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Hansen JS, Boix F, Hasselstrøm JB, Sørensen L, Kjolby M, Gustavsen S, Hansen R, Petersen T, Sellebjerg F, Kasch H, Rasmussen PV, Finnerup NB, Sædder EA, Svendsen KB. Pharmacokinetics and pharmacodynamics of cannabis-based medicine in a patient population included in a randomized, placebo-controlled, clinical trial. Clin Transl Sci 2024; 17:e13685. [PMID: 38054364 PMCID: PMC10772478 DOI: 10.1111/cts.13685] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 10/16/2023] [Accepted: 10/26/2023] [Indexed: 12/07/2023] Open
Abstract
Information on the pharmacokinetics (PK) and pharmacodynamics (PD) of orally administered cannabis-based medicine (CBM) in capsule formulation in patient populations is sparse. In this exploratory study, we aimed to evaluate the PK and PD in a probable steady state of CBM in neuropathic pain and spasticity in a population of patients with multiple sclerosis (MS). Of 134 patients participating in a randomized, double-blinded, placebo-controlled, trial, 23 patients with MS (17 female) mean age 52 years (range 21-67) were enrolled in this substudy. They received oral capsules containing Δ9 -tetrahydrocannabinol (THC, n = 4), cannabidiol (CBD, n = 6), a combination (THC&CBD, n = 4), or placebo (n = 9). Maximum doses were 22.5 mg (THC) and 45 mg (CBD) a day divided into three administrations. PD parameters were evaluated for pain and spasticity. Blood samples were analyzed using an ultra-high-performance liquid chromatography-tandem mass spectrometer after protein precipitation and phospholipid removal. PK parameters were estimated using computerized modeling. The variation in daily dose and PK between individuals was considerable in a steady state, yet comparable with previous reports from healthy controls. Based on a simulation of the best model, the estimated PK parameters (mean) for THC (5 mg) were Cmax 1.21 ng/mL, Tmax 2.68 h, and half-life 2.75 h, and for CBD (10 mg) were Cmax 2.67 ng/mL, Tmax 0.10 h, and half-life 4.95 h, respectively. No effect was found on the PD parameters, but the placebo response was considerable. More immediate adverse events were registered in the active treatment groups compared with the placebo group.
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Affiliation(s)
- Julie Schjødtz Hansen
- Department of NeurologyAarhus University HospitalAarhusDenmark
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Fernando Boix
- Section for Drug Abuse Research, Department of Forensic Sciences, Division of Laboratory MedicineOslo University HospitalOsloNorway
| | | | | | - Mads Kjolby
- Department of Clinical PharmacologyAarhus University HospitalAarhusDenmark
- Department of BiomedicineAarhus UniversityAarhusDenmark
| | - Stefan Gustavsen
- Danish Multiple Sclerosis Center, Department of NeurologyCopenhagen University Hospital – RigshospitaletGlostrupDenmark
| | | | - Thor Petersen
- Department of NeurologyHospital of Southern Jutland and Research Unit in NeurologyAabenraaDenmark
- Department of Regional Health ResearchUniversity of Southern DenmarkOdenseDenmark
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, Department of NeurologyCopenhagen University Hospital – RigshospitaletGlostrupDenmark
| | - Helge Kasch
- Department of NeurologyAarhus University HospitalAarhusDenmark
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
| | | | - Nanna Brix Finnerup
- Department of NeurologyAarhus University HospitalAarhusDenmark
- Danish Pain Research Centre, Department of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Eva Aggerholm Sædder
- Department of Clinical PharmacologyAarhus University HospitalAarhusDenmark
- Department of BiomedicineAarhus UniversityAarhusDenmark
| | - Kristina Bacher Svendsen
- Department of NeurologyAarhus University HospitalAarhusDenmark
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
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Bernal‐Chico A, Tepavcevic V, Manterola A, Utrilla C, Matute C, Mato S. Endocannabinoid signaling in brain diseases: Emerging relevance of glial cells. Glia 2023; 71:103-126. [PMID: 35353392 PMCID: PMC9790551 DOI: 10.1002/glia.24172] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/15/2022] [Accepted: 03/17/2022] [Indexed: 02/06/2023]
Abstract
The discovery of cannabinoid receptors as the primary molecular targets of psychotropic cannabinoid Δ9 -tetrahydrocannabinol (Δ9 -THC) in late 1980s paved the way for investigations on the effects of cannabis-based therapeutics in brain pathology. Ever since, a wealth of results obtained from studies on human tissue samples and animal models have highlighted a promising therapeutic potential of cannabinoids and endocannabinoids in a variety of neurological disorders. However, clinical success has been limited and major questions concerning endocannabinoid signaling need to be satisfactorily addressed, particularly with regard to their role as modulators of glial cells in neurodegenerative diseases. Indeed, recent studies have brought into the limelight diverse, often unexpected functions of astrocytes, oligodendrocytes, and microglia in brain injury and disease, thus providing scientific basis for targeting glial cells to treat brain disorders. This Review summarizes the current knowledge on the molecular and cellular hallmarks of endocannabinoid signaling in glial cells and its clinical relevance in neurodegenerative and chronic inflammatory disorders.
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Affiliation(s)
- Ana Bernal‐Chico
- Department of NeurosciencesUniversity of the Basque Country UPV/EHULeioaSpain,Achucarro Basque Center for NeuroscienceLeioaSpain,Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED)MadridSpain,Neuroimmunology UnitBiocruces BizkaiaBarakaldoSpain
| | | | - Andrea Manterola
- Department of NeurosciencesUniversity of the Basque Country UPV/EHULeioaSpain,Achucarro Basque Center for NeuroscienceLeioaSpain,Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED)MadridSpain,Present address:
Parque Científico y Tecnológico de GuipuzkoaViralgenSan SebastianSpain
| | | | - Carlos Matute
- Department of NeurosciencesUniversity of the Basque Country UPV/EHULeioaSpain,Achucarro Basque Center for NeuroscienceLeioaSpain,Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED)MadridSpain
| | - Susana Mato
- Department of NeurosciencesUniversity of the Basque Country UPV/EHULeioaSpain,Achucarro Basque Center for NeuroscienceLeioaSpain,Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED)MadridSpain,Neuroimmunology UnitBiocruces BizkaiaBarakaldoSpain
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3
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Abstract
Spasticity is characterized by an enhanced size and reduced threshold for activation of stretch reflexes and is associated with "positive signs" such as clonus and spasms, as well as "negative features" such as paresis and a loss of automatic postural responses. Spasticity develops over time after a lesion and can be associated with reduced speed of movement, cocontraction, abnormal synergies, and pain. Spasticity is caused by a combination of damage to descending tracts, reductions in inhibitory activity within spinal cord circuits, and adaptive changes within motoneurons. Increased tone, hypertonia, can also be caused by changes in passive stiffness due to, for example, increase in connective tissue and reduction in muscle fascicle length. Understanding the cause of hypertonia is important for determining the management strategy as nonneural, passive causes of stiffness will be more amenable to physical rather than pharmacological interventions. The management of spasticity is determined by the views and goals of the patient, family, and carers, which should be integral to the multidisciplinary assessment. An assessment, and treatment, of trigger factors such as infection and skin breakdown should be made especially in people with a recent change in tone. The choice of management strategies for an individual will vary depending on the severity of spasticity, the distribution of spasticity (i.e., whether it affects multiple muscle groups or is more prominent in one or two groups), the type of lesion, and the potential for recovery. Management options include physical therapy, oral agents; focal therapies such as botulinum injections; and peripheral nerve blocks. Intrathecal baclofen can lead to a reduction in required oral antispasticity medications. When spasticity is severe intrathecal phenol may be an option. Surgical interventions, largely used in the pediatric population, include muscle transfers and lengthening and selective dorsal root rhizotomy.
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Affiliation(s)
- Jonathan Marsden
- School of Health Professions, Faculty of Health, University of Plymouth, Plymouth, United Kingdom.
| | - Valerie Stevenson
- Department of Therapies and Rehabilitation, National Hospital for Neurology and Neurosurgery UCLH, London, United Kingdom
| | - Louise Jarrett
- Department of Neurology, Royal Devon and Exeter Hospital, Exeter, United Kingdom
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4
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Dangond F, Donnelly A, Hohlfeld R, Lubetzki C, Kohlhaas S, Leocani L, Ciccarelli O, Stankoff B, Sormani MP, Chataway J, Bozzoli F, Cucca F, Melton L, Coetzee T, Salvetti M. Facing the urgency of therapies for progressive MS - a Progressive MS Alliance proposal. Nat Rev Neurol 2021; 17:185-192. [PMID: 33483719 DOI: 10.1038/s41582-020-00446-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2020] [Indexed: 12/20/2022]
Abstract
Therapies for infiltrative inflammation in multiple sclerosis (MS) have advanced greatly, but neurodegeneration and compartmentalized inflammation remain virtually untargeted as in other diseases of the nervous system. Consequently, many therapies are available for the relapsing-remitting form of MS, but the progressive forms remain essentially untreated. The objective of the International Progressive MS Alliance is to expedite the development of effective therapies for progressive MS through new initiatives that foster innovative thinking and concrete advancements. Based on these principles, the Alliance is developing a new funding programme that will focus on experimental medicine trials. Here, we discuss the reasons behind the focus on experimental medicine trials, the strengths and weaknesses of these approaches and of the programme, and why we hope to advance therapies while improving the understanding of progression in MS. We are soliciting public and academic feedback, which will help shape the programme and future strategies of the Alliance.
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Affiliation(s)
| | - Alexis Donnelly
- Department of Computer Science, O'Reilly Institute, Trinity College, Dublin, Ireland
| | - Reinhard Hohlfeld
- Institute of Clinical Neuroimmunology, Biomedical Center and Hospital of the Ludwig Maximilians Universität München, Munich, Germany.,Munich Cluster for Systems Neurology (Synergy), Munich, Germany
| | - Catherine Lubetzki
- Neurology Department, Sorbonne University, Pitié-Salpêtrière Hospital, Paris, France
| | | | - Letizia Leocani
- Vita-Salute San Raffaele University, Milan, Italy.,Neurorehabilitation Department and Experimental Neurophysiology Unit, INSPE, Scientific Institute Hospital San Raffaele, Milan, Italy
| | - Olga Ciccarelli
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK.,National Institute for Health Research University College London Hospitals Biomedical Research Centre, London, UK
| | - Bruno Stankoff
- Sorbonne University, Brain and Spine Institute, ICM, Pitié-Salpêtrière Hospital, Paris, France
| | - Maria Pia Sormani
- Department of Health Sciences (DISSAL), University of Genova, Genova, Italy.,IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK.,National Institute for Health Research University College London Hospitals Biomedical Research Centre, London, UK
| | | | - Francesco Cucca
- Dipartimento di Scienze Biomediche, Università di Sassari, Sassari, Italy
| | - Lisa Melton
- MS Research Australia, North Sydney, New South Wales, Australia
| | | | - Marco Salvetti
- Department of Neurosciences, Mental Health and Sensory Organs, Centre for Experimental Neurological Therapies (CENTERS), Faculty of Medicine and Psychology, Sapienza University, Rome, Italy. .,IRCCS Istituto Neurologico Mediterraneo (INM) Neuromed, Pozzilli, Italy.
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5
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Farrell R, Baker D. An expert opinion: Optimisation of pharmacological management of multiple sclerosis related spasticity. ADVANCES IN CLINICAL NEUROSCIENCE & REHABILITATION 2019. [DOI: 10.47795/kaib7737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Spasticity is a frequent symptom in people with Multiple Sclerosis. Whilst many respond to first-line therapies it is estimated that 30-40% will have suboptimal treatment response requiring more specialised management. Such strategies include combination of oral medications, botulinum toxin, nabiximols and consideration of intrathecal therapies; baclofen or phenol. Early expert intervention as outlined in this review can have a positive impact on functional ability and quality of life for people with MS.
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6
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Ingram G, Pearson OR. Cannabis and multiple sclerosis. Pract Neurol 2019; 19:310-315. [PMID: 31201234 DOI: 10.1136/practneurol-2018-002137] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/22/2019] [Accepted: 03/26/2019] [Indexed: 12/20/2022]
Abstract
Patients with multiple sclerosis have long turned to complementary therapies to manage symptoms that licensed products can only partially control. Around half of patients with multiple sclerosis admit to previous or current cannabis use for medicinal purposes and would endorse legalisation. Despite many governments worldwide relaxing regulations around medicinal cannabis, there remain many unanswered questions as to how clinicians should prescribe or recommend products, and access to pharmaceutical-grade products remains highly restricted. Here we address what adult neurologists need to know about cannabis and its use in multiple sclerosis.
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Nielsen S, Murnion B, Campbell G, Young H, Hall W. Cannabinoids for the treatment of spasticity. Dev Med Child Neurol 2019; 61:631-638. [PMID: 30680713 DOI: 10.1111/dmcn.14165] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2018] [Indexed: 12/19/2022]
Abstract
This review summarizes studies that examined the effectiveness of cannabinoids in treating spasticity, with a focus on understanding the relevance of the existing evidence to paediatric populations. MEDLINE, Embase, PsycINFO, and the Cochrane Library were searched to identify studies that examined the use of cannabinoids in spasticity. We identified 32 studies in adult and paediatric populations. Results were summarized by condition, with adult and paediatric studies considered separately. There is evidence from randomized controlled clinical trials that cannabinoids are more effective than placebo in reducing symptoms of spasticity in adults with multiple sclerosis. Most positive effects were based on patient-rated rather than clinician-rated measures, were modest in size, and should be considered in the context of the narrow therapeutic index of cannabinoids for spasticity and adverse effects. There were comparatively few, and no large studies, of spasticity in conditions other than multiple sclerosis. Few studies have been conducted in paediatric populations. Paediatric studies of spasticity provide low quality evidence and are inadequate to inform clinical practice. Cannabinoids have modest efficacy in reducing muscle spasticity in adults with multiple sclerosis. There is limited evidence of efficacy for cannabinoid use in other conditions, particularly in paediatric populations. Studies in paediatric populations have been of low quality and are insufficient to inform clinical practice.
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Affiliation(s)
- Suzanne Nielsen
- Monash Addiction Research Centre, Monash University, Melbourne, Victoria, Australia.,National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, New South Wales, Australia
| | - Bridin Murnion
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia.,Drug Health Services, Sydney Local Health District, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Gabrielle Campbell
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, New South Wales, Australia
| | - Helen Young
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.,Royal North Short Hospital, St Leonards, New South Wales, Australia.,Neurogenetics, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Wayne Hall
- Centre for Youth Substance Abuse Research, The University of Queensland, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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8
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PTL401, a New Formulation Based on Pro-Nano Dispersion Technology, Improves Oral Cannabinoids Bioavailability in Healthy Volunteers. J Pharm Sci 2018; 107:1423-1429. [DOI: 10.1016/j.xphs.2017.12.020] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 12/12/2017] [Accepted: 12/12/2017] [Indexed: 02/07/2023]
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9
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Neuroprotective effect of cannabinoids nanoplatforms in neurodegenerative diseases. J Drug Deliv Sci Technol 2017. [DOI: 10.1016/j.jddst.2017.04.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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10
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Baker D, Pryce G, Visintin C, Sisay S, Bondarenko AI, Vanessa Ho WS, Jackson SJ, Williams TE, Al-Izki S, Sevastou I, Okuyama M, Graier WF, Stevenson LA, Tanner C, Ross R, Pertwee RG, Henstridge CM, Irving AJ, Schulman J, Powell K, Baker MD, Giovannoni G, Selwood DL. Big conductance calcium-activated potassium channel openers control spasticity without sedation. Br J Pharmacol 2017; 174:2662-2681. [PMID: 28677901 PMCID: PMC5522996 DOI: 10.1111/bph.13889] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 04/27/2017] [Accepted: 05/17/2017] [Indexed: 12/19/2022] Open
Abstract
Background and Purpose Our initial aim was to generate cannabinoid agents that control spasticity, occurring as a consequence of multiple sclerosis (MS), whilst avoiding the sedative side effects associated with cannabis. VSN16R was synthesized as an anandamide (endocannabinoid) analogue in an anti‐metabolite approach to identify drugs that target spasticity. Experimental Approach Following the initial chemistry, a variety of biochemical, pharmacological and electrophysiological approaches, using isolated cells, tissue‐based assays and in vivo animal models, were used to demonstrate the activity, efficacy, pharmacokinetics and mechanism of action of VSN16R. Toxicological and safety studies were performed in animals and humans. Key Results VSN16R had nanomolar activity in tissue‐based, functional assays and dose‐dependently inhibited spasticity in a mouse experimental encephalomyelitis model of MS. This effect occurred with over 1000‐fold therapeutic window, without affecting normal muscle tone. Efficacy was achieved at plasma levels that are feasible and safe in humans. VSN16R did not bind to known CB1/CB2/GPPR55 cannabinoid‐related receptors in receptor‐based assays but acted on a vascular cannabinoid target. This was identified as the major neuronal form of the big conductance, calcium‐activated potassium (BKCa) channel. Drug‐induced opening of neuronal BKCa channels induced membrane hyperpolarization, limiting excessive neural‐excitability and controlling spasticity. Conclusions and Implications We identified the neuronal form of the BKCa channel as the target for VSN16R and demonstrated that its activation alleviates neuronal excitability and spasticity in an experimental model of MS, revealing a novel mechanism to control spasticity. VSN16R is a potential, safe and selective ligand for controlling neural hyper‐excitability in spasticity.
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Affiliation(s)
- David Baker
- Neuroimmunology Unit, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Department of Neuroinflammation, UCL Institute of Neurology, University College London, London, UK
| | - Gareth Pryce
- Neuroimmunology Unit, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Department of Neuroinflammation, UCL Institute of Neurology, University College London, London, UK
| | - Cristina Visintin
- Department of Neuroinflammation, UCL Institute of Neurology, University College London, London, UK.,Department of Medicinal Chemistry, UCL Wolfson Institute for Biomedical Research, University College London, London, UK
| | - Sofia Sisay
- Neuroimmunology Unit, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Alexander I Bondarenko
- Institute of Molecular Biology and Biochemistry, Medical University of Graz, Graz, Austria.,A.A. Bogomoletz Institute of Physiology, Kiev, Ukraine
| | - W S Vanessa Ho
- Vascular Biology Research Centre. St. George's, University of London, London, UK
| | - Samuel J Jackson
- Neuroimmunology Unit, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Thomas E Williams
- Neuroimmunology Unit, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sarah Al-Izki
- Neuroimmunology Unit, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Ioanna Sevastou
- Department of Medicinal Chemistry, UCL Wolfson Institute for Biomedical Research, University College London, London, UK
| | - Masahiro Okuyama
- Department of Medicinal Chemistry, UCL Wolfson Institute for Biomedical Research, University College London, London, UK
| | - Wolfgang F Graier
- Institute of Molecular Biology and Biochemistry, Medical University of Graz, Graz, Austria
| | - Lesley A Stevenson
- Vascular Biology Research Centre. St. George's, University of London, London, UK
| | - Carolyn Tanner
- Department of Biomedical Sciences, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Ruth Ross
- Department of Biomedical Sciences, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Roger G Pertwee
- Department of Biomedical Sciences, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Christopher M Henstridge
- Neurosciences Institute, Division of Pathology and Neuroscience, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Andrew J Irving
- Neurosciences Institute, Division of Pathology and Neuroscience, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Jesse Schulman
- Canbex Therapeutics Ltd, London BioScience Innovation Centre, London, UK
| | - Keith Powell
- Canbex Therapeutics Ltd, London BioScience Innovation Centre, London, UK
| | - Mark D Baker
- Neuroimmunology Unit, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Gavin Giovannoni
- Neuroimmunology Unit, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Department of Neuroinflammation, UCL Institute of Neurology, University College London, London, UK
| | - David L Selwood
- Department of Medicinal Chemistry, UCL Wolfson Institute for Biomedical Research, University College London, London, UK
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11
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Keating GM. Delta-9-Tetrahydrocannabinol/Cannabidiol Oromucosal Spray (Sativex ®): A Review in Multiple Sclerosis-Related Spasticity. Drugs 2017; 77:563-574. [PMID: 28293911 DOI: 10.1007/s40265-017-0720-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Delta-9-tetrahydrocannabinol (THC)/cannabidiol (CBD) oromucosal spray (THC/CBD, Sativex®, nabiximols) is available in numerous countries worldwide for the treatment of multiple sclerosis (MS)-related moderate to severe spasticity in patients who have not responded adequately to other anti-spasticity medication and who demonstrate clinically significant improvement in spasticity-related symptoms during an initial trial of therapy. Twelve weeks' therapy with THC/CBD improved MS-related spasticity in patients with an inadequate response to other anti-spasticity agents who had undergone a successful initial trial of THC/CBD therapy, according to the results of a pivotal phase 3 trial. Improvements in spasticity were maintained in the longer term with THC/CBD with no evidence of dose tolerance, and results of real-world studies confirm the effectiveness of THC/CBD in everyday clinical practice. Improvements in health-related quality of life and activities of daily living were also seen with THC/CBD. THC/CBD is generally well tolerated; adverse effects such as dizziness may occur whilst the THC/CBD dosage is being optimized. THC/CBD has low abuse potential and a low risk of psychoactive effects. In conclusion, THC/CBD oromucosal spray is a useful option for the treatment of MS-related spasticity not completely relieved with current anti-spasticity medication.
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Affiliation(s)
- Gillian M Keating
- Springer, Private Bag 65901, Mairangi Bay, 0754, Auckland, New Zealand.
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12
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Practical Aspects of Discussing Marijuana in a New Era. J Psychiatr Pract 2016; 22:471-477. [PMID: 27824781 DOI: 10.1097/pra.0000000000000189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The use of marijuana for the treatment of medical conditions is a highly controversial topic. Misconceptions by both patients and providers concerning the safety of and evidence-based indications for marijuana can complicate treatment planning and outcomes. Maintaining skills such as motivational interviewing, providing evidence-based informed consent, and increasing access to care remain top priorities for providing quality patient care. The goal of this article is to offer guidance to clinical providers who are adapting to the changing realities of medical marijuana and legalized recreational marijuana.
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13
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Moreno-Martet M, Feliú A, Espejo-Porras F, Mecha M, Carrillo-Salinas FJ, Fernández-Ruiz J, Guaza C, de Lago E. The disease-modifying effects of a Sativex-like combination of phytocannabinoids in mice with experimental autoimmune encephalomyelitis are preferentially due to Δ9-tetrahydrocannabinol acting through CB1 receptors. Mult Scler Relat Disord 2015; 4:505-11. [DOI: 10.1016/j.msard.2015.08.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 07/22/2015] [Accepted: 08/04/2015] [Indexed: 02/07/2023]
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14
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Polypharmacology Shakes Hands with Complex Aetiopathology. Trends Pharmacol Sci 2015; 36:802-821. [PMID: 26434643 DOI: 10.1016/j.tips.2015.08.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 08/13/2015] [Accepted: 08/18/2015] [Indexed: 02/07/2023]
Abstract
Chronic diseases are due to deviations of fundamental physiological systems, with different pathologies being characterised by similar malfunctioning biological networks. The ensuing compensatory mechanisms may weaken the body's dynamic ability to respond to further insults and reduce the efficacy of conventional single target treatments. The multitarget, systemic, and prohomeostatic actions emerging for plant cannabinoids exemplify what might be needed for future medicines. Indeed, two combined cannabis extracts were approved as a single medicine (Sativex(®)), while pure cannabidiol, a multitarget cannabinoid, is emerging as a treatment for paediatric drug-resistant epilepsy. Using emerging cannabinoid medicines as an example, we revisit the concept of polypharmacology and describe a new empirical model, the 'therapeutic handshake', to predict efficacy/safety of compound combinations of either natural or synthetic origin.
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15
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Delta-9-tetrahydrocannabinol/cannabidiol (Sativex®): a review of its use in patients with moderate to severe spasticity due to multiple sclerosis. Drugs 2015; 74:563-78. [PMID: 24671907 DOI: 10.1007/s40265-014-0197-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Delta-9-tetrahydrocannabinol (THC)/cannabidiol (CBD) [Sativex®] is an oromucosal spray formulation that contains principally THC and CBD at an approximately 1:1 fixed ratio, derived from cloned Cannabis sativa L. plants. The main active substance, THC, acts as a partial agonist at human cannabinoid receptors (CB1 and CB2), and thus, may modulate the effects of excitatory (glutamate) and inhibitory (gamma-aminobutyric acid) neurotransmitters. THC/CBD is approved in a number of countries, including Germany and the UK, as an add-on treatment for symptom improvement in adult patients with moderate to severe spasticity due to multiple sclerosis who have not responded adequately to other anti-spasticity medication and who demonstrate clinically significant improvement in spasticity-related symptoms during an initial trial of therapy. In the largest multinational clinical trial that evaluated the approved THC/CBD regimen in this population, 12 weeks' double-blind treatment with THC/CBD significantly reduced spasticity severity (primary endpoint) compared with placebo in patients who achieved a clinically significant improvement in spasticity after 4 weeks' single-blind THC/CBD treatment, as assessed by a patient-rated numerical rating scale. A significantly greater proportion of THC/CBD than placebo recipients achieved a ≥ 30% reduction (a clinically relevant reduction) in spasticity severity. The efficacy of THC/CBD has been also shown in at least one everyday clinical practice study (MOVE 2). THC/CBD was generally well tolerated in clinical trials. Dizziness and fatigue were reported most frequently during the first 4 weeks of treatment and resolved within a few days even with continued treatment. Thus, add-on THC/CBD is a useful symptomatic treatment option for its approved indication.
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Luquiens A, Lourenco N, Benyamina A, Aubin HJ. Self-medication of achalasia with cannabis, complicated by a cannabis use disorder. World J Gastroenterol 2015; 21:6381-6383. [PMID: 26034374 PMCID: PMC4445116 DOI: 10.3748/wjg.v21.i20.6381] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 11/26/2014] [Accepted: 01/08/2015] [Indexed: 02/06/2023] Open
Abstract
Achalasia is a rare esophagus motility disorder. Medical, endoscopic and surgical treatments are available, but all endorse high relapse rates. No data has been published to date reporting a therapeutic effect of cannabis use neither in achalasia nor on its influence on manometric measurements. We report the case of a patient diagnosed with achalasia. He could benefit from a large panel of therapeutic interventions, but none of them was effective over the time. He first used cannabis at age 20 and identified benefits regarding achalasia symptoms. He maintained regular moderate cannabis use for 9 years, with minimal digestive inconvenience. A manometry performed without cannabis premedication was realized at age 26 and still found a cardiospasm. Cannabis use could explain the gap between functional symptoms assessment and manometry measurement. Further investigations are warranted to explore a therapeutic effect of cannabis in achalasia and possible influence on outcome measurements.
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Neuroprotection in Experimental Autoimmune Encephalomyelitis and Progressive Multiple Sclerosis by Cannabis-Based Cannabinoids. J Neuroimmune Pharmacol 2014; 10:281-92. [PMID: 25537576 DOI: 10.1007/s11481-014-9575-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Accepted: 12/10/2014] [Indexed: 02/06/2023]
Abstract
Multiple sclerosis (MS) is the major immune-mediated, demyelinating, neurodegenerative disease of the central nervous system. Compounds within cannabis, notably Δ9-tetrahydrocannabinol (Δ9-THC) can limit the inappropriate neurotransmissions that cause MS-related problems and medicinal cannabis is now licenced for the treatment of MS symptoms. However, the biology indicates that the endocannabinoid system may offer the potential to control other aspects of disease. Although there is limited evidence that the cannabinoids from cannabis are having significant immunosuppressive activities that will influence relapsing autoimmunity, we and others can experimentally demonstrate that they may limit neurodegeneration that drives progressive disability. Here we show that synthetic cannabidiol can slow down the accumulation of disability from the inflammatory penumbra during relapsing experimental autoimmune encephalomyelitis (EAE) in ABH mice, possibly via blockade of voltage-gated sodium channels. In addition, whilst non-sedating doses of Δ9-THC do not inhibit relapsing autoimmunity, they dose-dependently inhibit the accumulation of disability during EAE. They also appear to slow down clinical progression during MS in humans. Although a 3 year, phase III clinical trial did not detect a beneficial effect of oral Δ9-THC in progressive MS, a planned subgroup analysis of people with less disability who progressed more rapidly, demonstrated a significant slowing of progression by oral Δ9-THC compared to placebo. Whilst this may support the experimental and biological evidence for a neuroprotective effect by the endocannabinoid system in MS, it remains to be established whether this will be formally demonstrated in further trials of Δ9-THC/cannabis in progressive MS.
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Baker D, Amor S. Experimental autoimmune encephalomyelitis is a good model of multiple sclerosis if used wisely. Mult Scler Relat Disord 2014; 3:555-64. [PMID: 26265267 DOI: 10.1016/j.msard.2014.05.002] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 05/01/2014] [Accepted: 05/05/2014] [Indexed: 02/07/2023]
Abstract
Although multiple sclerosis is a uniquely human disease, many pathological features can be induced in experimental autoimmune encephalomyelitis (EAE) models following induction of central nervous system-directed autoimmunity. Whilst it is an imperfect set of models, EAE can be used to identify pathogenic mechanisms and therapeutics. However, the failure to translate many treatments from EAE into human benefit has led some to question the validity of the EAE model. Whilst differences in biology between humans and other species may account for this, it is suggested here that the failure to translate may be considerably influenced by human activity. Basic science contributes to failings in aspects of experimental design and over-interpretation of results and lack of transparency and reproducibility of the studies. Importantly issues in trial design by neurologists and other actions of the pharmaceutical industry destine therapeutics to failure and terminate basic science projects. However animal, particularly mechanism-orientated, studies have increasingly identified useful treatments and provided mechanistic ideas on which most hypothesis-led clinical research is based. Without EAE and other animal studies, clinical investigations will continue to be "look-see" exercises, which will most likely provide more misses than hits and will fail the people with MS that they aim to serve.
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Affiliation(s)
- David Baker
- Neuroimmunology Unit, Blizard Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, 4 Newark Street, London E1 2AT, United Kingdom.
| | - Sandra Amor
- Neuroimmunology Unit, Blizard Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, 4 Newark Street, London E1 2AT, United Kingdom; Pathology Department, VU Medical Centre, Free University of Amsterdam, The Netherlands
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Pryce G, Visintin C, Ramagopalan SV, Al-Izki S, De Faveri LE, Nuamah RA, Mein CA, Montpetit A, Hardcastle AJ, Kooij G, de Vries HE, Amor S, Thomas SA, Ledent C, Marsicano G, Lutz B, Thompson AJ, Selwood DL, Giovannoni G, Baker D. Control of spasticity in a multiple sclerosis model using central nervous system-excluded CB1 cannabinoid receptor agonists. FASEB J 2013; 28:117-30. [PMID: 24121462 DOI: 10.1096/fj.13-239442] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The purpose of this study was the generation of central nervous system (CNS)-excluded cannabinoid receptor agonists to test the hypothesis that inhibition of spasticity, due to CNS autoimmunity, could be controlled by affecting neurotransmission within the periphery. Procedures included identification of chemicals and modeling to predict the mode of exclusion; induction and control of spasticity in the ABH mouse model of multiple sclerosis; conditional deletion of CB1 receptor in peripheral nerves; side-effect profiling to demonstrate the mechanism of CNS-exclusion via drug pumps; genome-wide association study in N2(129×ABH) backcross to map polymorphic cannabinoid drug pump; and sequencing and detection of cannabinoid drug-pump activity in human brain endothelial cell lines. Three drugs (CT3, SAB378 and SAD448) were identified that control spasticity via action on the peripheral nerve CB1 receptor. These were peripherally restricted via drug pumps that limit the CNS side effects (hypothermia) of cannabinoids to increase the therapeutic window. A cannabinoid drug pump is polymorphic and functionally lacking in many laboratory (C57BL/6, 129, CD-1) mice used for transgenesis, pharmacology, and toxicology studies. This phenotype was mapped and controlled by 1-3 genetic loci. ABCC1 within a cluster showing linkage is a cannabinoid CNS-drug pump. Global and conditional CB1 receptor-knockout mice were used as controls. In summary, CNS-excluded CB1 receptor agonists are a novel class of therapeutic agent for spasticity.
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Affiliation(s)
- Gareth Pryce
- 1Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark St., London E1 2AT, UK.
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Sisay S, Pryce G, Jackson SJ, Tanner C, Ross RA, Michael GJ, Selwood DL, Giovannoni G, Baker D. Genetic background can result in a marked or minimal effect of gene knockout (GPR55 and CB2 receptor) in experimental autoimmune encephalomyelitis models of multiple sclerosis. PLoS One 2013; 8:e76907. [PMID: 24130809 PMCID: PMC3793915 DOI: 10.1371/journal.pone.0076907] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 08/26/2013] [Indexed: 12/20/2022] Open
Abstract
Endocannabinoids and some phytocannabinoids bind to CB1 and CB2 cannabinoid receptors, transient receptor potential vanilloid one (TRPV1) receptor and the orphan G protein receptor fifty-five (GPR55). Studies using C57BL/10 and C57BL/6 (Cnr2tm1Zim) CB2 cannabinoid receptor knockout mice have demonstrated an immune-augmenting effect in experimental autoimmune encephalomyelitis (EAE) models of multiple sclerosis. However, other EAE studies in Biozzi ABH mice often failed to show any treatment effect of either CB2 receptor agonism or antagonism on inhibition of T cell autoimmunity. The influence of genetic background on the induction of EAE in endocannabinoid system-related gene knockout mice was examined. It was found that C57BL/6.GPR55 knockout mice developed less severe disease, notably in female mice, following active induction with myelin oligodendrocyte glycoprotein 35-55 peptide. In contrast C57BL/6.CB2 (Cnr2Dgen) receptor knockout mice developed augmented severity of disease consistent with the genetically and pharmacologically-distinct, Cnr2tm1Zim mice. However, when the knockout gene was bred into the ABH mouse background and EAE induced with spinal cord autoantigens the immune-enhancing effect of CB2 receptor deletion was lost. Likewise CB1 receptor and transient receptor potential vanilloid one knockout mice on the ABH background demonstrated no alteration in immune-susceptibility, in terms of disease incidence and severity of EAE, in contrast to that reported in some C57BL/6 mouse studies. Furthermore the immune-modulating influence of GPR55 was marginal on the ABH mouse background. Whilst sedative doses of tetrahydrocannabinol could induce immunosuppression, this was associated with a CB1 receptor rather than a CB2 receptor-mediated effect. These data support the fact that non-psychoactive doses of medicinal cannabis have a marginal influence on the immune response in MS. Importantly, it adds a note of caution for the translational value of some transgenic/gene knockout and other studies on low-EAE susceptibility backgrounds with inconsistent disease course and susceptibility.
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MESH Headings
- Animals
- Disease Models, Animal
- Encephalomyelitis, Autoimmune, Experimental/genetics
- Encephalomyelitis, Autoimmune, Experimental/immunology
- Female
- Gene Deletion
- Gene Knockout Techniques
- Immunomodulation/genetics
- Male
- Mice
- Multiple Sclerosis/genetics
- Multiple Sclerosis/immunology
- Phenotype
- Receptor, Cannabinoid, CB2/deficiency
- Receptor, Cannabinoid, CB2/genetics
- Receptors, Cannabinoid/deficiency
- Receptors, Cannabinoid/genetics
- Species Specificity
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Affiliation(s)
- Sofia Sisay
- Neuroimmunology, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Gareth Pryce
- Neuroimmunology, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Samuel J. Jackson
- Neuroimmunology, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Carolyn Tanner
- School of Medical Science, Institute of Medical Sciences, University of Aberdeen, Foresterhill, Aberdeen, United Kingdom
| | - Ruth A. Ross
- School of Medical Science, Institute of Medical Sciences, University of Aberdeen, Foresterhill, Aberdeen, United Kingdom
- Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Gregory J. Michael
- Neuroimmunology, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - David L. Selwood
- Biological and Medical Chemistry, the Wolfson Institute for Biomedical Research, University College London, London, United Kingdom
| | - Gavin Giovannoni
- Neuroimmunology, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - David Baker
- Neuroimmunology, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
- * E-mail:
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Pryce G, Cabranes A, Fernández-Ruiz J, Bisogno T, Di Marzo V, Long JZ, Cravatt BF, Giovannoni G, Baker D. Control of experimental spasticity by targeting the degradation of endocannabinoids using selective fatty acid amide hydrolase inhibitors. Mult Scler 2013; 19:1896-904. [PMID: 23625705 DOI: 10.1177/1352458513485982] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND It has been previously shown that CB1 cannabinoid receptor agonism using cannabis extracts alleviates spasticity in both a mouse experimental autoimmune encephalomyelitis (EAE) model and multiple sclerosis (MS) in humans. However, this action can be associated with dose-limiting side effects. OBJECTIVE We hypothesised that blockade of anandamide (endocannabinoid) degradation would inhibit spasticity, whilst avoiding overt cannabimimetic effects. METHODS Spasticity eventually developed following the induction of EAE in either wild-type or congenic fatty acid amide hydrolase (FAAH)-deficient Biozzi ABH mice. These animals were treated with a variety of different FAAH inhibitors and the effect on the degree of limb stiffness was assessed using a strain gauge. RESULTS Control of spasticity was achieved using FAAH inhibitors CAY100400, CAY100402 and URB597, which was sustained following repeated administrations. Therapeutic activity occurred in the absence of overt cannabimimetic effects. Importantly, the therapeutic value of the target could be definitively validated as the treatment activity was lost in FAAH-deficient mice. Spasticity was also controlled by a selective monoacyl glycerol lipase inhibitor, JZL184. CONCLUSIONS This study demonstrates definitively that FAAH inhibitors provide a new class of anti-spastic agents that may have utility in treating spasticity in MS and avoid the dose-limiting side effects associated with cannabis use.
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Affiliation(s)
- G Pryce
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
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