones Cerebrales, Universidad Veracruzana, Luis Castelazo Ayala s/n, Col. Industrial Ánimas, Xalapa 91190, Mexico
| | - Manola Cuellar-Herrera
- Epilepsy Clinic, Hospital General de México Dr. Eduardo Liceaga, Dr. Balmis 148, Doctores, Mexico City 06720, Mexico
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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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Tonoyan L, Babu D, Reiz B, Le T, Siraki AG. Heating of consumer cannabis oils can lead to free radical initiated degradation, causing CBD and THC depletion. Free Radic Biol Med 2022; 192:77-83. [PMID: 36113706 DOI: 10.1016/j.freeradbiomed.2022.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 08/29/2022] [Accepted: 09/08/2022] [Indexed: 10/31/2022]
Abstract
Commercial cannabis oil products are widely available in Canada even though there is a significant gap in scientific information regarding them. Oils, such as vegetable oils, are known to undergo oxidative changes through free radical mechanisms when they are heated or aged, but the cannabis oils used in this study did not have expiry dates or best-before usage dates. This led to the question of how these products would be affected with time. We hypothesized that cannabis oils would produce increased concentrations of free radicals in aging-simulated conditions, which would be related to a decrease in cannabidiol (CBD) or Δ9-tetrahydrocannabinol (THC) content. Cannabis oils and their respective vehicles (oils) were heated using two protocols: One (moderate aging method) used a 2-day heating protocol at 50 °C, and the other (enhanced aging method) used a 14-day heating protocol at 70 °C. We used electron paramagnetic resonance (EPR) spectroscopy for free radical analysis using the spin trapping technique using 200 mM PBN and 0.02 mM CuCl2 (for peroxide breakdown to free radicals). For active ingredient analysis (CBD, THC), we used LC/MS. Cannabis oils that contained unsaturated oils as their vehicles, such as olive or sunflower oil, all showed varying degrees of free radical formation. In both aged and unaged oils containing CBD or THC, less free radical formation was detected compared to the vehicle controls. Cannabis oils using medium-chain triglycerides (MCT) showed little or no free radical formation. The most significant decrease in CBD or THC was observed in the products using sunflower oil, to a lesser extent in MCT oil, and THC also decreased in olive oil. These findings are important for consumers and policymakers considering using such products in hot beverages or cooking and highlighting the importance of appropriate storage conditions.
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Affiliation(s)
- Lusine Tonoyan
- Applied Pharmaceutical Innovation, Edmonton, Canada; College of Health Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Canada
| | - Dinesh Babu
- College of Health Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Canada
| | - Bela Reiz
- College of Natural and Applied Sciences, Faculty of Science, University of Alberta, Edmonton, Canada
| | - Tyson Le
- Applied Pharmaceutical Innovation, Edmonton, Canada; College of Health Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Canada
| | - Arno G Siraki
- College of Health Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Canada.
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Armstrong C, Zavez A, Mulcahey PJ, Sogawa Y, Gotoff JM, Hagopian S, Minnick J, Marsh ED. Quantitative electroencephalographic analysis as a potential biomarker of response to treatment with cannabidiol. Epilepsy Res 2022; 185:106996. [PMID: 35963151 DOI: 10.1016/j.eplepsyres.2022.106996] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/26/2022] [Accepted: 08/04/2022] [Indexed: 02/03/2023]
Abstract
PURPOSE Pharmaceutical grade cannabidiol (CBD) is one of the newest anti-seizure medications for refractory epilepsy, and the effects of CBD on EEG have not been fully described. METHODS Patients enrolled in a CBD expanded access study had EEGs prior to and 12 weeks after initiation of CBD treatment for their refractory epilepsy. In addition to evaluating the clinical EEG reports, a nonbiased quantitative EEG (qEEG) analysis of background EEG was performed to determine whether consistent changes occur in the EEG in response to administration of CBD. RESULTS No significant qualitative changes were seen, nor changes in quantitative markers of EEG amplitude (RMS amplitude, standard deviation of the amplitude, skewness, or kurtosis), frequency (relative delta, theta, or alpha power), Spearman correlation, or coherence between brain regions. However, relative beta power and 1/f slope, a measure of signal noise increased with the addition of CBD. When patients were separated into responders and nonresponders based on seizure reduction with CBD, responders also had decreased Spearman correlation between the frontopolar and occipital regions after addition of CBD, suggesting that responders may have quantitatively improved EEG background organization after CBD initiation. The differences in beta and 1/f slope were also seen more robustly in CBD responders compared with nonresponders after CBD initiation. These differences disappeared when analyzing only patients not taking benzodiazepines, suggesting that the effect of CBD on seizures was related to the ability of the brain to further increase beta in response to CBD in patients already taking benzodiazepines. We noted that even before initiation of CBD, 1/f slope was also significantly different in responders compared to nonresponders. Therefore, to explore the baseline EEG in responders and nonresponders, we utilized a variable selection procedure to identify baseline EEG features that could predict whether a patient's seizures would improve with CBD. In the optimal multivariable logistic model, baseline coherence, Spearman correlation, and patient sex jointly predicted whether a patient in this cohort would respond to CBD (defined as a seizure reduction of 40% or greater) with 74% accuracy. This model performed less well on a data set of reduced duration and variability, highlighting the importance of real-world testing of any clinically relevant model. CONCLUSION These results suggest that there are subtle changes in certain metrics detected by qEEG even at baseline that may not be perceived during qualitative EEG analysis and that could be used in the future as a biomarker to predict a patient's clinical response to CBD administration. Development of such a predictive EEG biomarker, especially before the initiation of a medication trial, could reduce unnecessary ASM exposure and improve outcomes for patients with epilepsy facing new medication selection.
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Affiliation(s)
- Caren Armstrong
- Division of Neurology and Pediatric Epilepsy Program, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Alexis Zavez
- Orphan Disease Center, Suite 1200, 125 S 31st St, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Patrick J Mulcahey
- Division of Neurology and Pediatric Epilepsy Program, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Yoshimi Sogawa
- UPMC Children's Hospital of Pittsburgh, Pediatric Neurology 4401 Penn Avenue, Pittsburgh, PA 15224, USA
| | - Jill M Gotoff
- Geisinger Medical Center, 100 N Academy Avenue, Danville, PA 17822, USA
| | - Samantha Hagopian
- Division of Neurology and Pediatric Epilepsy Program, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Jennie Minnick
- Division of Neurology and Pediatric Epilepsy Program, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Eric D Marsh
- Division of Neurology and Pediatric Epilepsy Program, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA; Orphan Disease Center, Suite 1200, 125 S 31st St, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Departments of Pediatrics and Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, Philadelphia, PA 19104, USA.
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Wu J, Zhang L, Zhou X, Wang J, Zheng X, Hu H, Wu D. Efficacy and safety of adjunctive antiseizure medications for dravet syndrome: A systematic review and network meta-analysis. Front Pharmacol 2022; 13:980937. [PMID: 36120377 PMCID: PMC9471196 DOI: 10.3389/fphar.2022.980937] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/05/2022] [Indexed: 11/24/2022] Open
Abstract
Purpose: Recently, the U.S. Food and Drug Administration (FDA) approved stiripentol, cannabidiol, and fenfluramine to treat patients with Dravet syndrome (DS). Moreover, soticlestat was determined as a promising new drug for the treatment of DS as it has good efficacy and safety. However, the efficacy and safety of these drugs have not yet been evaluated in "head-to-head" trials. This study aimed to compare and evaluate the efficacy and safety of these adjunctive antiseizure medications in the treatment of DS. Methods: We searched in PubMed, Embase, Cochrane Library, and Web of Science databases for randomized controlled trials (RCTs) and open-label extension (OLE) studies in patients with DS. We performed a random-effect meta-analysis of OLE studies and a network meta-analysis for RCTs to evaluate the efficacy and safety of antiseizure medications in the treatment of DS. Primary efficacy outcomes were defined as a ≥50% reduction in seizure frequency compared with baseline. Furthermore, safety evaluation indicators were defined as the incidence of adverse events (AEs) and serious adverse events (SAEs) during treatment. Relative ranking was assessed using the surface under the cumulative ranking curve (SUCRA) probabilities. Results: Seven RCTs involving four antiseizure medications (stiripentol, cannabidiol, fenfluramine, and soticlestat) and a total of 634 patients were included in the analysis. According to the SUCRA results, all four drugs significantly reduced the frequency of seizures compared with the placebo. Soticlestat was the most likely to reduce seizure frequency by ≥50% compared to the baseline [risk ratio (RR): 19.32; 95% confidence interval (CI): 1.20-311.40], followed by stiripentol and fenfluramine. Stiripentol was ranked highest for the near percentage reduction in the seizure rate from baseline [RR: 12.33; 95% CI: 1.71-89.17] and the occurrence of any treatment-emergent adverse events [RR: 3.73; 95% CI: 1.65-8.43] and serious adverse events [RR: 4.76; 95% CI: 0.61-37.28]. A total of ten OLE studies containing 1,121 patients were included in our study. According to the results of the meta-analysis, the order of probability of reducing seizure frequency by ≥50% was fenfluramine (0.715, 95% CI: 0.621-0.808), stiripentol (0.604, 95% CI: 0.502-0.706), cannabidiol (0.448, 95% CI: 0.403-0.493). And the probability of occurrence of AEs is ranked as fenfluramine(0.832, 95% CI: 0.795-0.869), cannabidiol (0.825, 95% CI:0.701-0.950), stiripentol (0.823, 95% CI: 0.707-0.938), soticlestat (0.688, 95% CI: 0.413-0.890). Conclusion: According to the results of indirect comparison of efficacy and safety, cannabidiol is slightly inferior to the other three antiseizure medications in terms of efficacy and safety. Soticlestat, fenfluramine, and stripentol may have little difference in efficacy, but soticlestat and fenfluramine are safer. Soticlestat is probably the best adjunctive antiseizure medication, followed by fenfluramine. This conclusion is consistent with the comparison of long-term efficacy and safety.
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Affiliation(s)
| | | | | | | | | | - Hankun Hu
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Dongfang Wu
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, Wuhan, China
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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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45
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An Italian consensus on the management of Lennox-Gastaut syndrome. Seizure 2022; 101:134-140. [DOI: 10.1016/j.seizure.2022.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 11/19/2022] Open
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Ling J, Yeung WL, Hon KL, Lo IFM, Luk HM, Fung CW, Leung AKC. Successful Treatment of Drug-Resistant Seizures Secondary to Ring 20 Mosaicism with Perampanel as an Add-On Antiepileptic Drug. Case Rep Pediatr 2022; 2022:7414628. [PMID: 35664544 PMCID: PMC9162848 DOI: 10.1155/2022/7414628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 04/21/2022] [Indexed: 11/27/2022] Open
Abstract
We report a girl with drug-resistant seizures, progressive behavioral changes, and cognitive decline. Investigations showed abnormal EEG with frequent high-voltage bifrontotemporal sharp and slow waves, especially during sleep. Seizures were difficult to control, despite the usage of various antiepileptic drugs. Perampanel as an add-on antiepileptic drug appeared efficacious. Due to the recognizable pattern of seizures and EEG findings, a karyotype study was performed which revealed 46 chromosomes with a ring 20 chromosome mosaicism. Ring 20 chromosome is associated with drug-resistant refractory seizures, cognitive decline, and behavioral problems. This case highlights the difficulty and challenge faced in managing drug-resistant refractory seizures associated with ring 20 chromosome. While ring 20 chromosome is often underdiagnosed, one should have a high index of awareness and suspicion of such rare epilepsy syndrome, so that an early diagnosis can be made.
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Affiliation(s)
- Janet Ling
- The Hong Kong Children's Hospital, Kowloon Bay, Hong Kong
| | - Wai Lan Yeung
- The Hong Kong Children's Hospital, Kowloon Bay, Hong Kong
| | - Kam Lun Hon
- The Hong Kong Children's Hospital, Kowloon Bay, Hong Kong
| | - Ivan F. M. Lo
- Clinical Genetic Service, Department of Health, HKSAR, Kowloon Bay, Hong Kong
| | - Ho-Ming Luk
- Clinical Genetics Service Unit, Hong Kong Children's Hospital, Ngau Tau Kok, Hong Kong
| | | | - Alexander K. C. Leung
- Department of Pediatrics, The University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
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Oshiro CA, Castro LHM. Cannabidiol and epilepsy in Brazil: a current review. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:182-192. [PMID: 35976327 PMCID: PMC9491442 DOI: 10.1590/0004-282x-anp-2022-s137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Cannabidiol (CBD) has become a promising therapeutic option in the treatment of epilepsy. Recent studies provide robust evidence that CBD is effective and safe. Limitations in current knowledge and regulatory issues still limit CBD use. CBD use regarding epilepsy types still lacks clear guidelines. OBJECTIVE To critically review the main current pharmacological features and clinical issues regarding CBD use in epilepsy, to provide current regulatory background regarding CBD use in Brazil, and to suggest a practical CBD therapeutic guide in Brazil. METHODS Non-systematic literature review (up to February 2022) of current concepts of CBD and epilepsy, including the authors' personal experience. RESULTS Five pivotal trials have led to CBD approval as an adjunctive treatment for Dravet and Lennox-Gastaut syndromes, and for the tuberous sclerosis complex. Efficacy of CBD in other drug-resistant epilepsies remains not completely understood. CBD adverse event profile and drug interactions are better understood. CBD is well tolerated. In Brazil, CBD is not classified as a medication, but as a product subject to a distinct regulatory legislation. CBD is still not offered by the National Brazilian health system, but can be purchased in authorized pharmacies or imported under prescription and signed informed consent. CONCLUSION CBD is a recognized novel treatment for epilepsy. Future well-designed studies and public health strategies are needed to offer widespread access to CBD, and to improve the quality of life of people living with epilepsy in Brazil.
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Affiliation(s)
- Carlos André Oshiro
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo, SP, Brazil
| | - Luiz Henrique Martins Castro
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo, SP, Brazil
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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: 13] [Impact Index Per Article: 6.5] [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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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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Zhou D, Dennis E, Snehal I, Swaminathan A. Cannabinoids in the Treatment of Epilepsy: A Review. EUROPEAN MEDICAL JOURNAL 2021. [DOI: 10.33590/emj/21-000951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Cannabinoids have been studied for their role in the treatment of epilepsy for many years. The U.S. Food and Drug Administration (FDA) approved them for the treatment of some refractory syndromes in 2018. Cannabidiol and tetrahydrocannabinol are the most commonly studied cannabinoids and have been studied in great depth vis-à-vis their pharmacokinetics and pharmacodynamics. Studies have shown the efficacy of cannabinoids in the treatment of refractory epilepsy. A substantial amount of research has been performed exploring the interactions between cannabinoids and other conventional antiseizure medications. The exact mechanisms by which cannabinoids exert their effects on seizure control remain unclear and research into these mechanisms continues in great earnest. Cognitive changes from cannabinoids are constantly being studied and add to potential benefits from the use of these compounds. Cultural and social misconceptions and roadblocks about the use of cannabinoids persist and represent an ongoing obstacle to increasing research and therapeutic use of these compounds. This review focuses on all these aspects and of the use of these cannabinoids in the treatment of epilepsy and seeks to offer a fairly comprehensive description of the facets of cannabinoid therapy for refractory epilepsy.
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Affiliation(s)
- Daniel Zhou
- University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Erin Dennis
- University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Isha Snehal
- University of Nebraska Medical Center, Omaha, Nebraska, USA
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