1
|
Mick G, Douek P. Clinical Benefits and Safety of Medical Cannabis Products: A Narrative Review on Natural Extracts. Pain Ther 2024; 13:1063-1094. [PMID: 39096481 DOI: 10.1007/s40122-024-00643-0] [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: 05/24/2024] [Accepted: 07/23/2024] [Indexed: 08/05/2024] Open
Abstract
Interest in medical cannabis and cannabis-based medicinal products (CBMPs) has increased greatly in recent years. Two cannabinoids are of principal importance; delta-9-tetrahydrocannabinol (∆9-THC), the primary psychoactive component, and also cannabidiol (CBD), considered non-intoxicating. Each has distinct mechanisms of action and different therapeutic potentials. CBMPs differ in their ∆9-THC and CBD components; predominantly ∆9-THC, balanced formulations with equivalent ∆9-THC and CBD elements, and CBD-predominant products. In this narrative review, we evaluate the published evidence for the clinical benefits of CBMPs and overall benefits in well-being. We also review the overall safety profile and discuss the potential for dependence with CBMPs. Evidence can be drawn from a wide range of randomized and other controlled studies and from observational real-world studies. Most data from observational registry studies are supportive of ∆9-THC-based products (∆9-THC-predominant or balanced CBMPs) in the management of chronic neuropathic pain. Balanced products are also effective in reducing spasticity in multiple sclerosis. Most CBMPs show benefit in providing symptomatic benefits in reducing anxiety, nausea, and in improving sleep, but the place of specific products is more subtle, and choice guided by specific circumstances. Symptomatic improvements are accompanied by improved quality of life and well-being. Safety data indicate that CBMPs are generally well tolerated in most patients without specific contraindications. The majority of adverse effects are non-serious, and transient; most are principally associated with ∆9-THC and are dose-dependent. In contrast to recreational cannabis use, there is little evidence from clinical studies that CBMPs have any potential for dependence.
Collapse
Affiliation(s)
- Gérard Mick
- Pain Center, Voiron Hospital, CHU Grenoble-Alpes-Voiron, Voiron, 38500, Grenoble, France.
- CETD, Hôpital Neurologique Pierre Wertheimer, CHU de Lyon-Hospices Civils de Lyon (HCL), 69500, Bron, France.
- Health Systemic Process (P2S) Laboratory, Research Unit 4129, Université Claude Bernard Lyon 1, 69008, Lyon, France.
- THEMAS Team, TIMC Laboratory, Université Grenoble Alpes, 38000, Grenoble, France.
| | | |
Collapse
|
2
|
Murphy M, Kaur V, Bui HL, Yang T, Erridge S, Holvey C, Coomber R, Rucker JJ, Weatherall MW, Sodergren MH. Clinical outcome analysis of patients with multiple sclerosis - Analysis from the UK Medical Cannabis Registry. Mult Scler Relat Disord 2024; 87:105665. [PMID: 38728958 DOI: 10.1016/j.msard.2024.105665] [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: 12/20/2022] [Revised: 12/01/2023] [Accepted: 05/03/2024] [Indexed: 05/12/2024]
Abstract
INTRODUCTION Whilst disease-modifying therapies are the cornerstone for treatment of multiple sclerosis (MS), there is a need to develop novel therapeutics for the symptomatic sequalae of the disease. Cannabis-based medicinal products (CBMPs) have been suggested as a potential therapy for the associated pain, spasticity, and mental health disorders. However, there is a paucity of clinical evidence on CBMPs in MS. The aim of this study is to assess changes in MS-specific and general health-related quality of life (HRQoL) outcomes alongside adverse event incidence in patients prescribed CBMPs for MS from the UK Medical Cannabis Registry (UKMCR). METHOD Patients prescribed CBMPs for MS symptoms for longer than one month were identified from the UKMCR. The primary outcomes were changes from baseline in MS Quality of Life-54 (MSQoL-54), Generalised Anxiety Disorder-7 (GAD-7), Single-Item Sleep Quality Scale (SQS), and EQ-5D-5L scales at one month, three months and six months. p < 0.050 was defined as statistically significant. RESULTS 141 patients met the inclusion criteria for the study. There was an improvement in the following subscales of the MSQoL-54 at 6 months: change in health scale, cognitive function, mental health composition, physical health, role limitations due to physical limitation and due to emotional problems, as well as social and sexual function (p < 0.050). There were also improvements in the EQ-5D-5L index value, GAD-7 and SQS (p < 0.050). 146 (103.55 %) adverse events were reported in total. Most were considered mild (n = 47; 33.33 %) and moderate (n = 72; 51.06 %). CONCLUSIONS This preliminary analysis demonstrates a possible association with improved general health-related quality of life in those prescribed CBMPs for MS. Moreover, the results suggest that CBMPs are well-tolerated in the first 6 months of treatment. However, this must be interpreted with caution considering the limitations of the observational study design.
Collapse
Affiliation(s)
- Matthew Murphy
- Imperial College Medical Cannabis Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Varinder Kaur
- Imperial College Medical Cannabis Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Hanh Lan Bui
- Imperial College Medical Cannabis Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Toby Yang
- Imperial College Medical Cannabis Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Simon Erridge
- Imperial College Medical Cannabis Research Group, Department of Surgery and Cancer, Imperial College London, London, UK; Curaleaf Clinic, London, UK
| | | | - Ross Coomber
- Curaleaf Clinic, London, UK; St. George's Hospital NHS Trust, London, UK
| | - James J Rucker
- Curaleaf Clinic, London, UK; Department of Psychological Medicine, Kings College London, London, UK; South London & Maudsley NHS Foundation Trust, London, UK
| | - Mark W Weatherall
- Curaleaf Clinic, London, UK; Buckinghamshire Healthcare NHS Trust, Amersham, UK
| | - Mikael H Sodergren
- Imperial College Medical Cannabis Research Group, Department of Surgery and Cancer, Imperial College London, London, UK; Curaleaf Clinic, London, UK.
| |
Collapse
|
3
|
Taboun ZS, Sadeghi J. The bidirectional relationship between opioids and the gut microbiome: Implications for opioid tolerance and clinical interventions. Int Immunopharmacol 2023; 125:111142. [PMID: 37918085 DOI: 10.1016/j.intimp.2023.111142] [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: 08/22/2023] [Revised: 10/06/2023] [Accepted: 10/26/2023] [Indexed: 11/04/2023]
Abstract
Opioids are widely used in treating patients with acute and chronic pain; however, this class of drugs is also commonly abused. Opioid use disorder and associated overdoses are becoming more prevalent as the opioid crisis continues. Chronic opioid use is associated with tolerance, which decreases the efficacy of opioids over time, but also puts individuals at risk of fatal overdoses. Therefore, it is essential to identify strategies to reduce opioid tolerance in those that use these agents. The gut microbiome has been found to play a critical role in opioid tolerance, with opioids causing dysbiosis of the gut, and changes in the gut microbiome impacting opioid tolerance. These changes in turn have a detrimental effect on the gut microbiome, creating a positive feedback cycle. We review the bidirectional relationship between the gut microbiome and opioid tolerance, discuss the role of modulation of the gut microbiome as a potential therapeutic option in opioid-induced gut dysbiosis, and suggest opportunities for further research and clinical interventions.
Collapse
Affiliation(s)
- Zahra S Taboun
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Javad Sadeghi
- School of Engineering, University of British Columbia - Okanagan, Kelowna, British Columbia, Canada.
| |
Collapse
|
4
|
Chisari CG, Guadagno J, Adjamian P, Vila Silvan C, Greco T, Bagul M, Patti F. A post hoc evaluation of the shift in spasticity category in individuals with multiple sclerosis-related spasticity treated with nabiximols. Ther Adv Neurol Disord 2023; 16:17562864231195513. [PMID: 37745913 PMCID: PMC10515604 DOI: 10.1177/17562864231195513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/30/2023] [Indexed: 09/26/2023] Open
Abstract
Background Over 80% of individuals with multiple sclerosis (MS) experience MS-associated spasticity (MSS). In many European countries, after failure of first-line treatments, moderate or severe MSS can be treated with nabiximols, a cannabis-based add-on treatment. Objective This post hoc analysis assessed the shift of participants treated with nabiximols from higher (severe or moderate) to lower (moderate or mild/none) spasticity. Methods Previously published data from two randomised controlled trials (RCTs), GWSP0604 (NCT00681538) and SAVANT (EudraCT2015-004451-40), and one large real-world study (consistent with EU label), all enriched for responders, were re-analysed. Spasticity severity, measured using the 0-10 numerical rating scale (spasticity NRS), was categorised as none/mild (score <4), moderate (score ⩾4-7), or severe (score ⩾7). Results In the two RCTs, the shift of participants with severe MSS into a lower category was significantly greater at week 12 for those receiving nabiximols versus placebo [GWSP0604: OR (95% CI), 4.4 (1.4, 14.2), p = 0.0125; SAVANT: 5.2 (1.2, 22.3), p = 0.0267]. In all three studies, over 80% of assessed patients with severe spasticity at baseline reported a shift into a lower category of spasticity after 12 weeks. Conclusions A meaningful proportion of MSS patients treated with nabiximols shifted to a lower category of spasticity severity, typically maintained to the end of the 12-week study period.
Collapse
Affiliation(s)
- Clara Grazia Chisari
- Department of Medical and Surgical Sciences and Advanced Technologies ‘GF Ingrassia’, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Joe Guadagno
- Department of Neurology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Peyman Adjamian
- GW Pharmaceuticals, Cambridge, UK
- Jazz Pharmaceuticals, Inc., Dublin, Ireland
| | | | - Teresa Greco
- Jazz Pharmaceuticals – Gentium Srl, Villa Guardia, Italy
| | - Makarand Bagul
- GW Pharmaceuticals, Cambridge, UK
- Jazz Pharmaceuticals, Inc., Dublin, Ireland
| | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies ‘GF Ingrassia’, Multiple Sclerosis Center, University of Catania Italy
| |
Collapse
|
5
|
Pau M, Porta M, Spinicci G, Frau J, Lorefice L, Coghe G, Cocco E. Change in upper limb function in people with multiple sclerosis treated with nabiximols: a quantitative kinematic pilot study. Neurol Sci 2023; 44:685-691. [PMID: 36260259 PMCID: PMC9842567 DOI: 10.1007/s10072-022-06456-3] [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: 09/09/2022] [Accepted: 10/11/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Nabiximols represents an increasingly employed add-on treatment option for spasticity in people with multiple sclerosis (PwMS) who either were unresponsive or reported excessive adverse reactions to other therapies. While several studies performed in the last decade demonstrated its effectiveness, safety, and tolerability, few quantitative data are available on the impact on motor dysfunctions. In this open-label, not concurrently controlled study, we aimed to assess the impact of a 4-week treatment with nabiximols on upper limb functionality. METHODS Thirteen PwMS (9 female, 4 male) with moderate-severe spasticity underwent a combination of clinical tests (i.e., Box and Block, BBT and Nine-Hole Peg test, 9HPT) and instrumental kinematic analysis of the "hand to mouth" (HTM) movement by means of optical motion capture system. RESULTS After the treatment, improvements in gross and fine dexterity were found (BBT + 3 blocks/min, 9HPT - 2.9 s, p < 0.05 for both cases). The kinematic analysis indicated that HTM movement was faster (1.69 vs. 1.83 s, p = 0.05), smoother, and more stable. A significant reduction of the severity of spasticity, as indicated by the 0-10 numerical rating scale (4.2 vs. 6.3, p < 0.001), was also observed. CONCLUSION The findings from the present pilot study suggest that a 4-week treatment with nabiximols ameliorates the spasticity symptoms and the overall motor function of upper limb in PwMS with moderate-severe spasticity. The use of quantitative techniques for human movement analysis may provide valuable information about changes originated by the treatment in realistic upper limb motor tasks involved in activities of daily living.
Collapse
Affiliation(s)
- Massimiliano Pau
- Department of Mechanical, Chemical and Materials Engineering, University of Cagliari, Piazza d'Armi, 09123, Cagliari, Italy.
| | - Micaela Porta
- Department of Mechanical, Chemical and Materials Engineering, University of Cagliari, Piazza d'Armi, 09123, Cagliari, Italy
| | - Gabriella Spinicci
- Multiple Sclerosis Centre, Binaghi Hospital, ATS Sardegna, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Jessica Frau
- Multiple Sclerosis Centre, Binaghi Hospital, ATS Sardegna, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Lorena Lorefice
- Multiple Sclerosis Centre, Binaghi Hospital, ATS Sardegna, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Giancarlo Coghe
- Multiple Sclerosis Centre, Binaghi Hospital, ATS Sardegna, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Eleonora Cocco
- Multiple Sclerosis Centre, Binaghi Hospital, ATS Sardegna, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| |
Collapse
|
6
|
Paul F, Silván CV. Effect of nabiximols on Goal Attainment Scale scores in patients with treatment-resistant multiple sclerosis spasticity. Neurodegener Dis Manag 2021; 11:143-153. [PMID: 33641348 DOI: 10.2217/nmt-2020-0060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background: Nabiximols oromucosal spray (Sativex®) is an approved add-on treatment option for moderate-to-severe treatment-resistant multiple sclerosis (MS) spasticity. Materials & methods: This prospective, observational, noninterventional, 3-month follow-up pilot study assessed the evolution of patient-selected goal attainment scale (GAS) item scores and of MS spasticity and associated symptoms during nabiximols treatment. Results: In the full analysis set (n = 21), the mean (SD) overall unweighted GAS score increased from 32.1 (3.4) at baseline to 43.6 (14.6) at month 3 (p = 0.0060), constituting a clinically meaningful change. Slight improvements were observed in MS spasticity and most associated symptoms. Nabiximols improved walking ability and was well tolerated. Conclusion: The study provides proof-of-concept that GAS methodology can be applied to MS management in daily practice.
Collapse
Affiliation(s)
- Friedemann Paul
- Experimental & Clinical Research Center & NeuroCure Clinical Research Center, Max Delbrueck Center for Molecular Medicine & Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | |
Collapse
|
7
|
Evers I, Heerings M, de Roos NM, Jongen PJ, Visser LH. Adherence to dietary guidelines is associated with better physical and mental quality of life: results from a cross-sectional survey among 728 Dutch MS patients. Nutr Neurosci 2021; 25:1633-1640. [PMID: 33573531 DOI: 10.1080/1028415x.2021.1885240] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND A healthy diet has been associated with less symptoms or progression of disease in multiple sclerosis (MS). However, whether specific diets are needed, or general healthy diet recommendations are sufficient is unknown. OBJECTIVE To investigate the association between diet quality, use of diets, and quality of life (QoL) in men and women with MS. METHODS Diet quality was measured with the Dutch Healthy Diet-index, which measures adherence to the Dutch Guidelines for a Healthy Diet. QoL was assessed with the MSQoL-54 questionnaire. A total of 728 people were included (623 women, 105 men). Multiple linear regression, stratified for gender, was used to analyse the data. RESULTS In women with MS, an association was found between diet quality and both physical and mental QoL after adjusting for several confounders (Physical Health Composite Score (β=0.410; P=0.001); Mental Health Composite Score (β=0.462; P=0.002)). Similar results were less pronounced in men. Subjects following a specific diet had higher diet quality and QoL than subjects not following a diet. CONCLUSION Adherence to the Dutch dietary guidelines is associated with better physical and mental QoL, especially in women. Following an MS-specific diet may help to adhere to these guidelines.
Collapse
Affiliation(s)
- I Evers
- Division of Human Nutrition and Health, Wageningen University, Wageningen, Netherlands
| | - M Heerings
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, Netherlands
| | - N M de Roos
- Division of Human Nutrition and Health, Wageningen University, Wageningen, Netherlands
| | - P J Jongen
- MS4 Research Institute, Nijmegen, Netherlands.,Department of Community & Occupational Medicine, University of Groningen & University Medical Centre Groningen, Groningen, Netherlands
| | - L H Visser
- Department of Neurology, St. Elisabeth-Tweesteden Hospital, Tilburg, Netherlands.,Department Ethics of Care, University of Humanistic Studies, Utrecht, Netherlands
| |
Collapse
|
8
|
Patti F, Chisari CG, Solaro C, Benedetti MD, Berra E, Bianco A, Bruno Bossio R, Buttari F, Castelli L, Cavalla P, Cerqua R, Costantino G, Gasperini C, Guareschi A, Ippolito D, Lanzillo R, Maniscalco GT, Matta M, Paolicelli D, Petrucci L, Pontecorvo S, Righini I, Russo M, Saccà F, Salamone G, Signoriello E, Spinicci G, Spitaleri D, Tavazzi E, Trotta M, Zaffaroni M, Zappia M. Effects of THC/CBD oromucosal spray on spasticity-related symptoms in people with multiple sclerosis: results from a retrospective multicenter study. Neurol Sci 2020; 41:2905-2913. [PMID: 32335779 DOI: 10.1007/s10072-020-04413-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 04/13/2020] [Indexed: 01/18/2023]
Abstract
INTRODUCTION The approval of 9-δ-tetrahydocannabinol (THC)+cannabidiol (CBD) oromucosal spray (Sativex®) in Italy as an add-on medication for the management of moderate to severe spasticity in multiple sclerosis (MS) has provided a new opportunity for MS patients with drug-resistant spasticity. We aimed to investigate the improvement of MS spasticity-related symptoms in a large cohort of patients with moderate to severe spasticity in daily clinical practice. MATERIALS AND METHODS MS patients with drug-resistant spasticity were recruited from 30 Italian MS centers. All patients were eligible for THC:CBD treatment according to the approved label: ≥ 18 years of age, at least moderate spasticity (MS spasticity numerical rating scale [NRS] score ≥ 4) and not responding to the common antispastic drugs. Patients were evaluated at baseline (T0) and after 4 weeks of treatment (T1) with the spasticity NRS scale and were also asked about meaningful improvements in 6 key spasticity-related symptoms. RESULTS Out of 1615 enrolled patients, 1432 reached the end of the first month trial period (T1). Of these, 1010 patients (70.5%) reached a ≥ 20% NRS score reduction compared with baseline (initial responders; IR). We found that 627 (43.8% of 1432) patients showed an improvement in at least one spasticity-related symptom (SRSr group), 543 (86.6%) of them belonging to the IR group and 84 (13.4%) to the spasticity NRS non-responders group. CONCLUSION Our study confirmed that the therapeutic benefit of cannabinoids may extend beyond spasticity, improving spasticity-related symptoms even in non-NRS responder patients.
Collapse
Affiliation(s)
- Francesco Patti
- Department "G.F. Ingrassia", section of Neurosciences, University of Catania, Catania, Italy.
| | - Clara Grazia Chisari
- Department "G.F. Ingrassia", section of Neurosciences, University of Catania, Catania, Italy
| | - Claudio Solaro
- Department of Neurology, ASL3 Genovese, and Department of Rehabilitation, ML Novarese Hospital Moncrivello, Genoa, Italy
| | - Maria Donata Benedetti
- Department of Neuroscience, Biomedicine, and Movement Sciences, Section of Neurology, University of Verona, Verona, Italy
| | - Eliana Berra
- Neurorehabilitation Unit, Department of Neurology, Neurology Institute C. Mondino, Pavia, Italy
| | - Assunta Bianco
- Multiple Sclerosis Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Roberto Bruno Bossio
- Neurology Operating Unit and Multiple Sclerosis Center, Provincial Health Authority of Cosenza, Cosenza, Italy
| | - Fabio Buttari
- Synaptic Immunopathology Lab, Department of Systems Medicine, Tor Vergata University, Rome, Italy
| | - Letizia Castelli
- Neurology Unit, IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy
| | - Paola Cavalla
- Department Neuroscience and Mental Health, Multiple Sclerosis Centre, Health and Science City University Hospital of Turin, Turin, Italy
| | - Raffaella Cerqua
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | | | - Claudio Gasperini
- Multiple Sclerosis Centre, San Camillo-Forlanini Hospital, Rome, Italy
| | - Angelica Guareschi
- Multiple Sclerosis Center, Medicine Department, Fidenza Hospital, Fidenza, PR, Italy
| | - Domenico Ippolito
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Roberta Lanzillo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University Federico II, Naples, Italy
| | | | - Manuela Matta
- Neurobiology Unit, Neurologia 2, CReSM (Regional Referring Center Multiple Sclerosis), San Luigi Gonzaga University Hospital & Neuroscience Institute Cavalieri Ottolenghi (NICO), Orbassano, TO, Italy
| | - Damiano Paolicelli
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari Aldo Moro, Bari, Italy
| | | | - Simona Pontecorvo
- Multiple Sclerosis Center of Department of Neurology and Psychiatry of Sapienza, University of Rome, Rome, Italy
| | - Isabella Righini
- Department of NEUROFARBA, University of Florence, Florence, Italy
| | - Margherita Russo
- Multiple Sclerosis Centre, IRCCS-Bonino Pulejo Centre, Messina, Italy
| | - Francesco Saccà
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University Federico II, Naples, Italy
| | | | - Elisabetta Signoriello
- Department of Clinical and Experimental Medicine, Multiple Sclerosis Center, II Division of Neurology, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Gabriella Spinicci
- Department of Medical Sciences and Public Health, Multiple Sclerosis Center, University of Cagliari, Cagliari, Italy
| | - Daniele Spitaleri
- Azienda Ospedaliera di Rilievo Nazionale, San Giuseppe Moscati, Avellino, Italy
| | - Eleonora Tavazzi
- Multiple Sclerosis Center, Unit of Motor Neurorehabilitation, IRCCS Santa Maria Nascente, Fondazione Don Gnocchi, Milan, Italy
| | - Maria Trotta
- Institute of Neurology, University "Magna Graecia", Germaneto, Catanzaro, Italy
| | - Mauro Zaffaroni
- Multiple Sclerosis Center, ASST della Valle Olona, Gallarate Hospital, Gallarate, VA, Italy
| | - Mario Zappia
- Department "G.F. Ingrassia", section of Neurosciences, University of Catania, Catania, Italy
| | | |
Collapse
|
9
|
Fernández Ó, Costa-Frossard L, Martínez-Ginés M, Montero P, Prieto JM, Ramió L. The Broad Concept of "Spasticity-Plus Syndrome" in Multiple Sclerosis: A Possible New Concept in the Management of Multiple Sclerosis Symptoms. Front Neurol 2020; 11:152. [PMID: 32256440 PMCID: PMC7090019 DOI: 10.3389/fneur.2020.00152] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 02/14/2020] [Indexed: 11/26/2022] Open
Abstract
Multiple sclerosis (MS) pathology progressively affects multiple central nervous system (CNS) areas. Due to this fact, MS produces a wide array of symptoms. Symptomatic therapy of one MS symptom can cause or worsen other unwanted symptoms (anticholinergics used for bladder dysfunction produce impairment of cognition, many MS drugs produce erectile dysfunction, etc.). Appropriate symptomatic therapy is an unmet need. Several important functions/symptoms (muscle tone, sleep, bladder, pain) are mediated, in great part, in the brainstem. Cannabinoid receptors are distributed throughout the CNS irregularly: There is an accumulation of CB1 and CB2 receptors in the brainstem. Nabiximols (a combination of THC and CBD oromucosal spray) interact with both CB1 and CB2 receptors. In several clinical trials with Nabiximols for MS spasticity, the investigators report improvement not only in spasticity itself, but also in several functions/symptoms mentioned before (spasms, cramps, pain, gait, sleep, bladder function, fatigue, and possibly tremor). We can conceptualize and, therefore, hypothesize, through this indirect information, that it could be considered the existence of a broad "Spasticity-Plus Syndrome" that involves, a cluster of symptoms apart from spasticity itself, the rest of the mentioned functions/symptoms, probably because they are interlinked after the increase of muscle tone and mediated, at least in part, in the same or close areas of the brainstem. If this holds true, there exists the possibility to treat several spasticity-related symptoms induced by MS pathology with a single therapy, which would permit to avoid the unnecessary adverse effects produced by polytherapy. This would result in an important advance in the symptomatic management of MS.
Collapse
Affiliation(s)
- Óscar Fernández
- Biomedical Research Institute of Malaga, University of Málaga, Málaga, Spain
| | | | | | - Paloma Montero
- Servicio de Neurología, Hospital Clínico San Carlos, Madrid, Spain
| | - José Maria Prieto
- Servicio de Neurologia, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Lluis Ramió
- Servicio de Neurologia, Hospital Universitari de Girona Doctor Josep Trueta, Girona, Spain
| |
Collapse
|
10
|
Montero-Escribano P, Vila Silván C. Application device for THC:CBD oromucosal spray in the management of resistant spasticity: pre-production testing. Expert Rev Med Devices 2019; 16:835-840. [PMID: 31393179 DOI: 10.1080/17434440.2019.1653182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Patients with multiple sclerosis spasticity (MSS) and upper limb/hand impairment who are taking 9-delta-tetrahydrocannabinol:cannabidiol (THC:CBD) oromucosal spray (Sativex®) may have difficulty self-administering their medication, possibly limiting adherence and treatment effectiveness. A Class I EU device is available to support the administration of THC:CBD spray. Pre-production testing was undertaken in a patient sample. Methods: Current users of THC:CBD spray were recruited to review the instruction leaflet and test the device. Patients and observing health-care professionals (HCP) completed a purpose-designed questionnaire which captured user experience and HCP opinion. Results: Fifteen patients participated. Mean treatment time with THC:CBD spray was 4 (range: 0.1-6.1) years. 87% of participants 'always', 'often' or 'sometimes' had hand impairment, and 53% reported difficulty administering THC:CBD spray. Participants reported better application using the device (73%), with less strength required (54%). Most participants (93%) considered the instruction leaflet to be clear and many (66%) expressed interest in using the device. Most HCPs (93%) did not foresee any difficulties in use of the device. Conclusion: The proposed adherence device was useful to address self-application difficulties with THC:CBD spray in our sample. Providing the device to MSS patients with upper limb/hand spasticity impairment may restore autonomy and support adherence to THC:CBD spray.
Collapse
Affiliation(s)
| | - Carlos Vila Silván
- R&D Department, Global Medical Affairs, Almirall S.A , Barcelona , Spain
| |
Collapse
|
11
|
Akgün K, Essner U, Seydel C, Ziemssen T. Daily Practice Managing Resistant Multiple Sclerosis Spasticity With Delta-9-Tetrahydrocannabinol: Cannabidiol Oromucosal Spray: A Systematic Review of Observational Studies. J Cent Nerv Syst Dis 2019; 11:1179573519831997. [PMID: 30886530 PMCID: PMC6413425 DOI: 10.1177/1179573519831997] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 01/21/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND/PURPOSE Spasticity is one of the most common symptoms in people with multiple sclerosis (MS). Conventional anti-spasticity agents have limitations in their efficacy and tolerability. Delta-9-tetrahydrocannabinol: cannabidiol (THC:CBD) spray, a cannabinoid-based medicine, is approved as an add-on therapy for MS spasticity not adequately controlled by other anti-spasticity medications. The results from randomized controlled trials (RCTs) have demonstrated a reduction in the severity of spasticity and associated symptoms. However, RCTs do not always reflect real-life outcomes. We systematically reviewed the complementary evidence from non-interventional real-world studies. METHODS A systematic literature review was conducted to identify all non-RCT publications on THC:CBD spray between 2011 and 2017. Data on study design, patient characteristics, effectiveness, and safety outcomes were extracted from those publications meeting our inclusion criteria. RESULTS In total, we reviewed 14 real-world publications including observational studies and treatment registries. The proportion of patients reaching the threshold of minimal clinical important difference (MCID), with at least a 20% reduction of the spasticity Numeric Rating Scale (NRS) score after 4 weeks ranged from 41.9% to 82.9%. The reduction in the mean NRS spasticity score after 4 weeks was maintained over 6-12 months. The average daily dose was five to six sprays. Delta-9-tetrahydrocannabinol: cannabidiol was well tolerated in the evaluated studies in the same way as in the RCTs. No new or unexpected adverse events or safety signals were reported in everyday clinical practice. CONCLUSIONS The data evaluated in this systematic review provide evidence for the efficacy and safety of THC:CBD in clinical practice and confirm results obtained in RCTs.
Collapse
Affiliation(s)
- Katja Akgün
- Department of Neurology, Center of
Clinical Neuroscience, University Hospital Dresden, Dresden, Germany
| | - Ute Essner
- O.MEANY Consultancy GmbH, Hamburg,
Germany
| | | | - Tjalf Ziemssen
- Department of Neurology, Center of
Clinical Neuroscience, University Hospital Dresden, Dresden, Germany
| |
Collapse
|
12
|
Mallada Frechín J. Effect of tetrahydrocannabinol:cannabidiol oromucosal spray on activities of daily living in multiple sclerosis patients with resistant spasticity: a retrospective, observational study. Neurodegener Dis Manag 2018; 8:151-159. [DOI: 10.2217/nmt-2017-0055] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To examine evolution in activities of daily living (ADL) in patients with multiple sclerosis spasticity during long-term use of tetrahydrocannabinol (THC):cannabidiol (CBD) oromucosal spray. Methods: Functional impairment was assessed retrospectively (prior to start of treatment) and at the present moment using a 16-item ADL survey; results were compared. A control group without add-on THC:CBD oromucosal spray was included to investigate possible recall bias. Results: ADL was maintained or slightly improved with THC:CBD oromucosal spray across treatment time (mean 31.9 months) including significant improvement in ‘standing up’ (p < 0.05) and trends in other items. Significant improvements (p < 0.01) with THC:CBD oromucosal spray were observed in several multiple sclerosis spasticity-related symptoms. Overall, 96.9% of patients using THC:CBD oromucosal spray had a positive global impression of change during treatment. Conclusion: In this pilot study, THC:CBD oromucosal spray maintained or improved aspects of daily functioning. Further study in a larger trial is warranted.
Collapse
|
13
|
Messina S, Solaro C, Righini I, Bergamaschi R, Bonavita S, Bossio RB, Brescia Morra V, Costantino G, Cavalla P, Centonze D, Comi G, Cottone S, Danni MC, Francia A, Gajofatto A, Gasperini C, Zaffaroni M, Petrucci L, Signoriello E, Maniscalco GT, Spinicci G, Matta M, Mirabella M, Pedà G, Castelli L, Rovaris M, Sessa E, Spitaleri D, Paolicelli D, Granata A, Zappia M, Patti F. Sativex in resistant multiple sclerosis spasticity: Discontinuation study in a large population of Italian patients (SA.FE. study). PLoS One 2017; 12:e0180651. [PMID: 28763462 PMCID: PMC5538735 DOI: 10.1371/journal.pone.0180651] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 06/19/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The approval of Sativex for the management of multiple sclerosis (MS) spasticity opened a new opportunity to many patients. In Italy, the healthcare payer can be fully reimbursed by the involved pharma company with the cost of treatment for patients not responding after a 4 week (28 days) trial period (Payment by Results, PbR), and 50% reimbursed with the cost of 6 weeks (42 days) treatment for other patients discontinuing (Cost Sharing, CS). The aim of our study was to describe the Sativex discontinuation profile from a large population of spasticity treated Italian MS patients. METHODS We collected data of patients from 30 MS centres across the country starting Sativex between January 2014 and February 2015. Data were collected from the mandatory Italian Medicines Agency (AIFA) web-registry. Predictors of treatment discontinuation were assessed using a multivariate Cox proportional regression analysis. RESULTS During the observation period 631 out of 1597 (39.5%) patients discontinued Sativex. The Kaplan-Meier estimates curve showed that 333 patients (20.8%) discontinued treatment at 4 weeks while 422 patients (26.4%) discontinued at 6 weeks. We found after adjusted modeling that a higher NRS score at T1 (adjHR 2.23, 95% 2.07-2.41, p<0.001) and a lower baseline NRS score (adjHR 0.51 95% CI 0.46-0.56, p<0.001) were predictive of treatment discontinuation. CONCLUSION These data show that the first 6 weeks are useful in identifying those patients in which Sativex could be effective, thus avoiding the cost of longer term evaluation.
Collapse
Affiliation(s)
- Silvia Messina
- Department of Medical, Surgical Science and Advanced Technology "GF Ingrassia"–University of Catania, Catania, Italy
| | - Claudio Solaro
- Neurology Unit, Department Head And Neck, ASL3 Genova, Italy
| | | | | | | | - Roberto Bruno Bossio
- Neurology Operating Unit and Multiple Sclerosis Center—Provincial Health Authority of Cosenza, Cosenza, Italy
| | | | | | - Paola Cavalla
- A.O.U: Cittàdella Salute e dellaScienza di Torino, Torino, Italy
| | - Diego Centonze
- Neuroscience Department—University Tor Vegata, Rome, Italy
- Unit of Neurology and of Neurorehabilitation, IRCCS Neuromed, Pozzilli (IS), Italy
| | - Giancarlo Comi
- Department of Neurology–San Raffaele Hospital, Milan, Italy
| | | | | | - Ada Francia
- Multiple Sclerosis Center, Dept. Neurol. Psich—Sapienza University, Rome, Italy
| | - Alberto Gajofatto
- Department of Neuroscience, Biomedicine and Movement Multiple Sclerosis Centre–University of Verona, Verona, Italy
| | | | - Mauro Zaffaroni
- Multiple Sclerosis Centre—Sant'Antonio Abate Hospital, Gallarate, Italy
| | | | | | | | | | - Manuela Matta
- Multiple Sclerosis Centre (CRESM)—San Luigi Gonzaga Hospital, Orbassano, Italy
| | | | | | | | - Marco Rovaris
- Multiple Sclerosis Centre—IRCCS Don Gnocchi Foundation, Milan, Italy
| | - Edoardo Sessa
- Multiple Sclerosis Centre—IRCCS-Bonino Pulejo Centre, Messina, Italy
| | | | - Damiano Paolicelli
- Department of Basic Medical Sciences, Neuroscience and Sense Organs—University of Bari “Aldo Moro” Bari, Italy
| | - Alfredo Granata
- Department of Medical Sciences, Institute of Neurology—University “Magna Graecia”, Catanzaro, Italy
| | - Mario Zappia
- Department of Medical, Surgical Science and Advanced Technology "GF Ingrassia"–University of Catania, Catania, Italy
| | - Francesco Patti
- Department of Medical, Surgical Science and Advanced Technology "GF Ingrassia"–University of Catania, Catania, Italy
| | | |
Collapse
|
14
|
Zettl UK, Rommer P, Hipp P, Patejdl R. Evidence for the efficacy and effectiveness of THC-CBD oromucosal spray in symptom management of patients with spasticity due to multiple sclerosis. Ther Adv Neurol Disord 2016; 9:9-30. [PMID: 26788128 PMCID: PMC4710104 DOI: 10.1177/1756285615612659] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Spasticity, one of the main symptoms of multiple sclerosis (MS), can affect more than 80% of MS patients during the course of their disease and is often not treated adequately. δ-9-Tetrahydrocannabinol-cannabidiol (THC-CBD) oromucosal spray is a plant-derived, standardized cannabinoid-based oromucosal spray medicine for add-on treatment of moderate to severe, resistant multiple sclerosis-induced spasticity. This article reviews the current evidence for the efficacy and safety, with dizziness and fatigue as the most common treatment-related adverse events, being mostly mild to moderate in severity. Results from both randomized controlled phase III studies involving about,1600 MS patients or 1500 patient-years and recently published studies on everyday clinical practice involving more than 1000 patients or more than,1000 patient-years are presented.
Collapse
Affiliation(s)
- Uwe K. Zettl
- Department of Neurology, University of Rostock, Gehlsheimer Straße 20, D-18147 Rostock, Germany
| | - Paulus Rommer
- Department of Neurology, University of Rostock, Germany
- Department of Neurology, Medical University of Vienna, Austria
| | | | - Robert Patejdl
- Department of Neurology, University of Rostock, Germany Oscar-Langendorff-Institute of Physiology, University of Rostock, Germany
| |
Collapse
|
15
|
Vermersch P. MObility ImproVEment with spasticity in multiple sclerosis in Europe: the MOVE 1 EU study. Neurodegener Dis Manag 2015; 4:407-15. [PMID: 25531685 DOI: 10.2217/nmt.14.44] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM using a protocol similar to that of the MOVE 1 study in Germany, the multicenter, observational MOVE 1 EU study examined the burden of multiple sclerosis (MS)-related spasticity in other EU countries (Belgium, Finland, France, Ireland, Norway, Poland and Portugal). MATERIALS & METHODS A 12-month retrospective chart documentation was combined with questionnaires for physicians and patients at the time of enrollment. A total of 281 patients from neurology departments and MS units formed the per protocol population. RESULTS in most patients, MS spasticity frequently restricted daily activities and caused some/moderate problems in EQ-5D subdomains of mobility, usual activities and pain/discomfort. Overall, 48% of physicians and 34% of patients were at least partly dissatisfied with the effectiveness of available pharmacotherapy options for MS spasticity. CONCLUSION Results of the MOVE 1 Germany and MOVE 1 EU studies are aligned and highlight the need to optimize the therapeutic management of patients with MS spasticity across Europe so as to improve their overall well-being and quality of life.
Collapse
|
16
|
Meuth SG, Vila C, Dechant KL. Effect of Sativex on spasticity-associated symptoms in patients with multiple sclerosis. Expert Rev Neurother 2015; 15:909-18. [DOI: 10.1586/14737175.2015.1067607] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
17
|
Slof J, Ruiz L, Vila C. Cost-effectiveness of Sativex in multiple sclerosis spasticity: new data and application to Italy. Expert Rev Pharmacoecon Outcomes Res 2015; 15:379-91. [PMID: 25771713 DOI: 10.1586/14737167.2015.1025759] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Multiple sclerosis (MS) is a chronic progressive disease that carries a high socioeconomic burden. Spasticity (rigidity and spasms) is common in MS and contributes to MS-related disability. This study aims to evaluate the cost-effectiveness of Sativex(®) (9-delta-tetrahydrocannabinol plus cannabidiol oromucosal spray) when used as add-on therapy for management of resistant MS-related spasticity in the context of the Italian healthcare system. A previously published Markov model-based analysis for the German and Spanish context was replicated, adapting it to the Italian setting. Model parameters were updated to reflect recent findings about MS-related spasticity and use of Sativex in daily clinical practice. The base case incremental cost-effectiveness ratio for Sativex use in Italy over a 5-year period was estimated to be €4968 per quality-adjusted life-year gained (year of costing: 2013). Sativex remained an efficient option in the Italian healthcare context - below the commonly accepted incremental threshold of €30,000 per quality-adjusted life-year gained - when deterministic and probabilistic sensitivity analyses were conducted. Sativex can be regarded as a cost-effective treatment option for patients with MS-related spasticity in Italy.
Collapse
Affiliation(s)
- John Slof
- Universitat Autònoma de Barcelona, Campus de la UAB, 08193, Bellaterra, Spain
| | | | | |
Collapse
|