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Murray CH, Gannon BM, Winsauer PJ, Cooper ZD, Delatte MS. The Development of Cannabinoids as Therapeutic Agents in the United States. Pharmacol Rev 2024; 76:915-955. [PMID: 38849155 PMCID: PMC11331953 DOI: 10.1124/pharmrev.123.001121] [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] [Received: 11/10/2023] [Revised: 05/30/2024] [Accepted: 06/03/2024] [Indexed: 06/09/2024] Open
Abstract
Cannabis is one of the oldest and widely used substances in the world. Cannabinoids within the cannabis plant, known as phytocannabinoids, mediate cannabis' effects through interactions with the body's endogenous cannabinoid system. This endogenous system, the endocannabinoid system, has important roles in physical and mental health. These roles point to the potential to develop cannabinoids as therapeutic agents while underscoring the risks related to interfering with the endogenous system during nonmedical use. This scoping narrative review synthesizes the current evidence for both the therapeutic and adverse effects of the major (i.e., Δ9-tetrahydrocannabinol and cannabidiol) and lesser studied minor phytocannabinoids, from nonclinical to clinical research. We pay particular attention to the areas where evidence is well established, including analgesic effects after acute exposures and neurocognitive risks after acute and chronic use. In addition, drug development considerations for cannabinoids as therapeutic agents within the United States are reviewed. The proposed clinical study design considerations encourage methodological standards for greater scientific rigor and reproducibility to ultimately extend our knowledge of the risks and benefits of cannabinoids for patients and providers. SIGNIFICANCE STATEMENT: This work provides a review of prior research related to phytocannabinoids, including therapeutic potential and known risks in the context of drug development within the United States. We also provide study design considerations for future cannabinoid drug development.
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Affiliation(s)
- Conor H Murray
- UCLA Center for Cannabis and Cannabinoids, Jane and Terry Semel Institute for Neuroscience and Human Behavior, Departments of Psychiatry and Biobehavioral Sciences (C.H.M.) and Departments of Anesthesiology and Perioperative Medicine (Z.D.C.), David Geffen School of Medicine, University of California, Los Angeles, California; Department of Pharmacology and Toxicology, College of Medicine (B.M.G.) and Office of Research Regulatory Affairs, Division of Research and Innovation (B.M.G.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; Departments of Pharmacology and Experimental Therapeutics and Biochemistry and Molecular Biology, School of Medicine (P.J.W.), and Alcohol and Drug Abuse Center of Excellence (P.J.W.) Louisiana State University Health Sciences Center, New Orleans, Louisiana; and Regulatory and Drug Development Consulting, Allucent, Carey, North Carolina (M.S.D.)
| | - Brenda M Gannon
- UCLA Center for Cannabis and Cannabinoids, Jane and Terry Semel Institute for Neuroscience and Human Behavior, Departments of Psychiatry and Biobehavioral Sciences (C.H.M.) and Departments of Anesthesiology and Perioperative Medicine (Z.D.C.), David Geffen School of Medicine, University of California, Los Angeles, California; Department of Pharmacology and Toxicology, College of Medicine (B.M.G.) and Office of Research Regulatory Affairs, Division of Research and Innovation (B.M.G.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; Departments of Pharmacology and Experimental Therapeutics and Biochemistry and Molecular Biology, School of Medicine (P.J.W.), and Alcohol and Drug Abuse Center of Excellence (P.J.W.) Louisiana State University Health Sciences Center, New Orleans, Louisiana; and Regulatory and Drug Development Consulting, Allucent, Carey, North Carolina (M.S.D.)
| | - Peter J Winsauer
- UCLA Center for Cannabis and Cannabinoids, Jane and Terry Semel Institute for Neuroscience and Human Behavior, Departments of Psychiatry and Biobehavioral Sciences (C.H.M.) and Departments of Anesthesiology and Perioperative Medicine (Z.D.C.), David Geffen School of Medicine, University of California, Los Angeles, California; Department of Pharmacology and Toxicology, College of Medicine (B.M.G.) and Office of Research Regulatory Affairs, Division of Research and Innovation (B.M.G.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; Departments of Pharmacology and Experimental Therapeutics and Biochemistry and Molecular Biology, School of Medicine (P.J.W.), and Alcohol and Drug Abuse Center of Excellence (P.J.W.) Louisiana State University Health Sciences Center, New Orleans, Louisiana; and Regulatory and Drug Development Consulting, Allucent, Carey, North Carolina (M.S.D.)
| | - Ziva D Cooper
- UCLA Center for Cannabis and Cannabinoids, Jane and Terry Semel Institute for Neuroscience and Human Behavior, Departments of Psychiatry and Biobehavioral Sciences (C.H.M.) and Departments of Anesthesiology and Perioperative Medicine (Z.D.C.), David Geffen School of Medicine, University of California, Los Angeles, California; Department of Pharmacology and Toxicology, College of Medicine (B.M.G.) and Office of Research Regulatory Affairs, Division of Research and Innovation (B.M.G.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; Departments of Pharmacology and Experimental Therapeutics and Biochemistry and Molecular Biology, School of Medicine (P.J.W.), and Alcohol and Drug Abuse Center of Excellence (P.J.W.) Louisiana State University Health Sciences Center, New Orleans, Louisiana; and Regulatory and Drug Development Consulting, Allucent, Carey, North Carolina (M.S.D.)
| | - Marcus S Delatte
- UCLA Center for Cannabis and Cannabinoids, Jane and Terry Semel Institute for Neuroscience and Human Behavior, Departments of Psychiatry and Biobehavioral Sciences (C.H.M.) and Departments of Anesthesiology and Perioperative Medicine (Z.D.C.), David Geffen School of Medicine, University of California, Los Angeles, California; Department of Pharmacology and Toxicology, College of Medicine (B.M.G.) and Office of Research Regulatory Affairs, Division of Research and Innovation (B.M.G.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; Departments of Pharmacology and Experimental Therapeutics and Biochemistry and Molecular Biology, School of Medicine (P.J.W.), and Alcohol and Drug Abuse Center of Excellence (P.J.W.) Louisiana State University Health Sciences Center, New Orleans, Louisiana; and Regulatory and Drug Development Consulting, Allucent, Carey, North Carolina (M.S.D.)
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Duncan RS, Riordan SM, Gernon MC, Koulen P. Cannabinoids and endocannabinoids as therapeutics for nervous system disorders: preclinical models and clinical studies. Neural Regen Res 2024; 19:788-799. [PMID: 37843213 PMCID: PMC10664133 DOI: 10.4103/1673-5374.382220] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 06/08/2023] [Accepted: 07/01/2023] [Indexed: 10/17/2023] Open
Abstract
Cannabinoids are lipophilic substances derived from Cannabis sativa that can exert a variety of effects in the human body. They have been studied in cellular and animal models as well as in human clinical trials for their therapeutic benefits in several human diseases. Some of these include central nervous system (CNS) diseases and dysfunctions such as forms of epilepsy, multiple sclerosis, Parkinson's disease, pain and neuropsychiatric disorders. In addition, the endogenously produced cannabinoid lipids, endocannabinoids, are critical for normal CNS function, and if controlled or modified, may represent an additional therapeutic avenue for CNS diseases. This review discusses in vitro cellular, ex vivo tissue and in vivo animal model studies on cannabinoids and their utility as therapeutics in multiple CNS pathologies. In addition, the review provides an overview on the use of cannabinoids in human clinical trials for a variety of CNS diseases. Cannabinoids and endocannabinoids hold promise for use as disease modifiers and therapeutic agents for the prevention or treatment of neurodegenerative diseases and neurological disorders.
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Affiliation(s)
- R. Scott Duncan
- Department of Ophthalmology, School of Medicine, University of Missouri, Kansas, MO, USA
| | - Sean M. Riordan
- Department of Ophthalmology, School of Medicine, University of Missouri, Kansas, MO, USA
| | - Matthew C. Gernon
- Department of Ophthalmology, School of Medicine, University of Missouri, Kansas, MO, USA
| | - Peter Koulen
- Department of Ophthalmology, School of Medicine, University of Missouri, Kansas, MO, USA
- Department of Biomedical Sciences, School of Medicine, University of Missouri, Kansas, MO, USA
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Liu S, He Z, Li J. Long-term efficacy and adverse effects of cannabidiol in adjuvant treatment of drug-resistant epilepsy: a systematic review and meta-analysis. Ther Adv Neurol Disord 2023; 16:17562864231207755. [PMID: 37915501 PMCID: PMC10617284 DOI: 10.1177/17562864231207755] [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: 03/22/2023] [Accepted: 09/20/2023] [Indexed: 11/03/2023] Open
Abstract
Background Epilepsy is one of the most common chronic brain diseases. Almost one-third of patients have drug-resistant epilepsy (DRE). Cannabidiol is being considered as a potential novel drug for treating DRE. Objectives To investigate long-term efficacy and safety of cannabidiol in treatment of DRE and the differences in cannabidiol treatment among patients with different characteristics. Design Systematic review and meta-analysis. Data sources and methods Medline, Embase, and CENTRAL were searched for literature. RevMan5.4 was used for meta-analysis. The Intention-to-treat set and the random effect were used as the main analysis. Subgroup analyses were performed according to age, dose, concomitant antiseizure medications (ASMs), epilepsy syndromes, and study designs. Results Fifty studies were included in this systematic review. A total of 4791 participants were collected. The responder rates (seizure frequency reduced at least 50%) at 12-, 24-, 48-, 72-, 96-, and 144-week were 0.40 [0.36, 0.45], 0.39 [0.34, 0.44], 0.37 [0.30, 0.44], 0.27 [0.17, 0.37], 0.22 [0.14, 0.30], and 0.38 [0.23, 0.53]. Seizure-free rates were 0.04 [0.03, 0.06], 0.04 [0.03, 0.05], 0.03 [0.02, 0.05], 0.03 [0.02, 0.03], 0.02 [0.01, 0.03], and 0.04 [0.01, 0.06]. Proportion of adverse events were 0.72 [0.61, 0.83], 0.62 [0.42, 0.81], 0.60 [0.41, 0.79], 0.35 [0.14, 0.56], 0.83 [0.75, 0.90], and 0.96 [0.94, 0.99]. The pooled 12-, 24-, 48-, 96-, and 144-week proportion of serious adverse events were 0.15 [0.09, 0.21], 0.23 [0.14, 0.31], 0.10 [0.06, 0.15], 0.31 [0.24, 0.38], and 0.40 [0.35, 0.45]. Subgroup analyses showed that there was no significant difference on efficacy and safety among age subgroups and epilepsy syndromes subgroups. For most periods, there were no significant difference on efficacy among subgroups of dose and concomitant ASMs. However, higher doses and more concomitant ASMs were associated with higher proportion of adverse events. Conclusion Cannabidiol treatment of DRE has stable efficacy and fewer adverse events in early period. Long-term use may have decreased efficacy and increased adverse events. Dose escalation may not increase efficacy, but may increase adverse events. Furthermore, cannabidiol use may reduce dosage of other ASMs without reducing efficacy, thereby reducing adverse effects. Cannabidiol may have similar effects in various epilepsy syndromes. Trial registration PROSPERO (CRD42022351250).
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Affiliation(s)
- Shengyi Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Zihua He
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jinmei Li
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan 610041, China
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da Silva Rodrigues D, Santos Bastos Soares A, Dizioli Franco Bueno C. The use of cannabinoids in children with epilepsy: A systematic review. Epilepsy Behav 2023; 145:109330. [PMID: 37390729 DOI: 10.1016/j.yebeh.2023.109330] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/12/2023] [Accepted: 06/15/2023] [Indexed: 07/02/2023]
Abstract
INTRODUCTION Epileptic syndromes affecting children can sometimes be refractory to pharmacological treatments. Cannabinoids, especially cannabidiol, began to be studied to contribute to the treatment of these syndromes, configuring an expanding research area. The aim of this paper was to evaluate the scientific evidence available in the literature regarding the use of cannabinoids in the therapy of children with epilepsy. METHOD This is a systematic literature review, carried out according to the structure of the Preferred Reporting Items for Systematic Reviews and meta-analyses (PRISMA), in the SCIELO, Cochrane Library, and MEDLINE databases. Observational studies or clinical trials were included, conducted in humans, addressing the use of cannabinoids in pediatric patients with epilepsy, published in the last 10 years. RESULTS AND DISCUSSION In all, 626 studies were found and analyzed, of which 29 were considered eligible for the research; studies indicated good efficacy, safety, and tolerability of cannabidiol in several syndromes, with emphasis on Lennox-Gastaut and Dravet syndromes, in addition to practical issues were perceived regarding the applicability and expectations of patients and physicians. CONCLUSION The use of cannabidiol was considered effective and safe, yet the studies were mostly carried out in the same countries.
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O'Sullivan SE, Jensen SS, Nikolajsen GN, Bruun HZ, Bhuller R, Hoeng J. The therapeutic potential of purified cannabidiol. J Cannabis Res 2023; 5:21. [PMID: 37312194 DOI: 10.1186/s42238-023-00186-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 04/30/2023] [Indexed: 06/15/2023] Open
Abstract
The use of cannabidiol (CBD) for therapeutic purposes is receiving considerable attention, with speculation that CBD can be useful in a wide range of conditions. Only one product, a purified form of plant-derived CBD in solution (Epidiolex), is approved for the treatment of seizures in patients with Lennox-Gastaut syndrome, Dravet syndrome, or tuberous sclerosis complex. Appraisal of the therapeutic evidence base for CBD is complicated by the fact that CBD products sometimes have additional phytochemicals (like tetrahydrocannabinol (THC)) present, which can make the identification of the active pharmaceutical ingredient (API) in positive studies difficult. The aim of the present review is to critically review clinical studies using purified CBD products only, in order to establish the upcoming indications for which purified CBD might be beneficial. The areas in which there is the most clinical evidence to support the use of CBD are in the treatment of anxiety (positive data in 7 uncontrolled studies and 17 randomised controlled trials (RCTs)), psychosis and schizophrenia (positive data in 1 uncontrolled study and 8 RCTs), PTSD (positive data in 2 uncontrolled studies and 4 RCTs) and substance abuse (positive data in 2 uncontrolled studies and 3 RCTs). Seven uncontrolled studies support the use of CBD to improve sleep quality, but this has only been verified in one small RCT. Limited evidence supports the use of CBD for the treatment of Parkinson's (3 positive uncontrolled studies and 2 positive RCTs), autism (3 positive RCTs), smoking cessation (2 positive RCTs), graft-versus-host disease and intestinal permeability (1 positive RCT each). Current RCT evidence does not support the use of purified oral CBD in pain (at least as an acute analgesic) or for the treatment of COVID symptoms, cancer, Huntington's or type 2 diabetes. In conclusion, published clinical evidence does support the use of purified CBD in multiple indications beyond epilepsy. However, the evidence base is limited by the number of trials only investigating the acute effects of CBD, testing CBD in healthy volunteers, or in very small patient numbers. Large confirmatory phase 3 trials are required in all indications.
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Strzelczyk A, Schubert-Bast S. Psychobehavioural and Cognitive Adverse Events of Anti-Seizure Medications for the Treatment of Developmental and Epileptic Encephalopathies. CNS Drugs 2022; 36:1079-1111. [PMID: 36194365 PMCID: PMC9531646 DOI: 10.1007/s40263-022-00955-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2022] [Indexed: 02/06/2023]
Abstract
The developmental and epileptic encephalopathies encompass a group of rare syndromes characterised by severe drug-resistant epilepsy with onset in childhood and significant neurodevelopmental comorbidities. The latter include intellectual disability, developmental delay, behavioural problems including attention-deficit hyperactivity disorder and autism spectrum disorder, psychiatric problems including anxiety and depression, speech impairment and sleep problems. Classical examples of developmental and epileptic encephalopathies include Dravet syndrome, Lennox-Gastaut syndrome and tuberous sclerosis complex. The mainstay of treatment is with multiple anti-seizure medications (ASMs); however, the ASMs themselves can be associated with psychobehavioural adverse events, and effects (negative or positive) on cognition and sleep. We have performed a targeted literature review of ASMs commonly used in the treatment of developmental and epileptic encephalopathies to discuss the latest evidence on their effects on behaviour, mood, cognition, sedation and sleep. The ASMs include valproate (VPA), clobazam, topiramate (TPM), cannabidiol (CBD), fenfluramine (FFA), levetiracetam (LEV), brivaracetam (BRV), zonisamide (ZNS), perampanel (PER), ethosuximide, stiripentol, lamotrigine (LTG), rufinamide, vigabatrin, lacosamide (LCM) and everolimus. Bromide, felbamate and other sodium channel ASMs are discussed briefly. Overall, the current evidence suggest that LEV, PER and to a lesser extent BRV are associated with psychobehavioural adverse events including aggressiveness and irritability; TPM and to a lesser extent ZNS are associated with language impairment and cognitive dulling/memory problems. Patients with a history of behavioural and psychiatric comorbidities may be more at risk of developing psychobehavioural adverse events. Topiramate and ZNS may be associated with negative effects in some aspects of cognition; CBD, FFA, LEV, BRV and LTG may have some positive effects, while the remaining ASMs do not appear to have a detrimental effect. All the ASMs are associated with sedation to a certain extent, which is pronounced during uptitration. Cannabidiol, PER and pregabalin may be associated with improvements in sleep, LTG is associated with insomnia, while VPA, TPM, LEV, ZNS and LCM do not appear to have detrimental effects. There was variability in the extent of evidence for each ASM: for many first-generation and some second-generation ASMs, there is scant documented evidence; however, their extensive use suggests favourable tolerability and safety (e.g. VPA); second-generation and some third-generation ASMs tend to have the most robust evidence documented over several years of use (TPM, LEV, PER, ZNS, BRV), while evidence is still being generated for newer ASMs such as CBD and FFA. Finally, we discuss how a variety of factors can affect mood, behaviour and cognition, and untangling the associations between the effects of the underlying syndrome and those of the ASMs can be challenging. In particular, there is enormous heterogeneity in cognitive, behavioural and developmental impairments that is complex and can change naturally over time; there is a lack of standardised instruments for evaluating these outcomes in developmental and epileptic encephalopathies, with a reliance on subjective evaluations by proxy (caregivers); and treatment regimes are complex involving multiple ASMs as well as other drugs.
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Affiliation(s)
- Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University and University Hospital Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany. .,LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.
| | - Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University and University Hospital Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany.,LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.,Department of Neuropediatrics, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany
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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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A scoping review on cannabidiol therapy in tuberous sclerosis: Current evidence and perspectives for future development. Epilepsy Behav 2022; 128:108577. [PMID: 35151190 DOI: 10.1016/j.yebeh.2022.108577] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/06/2022] [Accepted: 01/14/2022] [Indexed: 12/30/2022]
Abstract
Cannabidiol (CBD) has recently been approved as an add-on therapy by various regulatory agencies for tuberous sclerosis complex (TSC)-associated seizures based on its short-term efficacy and safety in a pivotal randomized controlled trial. However, critical information about which patients with TSC and seizure types respond best to CBD (clinical, electrophysiological, and genetic predictors of responsiveness), when to use CBD in the treatment algorithm, and how CBD can be combined with other antiseizure medications (ASMs) in the form of a rational polypharmacy therapy is still lacking. In general, there is a limited in-depth critical review of CBD for the treatment of TSC to facilitate its optimal use in a clinical context. Here, we utilized a scoping review approach to report the current evidence of efficacy and safety of pharmaceutical-grade CBD in patients with TSC, including relevant mechanism of action and drug-drug interactions with other ASMs. We also discussed emerging information about CBD's long-term efficacy and safety data in patients with TSC. Finally, we discussed some critical unanswered questions in several domains related to effective clinical management of TSC using CBD, including barriers to early and aggressive treatment in infants, difficulty with universal access to CBD, a lack of studies to understand CBD's impact on seizure severity and specific seizure types, insufficient exploration of CBD in TSC-related cognitive and behavioral issues, and the need for more research into CBD's effects on various biomarkers.
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Laudanski K, Wain J. Considerations for Cannabinoids in Perioperative Care by Anesthesiologists. J Clin Med 2022; 11:jcm11030558. [PMID: 35160010 PMCID: PMC8836924 DOI: 10.3390/jcm11030558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/17/2022] [Accepted: 01/18/2022] [Indexed: 02/07/2023] Open
Abstract
Increased usage of recreational and medically indicated cannabinoid compounds has been an undeniable reality for anesthesiologists in recent years. These compounds’ complicated pharmacology, composition, and biological effects result in challenging issues for anesthesiologists during different phases of perioperative care. Here, we review the existing formulation of cannabinoids and their biological activity to put them into the context of the anesthesia plan execution. Perioperative considerations should include a way to gauge the patient’s intake of cannabinoids, the ability to gain consent properly, and vigilance to the increased risk of pulmonary and airway problems. Intraoperative management in individuals with cannabinoid use is complicated by the effects cannabinoids have on general anesthetics and depth of anesthesia monitoring while simultaneously increasing the potential occurrence of intraoperative hemodynamic instability. Postoperative planning should involve higher vigilance to the risk of postoperative strokes and acute coronary syndromes. However, most of the data are not up to date, rending definite conclusions on the importance of perioperative cannabinoid intake on anesthesia management difficult.
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Affiliation(s)
- Krzysztof Laudanski
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA 19104, USA
- Correspondence: (K.L.); (J.W.)
| | - Justin Wain
- School of Osteopathic Medicine, Campbell University, Buies Creek, NC 27506, USA
- Correspondence: (K.L.); (J.W.)
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