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Javid FA, Alam A, Williams E, Malik SS, Mohayuddin U, Hasan SS. Trends in prescription and cost of Sativex, a cannabinoid-based medicine, in treating patients with multiple sclerosis in England. J Pharm Policy Pract 2024; 17:2342318. [PMID: 38726319 PMCID: PMC11080669 DOI: 10.1080/20523211.2024.2342318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024] Open
Abstract
Aim Cannabis-based medication has recently been made available in the NHS for reducing pain and spasticity in patients with multiple sclerosis (MS). The currently available preparation of Sativex (nabiximols) contains a combination of botanical cannabis extracts with cannabidiol (CBD) and tetrahydrocannabinol (THC) with almost equal amounts in addition to minor cannabinoids and terpenoids and is delivered via an oro-mucosal spray. The present study aims to examine the use and trends in prescribing cannabinoid-based Sativex to control pain in patients diagnosed with MS. Methods Primary care prescribing data for cannabinoid-based Sativex (2013-2022) from the Prescription Cost Analysis were extracted and analysed. Linear regression analyses were performed to examine prescription trends and prescription costs (average change per year). Results There was a general increasing trend in the number of prescriptions each year, from 4.42 items dispensed per 100,000 people in 2013 to 5.15 in 2022. Overall, prescription items for cannabinoid-based Sativex increased by 0.34% per year (95% CI:-3.98, 4.67, p = 0.860) on average between 2013 and 2022. On average, a 2.43% (95% CI: -5.78, 0.92, p = 0.133) increase per year was observed for the costs of cannabinoid-based Sativex from 2013 to 2022. Conclusion The results suggested that cannabinoid-based Sativex should be considered an option due to its effectiveness, acceptable tolerance, and safety profile in the prescribing of Sativex.
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Affiliation(s)
- Farideh A. Javid
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield, UK
| | - Anam Alam
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield, UK
| | - Emily Williams
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield, UK
| | - Sidhra Sajid Malik
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield, UK
| | - Usama Mohayuddin
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield, UK
| | - Syed Shahzad Hasan
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield, UK
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Martinez-Paz C, García-Cabrera E, Vilches-Arenas Á. Effectiveness and Safety of Cannabinoids as an Add-On Therapy in the Treatment of Resistant Spasticity in Multiple Sclerosis: A Systematic Review. Cannabis Cannabinoid Res 2023; 8:580-588. [PMID: 37057959 DOI: 10.1089/can.2022.0254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023] Open
Abstract
Background: Spasticity continues to be a very prevalent, highly invalidating, and difficult-to-manage symptom in patients with multiple sclerosis (MS). The aim of this systematic review is to evaluate the effectiveness of the use of cannabis and cannabinoids in these patients, evaluating its use as an additional therapy. Methods: We performed a systematic review of the literature searching in the major scientific databases (PubMed, Scopus, EMBASE, WOS, and Cochrane Library) for articles from January 2017 to May 2022 containing information about the effectiveness of cannabis and cannabinoids in patients with insufficient response to first-line oral antispastic treatment. Results: A total of five medium high-quality articles were selected to be part of the study and all evaluated the effectiveness of the tetrahydrocannabinol (THC) and cannabidiol (CBD) spray. The effectiveness of this drug and the significant improvements are produced on the patient-related spasticity assessment scales, obtaining improvement up to 45%; and on quality of life, producing a decrease in the appearance of symptoms related to spasticity, as well as an increase in the development of basic activities of daily living. The average dose is 5-7 sprays/day. The discontinuation rate for these treatments is around 40% due to lack of effectiveness and adverse events. All reported adverse effects are mild to moderate in severity and their incidence is ∼17%, although this figure tends to decrease with drug use. Conclusions: Adding the THC:CBD sprays have been shown to be more effective in treating MS spasticity than optimizing the dose of first-line antispastic drugs in selected responders patients. The safety and tolerability profiles remain in line with those obtained in other trials. More patients would benefit from treatment if the initial response search period was extended.
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Affiliation(s)
- Carmen Martinez-Paz
- Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Seville, Seville, Spain
| | - Emilio García-Cabrera
- Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Seville, Seville, Spain
| | - Ángel Vilches-Arenas
- Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Seville, Seville, Spain
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Hansen JS, Gustavsen S, Roshanisefat H, Kant M, Biering-Sørensen F, Andersen C, Olsson A, Chow HH, Asgari N, Hansen JR, Nielsen HH, Hansen RM, Petersen T, Oturai AB, Sellebjerg F, Sædder EA, Kasch H, Rasmussen PV, Finnerup NB, Svendsen KB. Cannabis-Based Medicine for Neuropathic Pain and Spasticity-A Multicenter, Randomized, Double-Blinded, Placebo-Controlled Trial. Pharmaceuticals (Basel) 2023; 16:1079. [PMID: 37630995 PMCID: PMC10459421 DOI: 10.3390/ph16081079] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 07/22/2023] [Accepted: 07/24/2023] [Indexed: 08/27/2023] Open
Abstract
Patients with multiple sclerosis (MS) and spinal cord injury (SCI) commonly sustain central neuropathic pain (NP) and spasticity. Despite a lack of consistent evidence, cannabis-based medicine (CBM) has been suggested as a supplement treatment. We aimed to investigate the effect of CBM on NP and spasticity in patients with MS or SCI. We performed a randomized, double-blinded, placebo-controlled trial in Denmark. Patients aged ≥18 years with NP (intensity >3, ≤9 on a numerical rating scale (NRS0-10) and/or spasticity (>3 on NRS0-10) were randomized to treatment consisting of either delta-9-tetrahydrocannabinol (THC), cannabidiol (CBD), a combination of THC&CBD in maximum doses of 22.5 mg, 45 mg and 22.5/45 mg per day, respectively, or placebo. A baseline registration was performed before randomization. Treatment duration was six weeks followed by a one-week phaseout. Primary endpoints were the intensity of patient-reported NP and/or spasticity. Between February 2019 and December 2021, 134 patients were randomized (MS n = 119, SCI n = 15), where 32 were assigned to THC, 31 to CBD, 31 to THC&CBD, and 40 to placebo. No significant difference was found for: mean pain intensity (THC 0.42 (-0.54-1.38), CBD 0.45 (-0.47-1.38) and THC&CBD 0.16 (-0.75-1.08)), mean spasticity intensity (THC 0.24 (-0.67-1.45), CBD 0.46 (-0.74-1.65), and THC&CBD 0.10 (-1.18-1.39), secondary outcomes (patient global impression of change and quality of life), or any tertiary outcomes. We aimed to include 448 patients in the trial; however, due to COVID-19 and recruitment challenges, fewer were included. Nevertheless, in this four-arm parallel trial, no effect was found between placebo and active treatment with THC or CBD alone or in combination on NP or spasticity in patients with either MS or SCI. The trial was registered with the EU Clinical Trials Register EudraCT (2018-002315-98).
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Affiliation(s)
- Julie Schjødtz Hansen
- Department of Neurology, Aarhus University Hospital (AUH), 8200 Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark
| | - Stefan Gustavsen
- Danish Multiple Sclerosis Center (DMSC), Department of Neurology, Copenhagen University Hospital, Rigshospitalet, 2600 Glostrup, Denmark
| | - Homayoun Roshanisefat
- Department of Neurology, Naestved, Slagelse & Ringsted Hospitals, Region Zealand, 4200 Slagelse, Denmark
| | - Matthias Kant
- Department of Neurology, Hospital of Southern Jutland, 6400 Soenderborg, Denmark
- Department of Neurology, Hospital South-West Jutland Esbjerg, 6700 Esbjerg, Denmark
| | - Fin Biering-Sørensen
- Department of Brain and Spinal Cord Injuries, Copenhagen University Hospital, Rigshospitalet, 2600 Glostrup, Denmark
| | - Claus Andersen
- Department of Brain and Spinal Cord Injuries, Copenhagen University Hospital, Rigshospitalet, 2600 Glostrup, Denmark
| | - Anna Olsson
- Danish Multiple Sclerosis Center (DMSC), Department of Neurology, Copenhagen University Hospital, Rigshospitalet, 2600 Glostrup, Denmark
| | - Helene Højsgaard Chow
- Danish Multiple Sclerosis Center (DMSC), Department of Neurology, Copenhagen University Hospital, Rigshospitalet, 2600 Glostrup, Denmark
| | - Nasrin Asgari
- Department of Neurology, Naestved, Slagelse & Ringsted Hospitals, Region Zealand, 4200 Slagelse, Denmark
- Institute of Regional Health Research and Molecular Medicine, University of Southern Denmark, 5000 Odense, Denmark
| | - Julie Richter Hansen
- Danish Multiple Sclerosis Center (DMSC), Department of Neurology, Copenhagen University Hospital, Rigshospitalet, 2600 Glostrup, Denmark
- Department of Neurology, Herlev Hospital, 2730 Herlev, Denmark
| | | | - Rikke Middelhede Hansen
- Spinal Cord Injury Centre of Western Denmark (SCIWDK), Viborg Regional Hospital, 8800 Viborg, Denmark
| | - Thor Petersen
- Department of Neurology, Hospital of Southern Jutland and Research Unit in Neurology, Department of Regional Health Research, University of Southern Denmark, 5000 Odense, Denmark
| | - Annette Bang Oturai
- Danish Multiple Sclerosis Center (DMSC), Department of Neurology, Copenhagen University Hospital, Rigshospitalet, 2600 Glostrup, Denmark
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center (DMSC), Department of Neurology, Copenhagen University Hospital, Rigshospitalet, 2600 Glostrup, Denmark
| | - Eva Aggerholm Sædder
- Department of Clinical Pharmacology, Aarhus University Hospital, 8000 Aarhus, Denmark
| | - Helge Kasch
- Department of Neurology, Aarhus University Hospital (AUH), 8200 Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark
| | | | - Nanna Brix Finnerup
- Department of Neurology, Aarhus University Hospital (AUH), 8200 Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark
- Danish Pain Research Centre, Aarhus University, 8200 Aarhus, Denmark
| | - Kristina Bacher Svendsen
- Department of Neurology, Aarhus University Hospital (AUH), 8200 Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark
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Borgonetti V, Anceschi L, Brighenti V, Corsi L, Governa P, Manetti F, Pellati F, Galeotti N. Cannabidiol-rich non-psychotropic Cannabis sativa L. oils attenuate peripheral neuropathy symptoms by regulation of CB2-mediated microglial neuroinflammation. Phytother Res 2023; 37:1924-1937. [PMID: 36583304 DOI: 10.1002/ptr.7710] [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: 06/29/2022] [Revised: 12/02/2022] [Accepted: 12/04/2022] [Indexed: 12/31/2022]
Abstract
Neuropathic pain (NP) is a chronic disease that affects the normal quality of life of patients. To date, the therapies available are only symptomatic and they are unable to reduce the progression of the disease. Many studies reported the efficacy of Cannabis sativa L. (C. sativa) on NP, but no Δ9 -tetrahydrocannabinol (Δ9 -THC)-free extracts have been investigated in detail for this activity so far. The principal aim of this work is to investigate the potential pain-relieving effect of innovative cannabidiol-rich non-psychotropic C. sativa oils, with a high content of terpenes (K2), compared to the same extract devoid of terpenes (K1). Oral administration of K2 (25 mg kg-1 ) induced a rapid and long-lasting relief of pain hypersensitivity in a mice model of peripheral neuropathy. In spinal cord samples, K2 reduced mitogen-activated protein kinase (MAPKs) levels and neuroinflammatory factors. These effects were reverted by the administration of a CB2 antagonist (AM630), but not by a CB1 antagonist (AM251). Conversely, K1 showed a lower efficacy in the absence of CB1/CB2-mediated mechanisms. In LPS-stimulated murine microglial cells (BV2), K2 reduced microglia pro-inflammatory phenotype through the downregulation of histone deacetylase 1 (HDAC-1) and nuclear factor of kappa light polypeptide gene enhancer in B-cells inhibitor (IKBα) and increased interleukin-10 (IL-10) expression, an important antiinflammatory cytokine. In conclusion, these results suggested that K2 oral administration attenuated NP symptoms by reducing spinal neuroinflammation and underline the important role of the synergism between cannabinoids and terpenes.
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Affiliation(s)
- Vittoria Borgonetti
- Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), Section of Pharmacology and Toxicology, University of Florence, Florence, Italy
| | - Lisa Anceschi
- Department of Life Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Virginia Brighenti
- Department of Life Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Lorenzo Corsi
- Department of Life Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Paolo Governa
- Department of Biotechnology, Chemistry and Pharmacy - Department of Excellence 2018-2022, University of Siena, Siena, Italy
| | - Fabrizio Manetti
- Department of Biotechnology, Chemistry and Pharmacy - Department of Excellence 2018-2022, University of Siena, Siena, Italy
| | - Federica Pellati
- Department of Life Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Nicoletta Galeotti
- Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), Section of Pharmacology and Toxicology, University of Florence, Florence, Italy
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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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Perineural Invasion in Pancreatic Ductal Adenocarcinoma: From Molecules towards Drugs of Clinical Relevance. Cancers (Basel) 2022; 14:cancers14235793. [PMID: 36497277 PMCID: PMC9739544 DOI: 10.3390/cancers14235793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 11/26/2022] Open
Abstract
Pancreatic ductal adenocarcinoma is one of the most threatening solid malignancies. Molecular and cellular mediators that activate paracrine signalling also regulate the dynamic interaction between pancreatic cancer cells and nerves. This reciprocal interface leads to perineural invasion (PNI), defined as the ability of cancer cells to invade nerves, similar to vascular and lymphatic metastatic cascade. Targeting PNI in pancreatic cancer might help ameliorate prognosis and pain relief. In this review, the modern knowledge of PNI in pancreatic cancer has been analysed and critically presented. We focused on molecular pathways promoting cancer progression, with particular emphasis on neuropathic pain generation, and we reviewed the current knowledge of pharmacological inhibitors of the PNI axis. PNI represents a common hallmark of PDAC and correlates with recurrence, poor prognosis and pain in pancreatic cancer patients. The interaction among pancreatic cancer cells, immune cells and nerves is biologically relevant in each stage of the disease and stimulates great interest, but the real impact of the administration of novel agents in clinical practice is limited. It is still early days for PNI-targeted treatments, and further advanced studies are needed to understand whether they could be effective tools in the clinical setting.
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7
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Creta A, Gilio L, Centonze D, Fantozzi R. Usability of an application device for nabiximols oromucosal spray in patients with upper limb impaired multiple sclerosis. Neurodegener Dis Manag 2022; 12:195-201. [PMID: 35707977 DOI: 10.2217/nmt-2022-0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: This study aimed to assess the usability of a specific EU-available application device for Sativex® (USA adopted name: nabiximols) cannabinoid-based oromucosal spray in patients with multiple sclerosis (MS) and spasticity-related upper limb and hand impairment in routine daily practice. Methods: MS patients with upper limb and hand impairment evaluated the usability of the device using an ad hoc 18-item questionnaire. Results: 60 patients were included. The comprehensibility of the instructions for use, practical handling and ergonomics of the device were rated as optimal (mean scores ≥8.9/10 across questions). Assisting trained nurses also rated the device as easy to use and helpful for drug administration (mean scores 10/10). Conclusion: The application device may assist MS patients with upper limb impairment self-administer nabiximols oromucosal spray.
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Affiliation(s)
| | - Luana Gilio
- Unit of Neurology, IRCCS Neuromed, Pozzilli, Italy
| | - Diego Centonze
- Unit of Neurology, IRCCS Neuromed, Pozzilli, Italy.,Multiple Sclerosis Clinical & Research Unit, Department of Systems Medicine, Tor Vergata University, Rome, Italy
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8
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Patti F, Chisari CG, Fernández Ó, Sarroca J, Ferrer-Picón E, Hernández Vicente F, Vila Silván C. A real-world evidence study of nabiximols in multiple sclerosis patients with resistant spasticity: analysis in relation to the newly-described 'Spasticity-Plus syndrome'. Eur J Neurol 2022; 29:2744-2753. [PMID: 35590453 PMCID: PMC9539865 DOI: 10.1111/ene.15412] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/25/2022] [Accepted: 04/29/2022] [Indexed: 11/30/2022]
Abstract
Background and purpose Nabiximols is a therapeutic option for patients with multiple sclerosis (MS) spasticity whose symptoms are poorly controlled by conventional oral first‐line medications. This study aimed to assess the relationship between changes in spasticity severity (measured on the 0–10 numeric rating scale [NRS]) and the presence of associated symptoms in patients treated with nabiximols, and to investigate the presence of the newly described ‘spasticity‐plus syndrome’. Methods We analyzed real‐world data from the Italian Medicines Agency e‐Registry on 1138 patients with MS spasticity who began treatment with nabiximols. Evaluation time points were baseline, 4 weeks, and 3, 6, 12 and 18 months after treatment start. Results Common symptoms associated with MS spasticity in this cohort were pain (38.4% at baseline), sleep disturbances (32.7%), and spasms/cramps (28.5%). Pain was frequently clustered with sleep disturbances (57.2% of pain cases) and spasms/cramps (43.9%). Approximately one‐third of patients with data at all evaluation time points maintained treatment at 18 months. Nabiximols reduced the baseline mean spasticity 0–10 NRS score by 24.6% at Week 4, and by 33.9% at 18 months in treatment continuers. Nabiximols resolved a range of MS spasticity‐associated symptoms at Week 4, and after 18 months in treatment continuers. Conclusion This real‐world analysis supports the concept of a spasticity‐plus syndrome and suggests that nabiximols can favorably impact a range of spasticity‐associated symptoms.
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Affiliation(s)
- Francesco Patti
- Department "GF Ingrassia", Section of Neurosciences, University of Catania, Catania, Italy
| | - Clara Grazia Chisari
- Department "GF Ingrassia", Section of Neurosciences, University of Catania, Catania, Italy
| | - Óscar Fernández
- Institute of Biomedical Research of Malaga (IBIMA), Regional University Hospital and Department of Pharmacology, Faculty of Medicine, University of Malaga, Spain
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Chan A, Silván CV. Evidence-based management of multiple sclerosis spasticity with nabiximols oromucosal spray in clinical practice: a 10-year recap. Neurodegener Dis Manag 2022; 12:141-154. [PMID: 35377770 DOI: 10.2217/nmt-2022-0002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Effective symptomatic management of multiple sclerosis (MS) spasticity remains an unmet need for many patients. The second-line option nabiximols is the most widely investigated of the noninvasive antispasticity medications in this patient population. Clinical evidence accumulated with nabiximols since it was first approved in Europe in 2010 suggests that about 40% of initial responders (i.e., those with ≥20% improvement in their baseline 0-10 Numerical Rating Scale score) may expect to achieve clinically meaningful (≥30% Numerical Rating Scale response) and durable symptomatic improvement in MS spasticity. During 10 years' routine use of nabiximols, no new safety signals have emerged. Nabiximols-associated improvement in MS spasticity-related symptoms such as pain and sleep disruption suggests a need to track possible therapeutic effects beyond muscle tone control.
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Affiliation(s)
- Andrew Chan
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
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10
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Campos RMP, Aguiar AFL, Paes-Colli Y, Trindade PMP, Ferreira BK, de Melo Reis RA, Sampaio LS. Cannabinoid Therapeutics in Chronic Neuropathic Pain: From Animal Research to Human Treatment. Front Physiol 2021; 12:785176. [PMID: 34916962 PMCID: PMC8669747 DOI: 10.3389/fphys.2021.785176] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/10/2021] [Indexed: 12/25/2022] Open
Abstract
Despite the importance of pain as a warning physiological system, chronic neuropathic pain is frequently caused by damage in the nervous system, followed by persistence over a long period, even in the absence of dangerous stimuli or after healing of injuries. Chronic neuropathic pain affects hundreds of millions of adults worldwide, creating a direct impact on quality of life. This pathology has been extensively characterized concerning its cellular and molecular mechanisms, and the endocannabinoid system (eCS) is widely recognized as pivotal in the development of chronic neuropathic pain. Scientific evidence has supported that phyto-, synthetic and endocannabinoids are efficient for pain management, while strong data arise from the therapeutic use of Cannabis-derived products. The use of medicinal Cannabis products is directed toward not only relieving symptoms of chronic pain, but also improving several aspects of patients’ welfare. Here, we review the involvement of eCS, along with other cellular and molecular elements, in chronic neuropathic pain pathology and how this system can be targeted for pain management.
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Abyadeh M, Gupta V, Paulo JA, Gupta V, Chitranshi N, Godinez A, Saks D, Hasan M, Amirkhani A, McKay M, Salekdeh GH, Haynes PA, Graham SL, Mirzaei M. A Proteomic View of Cellular and Molecular Effects of Cannabis. Biomolecules 2021; 11:1411. [PMID: 34680044 PMCID: PMC8533448 DOI: 10.3390/biom11101411] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/17/2021] [Accepted: 09/21/2021] [Indexed: 12/17/2022] Open
Abstract
Cannabis (Cannabis sativa), popularly known as marijuana, is the most commonly used psychoactive substance and is considered illicit in most countries worldwide. However, a growing body of research has provided evidence of the therapeutic properties of chemical components of cannabis known as cannabinoids against several diseases including Alzheimer's disease (AD), multiple sclerosis (MS), Parkinson's disease, schizophrenia and glaucoma; these have prompted changes in medicinal cannabis legislation. The relaxation of legal restrictions and increased socio-cultural acceptance has led to its increase in both medicinal and recreational usage. Several biochemically active components of cannabis have a range of effects on the biological system. There is an urgent need for more research to better understand the molecular and biochemical effects of cannabis at a cellular level, to understand fully its implications as a pharmaceutical drug. Proteomics technology is an efficient tool to rigorously elucidate the mechanistic effects of cannabis on the human body in a cell and tissue-specific manner, drawing conclusions associated with its toxicity as well as therapeutic benefits, safety and efficacy profiles. This review provides a comprehensive overview of both in vitro and in vivo proteomic studies involving the cellular and molecular effects of cannabis and cannabis-derived compounds.
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Affiliation(s)
- Morteza Abyadeh
- ProGene Technologies Pty Ltd., Macquarie Park, Sydney, NSW 2113, Australia;
| | - Vivek Gupta
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, North Ryde, Sydney, NSW 2109, Australia; (N.C.); (A.G.); (D.S.); (S.L.G.)
| | - Joao A. Paulo
- Department of Cell Biology, Harvard Medical School, Boston, MA 02115, USA;
| | - Veer Gupta
- School of Medicine, Deakin University, Geelong, VIC 2600, Australia;
| | - Nitin Chitranshi
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, North Ryde, Sydney, NSW 2109, Australia; (N.C.); (A.G.); (D.S.); (S.L.G.)
| | - Angela Godinez
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, North Ryde, Sydney, NSW 2109, Australia; (N.C.); (A.G.); (D.S.); (S.L.G.)
| | - Danit Saks
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, North Ryde, Sydney, NSW 2109, Australia; (N.C.); (A.G.); (D.S.); (S.L.G.)
| | - Mafruha Hasan
- School of Life and Environmental Sciences, University of Sydney, Sydney, NSW 2006, Australia;
| | - Ardeshir Amirkhani
- Australian Proteome Analysis Facility, Macquarie University, Sydney, NSW 2109, Australia;
| | - Matthew McKay
- Bowel Cancer and Biomarker Laboratory, Kolling Institute, Northern Clinical School, The University of Sydney, Sydney, NSW 2006, Australia;
| | - Ghasem H. Salekdeh
- Department of Molecular Sciences, Macquarie University, Macquarie Park, Sydney, NSW 2109, Australia; (G.H.S.); (P.A.H.)
| | - Paul A. Haynes
- Department of Molecular Sciences, Macquarie University, Macquarie Park, Sydney, NSW 2109, Australia; (G.H.S.); (P.A.H.)
| | - Stuart L. Graham
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, North Ryde, Sydney, NSW 2109, Australia; (N.C.); (A.G.); (D.S.); (S.L.G.)
| | - Mehdi Mirzaei
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, North Ryde, Sydney, NSW 2109, Australia; (N.C.); (A.G.); (D.S.); (S.L.G.)
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Sartori A, Dinoto A, Stragapede L, Mazzon G, Morelli ME, Pasquin F, Bratina A, Bosco A, Manganotti P. Nabiximols and botulinum toxin injections for patients with multiple sclerosis: efficacy on spasticity and spasms in a single-centre experience. Neurol Sci 2021; 42:5037-5043. [PMID: 33742336 DOI: 10.1007/s10072-021-05182-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 03/13/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Spasticity is a common and disabling symptom in patients with multiple sclerosis (PwMS): as highlighted by many epidemiological studies, it is often a severe and not well treated. Despite the availability of evidence-based spasticity management guidelines, there is still great variability in everyday therapeutic approach, especially for the most complex cases. METHODS In our single-centre study, we retrospectively evaluated PwMS-treated nabiximols and botulinum toxin injections (BTI) from July 2015 to April 2019. Clinical and demographic data were collected. The severity of spasticity and spasms was recorded by modified Ashworth Scale (mAS) and Penn Spasm Frequency Scale (PSFS) at baseline and after 1 month of treatment. RESULTS We evaluated 64 treatments for MS-related spasticity: 28 patients were treated with BTI and 36 patients with nabiximols. We found that both BTI and nabiximols are effective in reducing mAS (nabiximols, BTI: p < 0.001), PSFS frequency (nabiximols: p = 0.001, BTI: p = 0.008) and intensity (nabiximols: p = 0.001, BTI p = 0.016). No differences were found when directly comparing the efficacy of the two treatments, except for a statistical trend favouring BTI on spasms intensity (p = 0.091). Eleven patients were treated with both BTI and nabiximols, and only four patients continued both treatments. All dropouts were due to inefficacy of at least one of the two therapies. CONCLUSIONS Our single-centre experience highlights that both BTI and nabiximols are effective in treating multiple sclerosis-related spasticity; however, BTI treatment may be more effective on spasms intensity. Combined nabiximols and BTI treatment could represent a therapeutic option for severe spasticity.
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Affiliation(s)
- Arianna Sartori
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy.
| | - Alessandro Dinoto
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Lara Stragapede
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Giulia Mazzon
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Maria Elisa Morelli
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Fulvio Pasquin
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Alessio Bratina
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Antonio Bosco
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Paolo Manganotti
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
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Abstract
The medicolegal landscape of cannabis continues to change, and with ever increasing access there has been a concurrent proliferation of research seeking to understand the utility of cannabinoids in treating innumerable conditions with pain at the forefront. This article seeks to summarize clinically relevant findings in cannabinoid research to better prepare clinicians in the utility of cannabis in the treatment of pain.
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Affiliation(s)
- Oliver Hulland
- Department of Emergency Medicine, Yale-New Haven Hospital, Yale University, 464 Congress Avenue, New Haven, CT 06519, USA
| | - Jessica Oswald
- Center for Pain Medicine, Department of Anesthesiology, UC San Diego Health, La Jolla, CA, USA; Department of Emergency Medicine, UC San Diego Health, La Jolla, CA, USA.
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A Critical Review of the Role of the Cannabinoid Compounds Δ 9-Tetrahydrocannabinol (Δ 9-THC) and Cannabidiol (CBD) and their Combination in Multiple Sclerosis Treatment. Molecules 2020; 25:molecules25214930. [PMID: 33113776 PMCID: PMC7663366 DOI: 10.3390/molecules25214930] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/02/2020] [Accepted: 10/07/2020] [Indexed: 02/07/2023] Open
Abstract
Many people with MS (pwMS) use unregulated cannabis or cannabis products to treat the symptoms associated with the disease. In line with this, Sativex, a synthetic combination of cannabidiol (CBD) and Δ9-tetrahydrocannabinol (Δ9-THC) has been approved to treat symptoms of spasticity. In animals, CBD is effective in reducing the amounts of T-cell infiltrates in the spinal cord, suggesting CBD has anti-inflammatory properties. By doing this, CBD has shown to delay symptom onset in animal models of multiple sclerosis and slow disease progression. Importantly, combinations of CBD and Δ9-THC appear more effective in treating animal models of multiple sclerosis. While CBD reduces the amounts of cell infiltrates in the spinal cord, Δ9-THC reduces scores of spasticity. In human studies, the results are less encouraging and conflict with the findings in animals. Drugs which deliver a combination of Δ9-THC and CBD in a 1:1 ratio appear to be only moderately effective in reducing spasticity scores, but appear to be almost as effective as current front-line treatments and cause less severe side effects than other treatments, such as baclofen (a GABA-B receptor agonist) and tizanidine (an α2 adrenergic receptor agonist). The findings of the studies reviewed suggest that cannabinoids may help treat neuropathic pain in pwMS as an add-on therapy to already established pain treatments. It is important to note that treatment with cannabinoid compounds may cause significant cognitive dysfunction. Long term double-blind placebo studies are greatly needed to further our understanding of the role of cannabinoids in multiple sclerosis treatment.
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Chisari CG, Solaro C, Annunziata P, Bergamaschi R, Bianco A, Bonavita S, Brescia Morra V, Bruno Bossio R, Capello E, Castelli L, Cavalla P, Costantino G, Centonze D, Cottone S, Danni MC, Esposito F, Gajofatto A, Gasperini C, Guareschi A, Lanzillo R, Lus G, Maniscalco GT, Matta M, Paolicelli D, Petrucci L, Pontecorvo S, Righini I, Rovaris M, Sessa E, Spinicci G, Spitaleri D, Valentino P, Zaffaroni M, Zappia M, Patti F. Nabiximols discontinuation rate in a large population of patients with multiple sclerosis: a 18-month multicentre study. J Neurol Neurosurg Psychiatry 2020; 91:914-920. [PMID: 32661083 DOI: 10.1136/jnnp-2019-322480] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 03/16/2020] [Accepted: 05/27/2020] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Delta-δ-tetrahydrocannabinol and cannabidiol (THC:CBD) oromucosal spray is used as an add-on therapy option for moderate to severe multiple sclerosis (MS) spasticity resistant to other medications. Aims of this study were to provide real-life data on long-term clinical outcomes in a large population of Italian patients treated with THC:CBD and to evaluate predictors of THC:CBD therapy continuation. MATERIALS AND METHODS This prospective observational multicentre Italian study screened all patients with MS consecutively included in the Agenzia Italiana del Farmaco e-registry at the start of THC:CBD treatment (baseline), after 4 weeks (T1), 12±3 weeks (T2), 24±3 weeks (T3), 48±3 weeks (T4) and 72±3 weeks (T5) from baseline. RESULTS A total of 1845 patients were recruited from 32 MS Italian centres. At T1, 1502 (81.4%) of patients reached a Numerical Rating Scale (NRS) improvement of ≥20%, with an NRS reduction of 26.9% at T1 and of 34.4% at T5. At T5, 725 patients (48.3% of 1502) discontinued treatment with highest discontinuation rate at T2 and T3. Daily number of puffs was generally stable through the observation period. The multivariate analysis showed that higher NRS scores at baseline (OR 2.28, 95% CI 1.15 to 6.36, p<0.01) and higher differences of NRS between T0 and T1 (OR 2.11, 95% CI 1.08 to 8.26, p<0.05) were associated with an increased probability to continue therapy after 18 months. DISCUSSION THC:CBD effects were sustained for 18 months with a relatively stable number of puffs per day. About 50% of patients abandoned THC:CBD therapy for loss of efficacy or adverse events.
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Affiliation(s)
- Clara Grazia Chisari
- Department of Medical, Surgical Science and Advanced Technology "GF Ingrassia", section of neurosciences, Università degli Studi di Catania, Catania, Sicilia, Italy
| | - Claudio Solaro
- Rehabilitation Unit, "Mons. L. Novarese" Hospital, Moncrivello, Vercelli, Piemonte, Italy
| | - Pasquale Annunziata
- Department of Medicine, Surgery and Neurosciences, Università degli Studi di Siena Facoltà di Medicina e Chirurgia, Siena, Toscana, Italy
| | - Roberto Bergamaschi
- Department of Neurology, Foundation National Neurological Institute C Mondino Institute for Hospitalization and Care Scientific, Pavia, Lombardia, Italy
| | - Assunta Bianco
- Multiple Sclerosis Unit, University Hospital Agostino Gemelli, Roma, Lazio, Italy
| | - Simona Bonavita
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, II Clinic of Neurology, University of Campania "Luigi Vanvitelli", Naples, Campania, Italy
| | - Vincenzo Brescia Morra
- Multiple Sclerosis Clinical Care and Research Centre, Department of Neuroscience, Reproductive Science and Odontostomatology, Federico II University Hospital, Napoli, Campania, Italy
| | - Roberto Bruno Bossio
- Neurology Operating Unit and Multiple Sclerosis Center, Cosenza Hospital Districts, Cosenza, Calabria, Italy
| | - Elisabetta Capello
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Ospedale Policlinico San Martino, Genova, Liguria, Italy
| | | | - Paola Cavalla
- Department of Neurosciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino Ospedale San Vito, Torino, Piemonte, Italy
| | | | - Diego Centonze
- Neuroscience Department, University of Rome Tor Vergata, Roma, Lazio, Italy.,Unit of Neurology and of Neurorehabilitation, NEUROMED, Pozzilli, Molise, Italy
| | | | - Maura Chiara Danni
- Neurological Clinic, Department of Experimental & Clinical Medicine, Università Politecnica delle Marche, Ancona, Marche, Italy
| | - Federica Esposito
- Department of Neurology, San Raffaele Hospital, Milano, Lombardia, Italy
| | - Alberto Gajofatto
- Department of Neuroscience, Biomedicine and Movement Multiple Sclerosis Centre, Università degli Studi di Verona, Verona, Veneto, Italy
| | | | - Angelica Guareschi
- Multiple Sclerosis Center, Medicine Department, Fidenza Hospital, Fidenza, Emilia Romagna, Italy
| | - Roberta Lanzillo
- Multiple Sclerosis Clinical Care and Research Centre, Department of Neuroscience, Reproductive Science and Odontostomatology, Federico II University Hospital, Napoli, Campania, Italy
| | - Giacomo Lus
- Multiple Sclerosis Center, II Division of Neurology, Department of Surgical Medical Science, Neurological, Metabolic and Aging, University of Campania Luigi Vanvitelli, Caserta, Campania, Italy
| | | | - Manuela Matta
- Multiple Sclerosis Centre (CRESM), San Luigi Gonzaga University Hospital, Orbassano, Italy
| | - Damiano Paolicelli
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, Università degli Studi di Bari Aldo Moro, Bari, Puglia, Italy
| | - Loredana Petrucci
- Multiple Sclerosis Centre, Pisa University Hospital, Pisa, Toscana, Italy
| | - Simona Pontecorvo
- Department of Human Neuroscience, Multiple Sclerosis Center, Sapienza University of Rome, Roma, Lazio, Italy
| | - Isabella Righini
- NEUROFARBA Department, Neuroscience Section, University of Florence, Firenze, Toscana, Italy
| | - Marco Rovaris
- Multiple Sclerosis Centre, Don Gnocchi Foundation, Milano, Lombardia, Italy
| | - Edoardo Sessa
- Multiple Sclerosis Centre, IRCCS Centro Neurolesi Bonino Pulejo, Messina, Sicilia, Italy
| | - Gabriella Spinicci
- Department of Medical Sciences, Università degli Studi di Cagliari, Cagliari, Sardegna, Italy
| | - Daniele Spitaleri
- Multiple Sclerosis Centre, Azienda Ospedaliera di Rilievo Nazionale e di Alta Specialità San Giuseppe Moscati, Avellino, Campania, Italy
| | - Paola Valentino
- Institute of Neurology, Magna Graecia University of Catanzaro, Catanzaro, Calabria, Italy
| | - Mauro Zaffaroni
- Multiple Sclerosis Centre, Gallarate Hospital, Azienda Socio Sanitaria Territoriale della Valle Olona, Gallarate, Lombardia, Italy
| | - Mario Zappia
- Department of Medical, Surgical Science and Advanced Technology "GF Ingrassia", section of neurosciences, Università degli Studi di Catania, Catania, Sicilia, Italy
| | - Francesco Patti
- Department of Medical, Surgical Science and Advanced Technology "GF Ingrassia", section of neurosciences, Università degli Studi di Catania, Catania, Sicilia, Italy
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Affiliation(s)
- Yara Dadalti Fragoso
- Post-Graduate Program on Health and Environment, Universidade Metropolitana De Santos, Santos, Brazil
- Department of Neurology, MS & Headache Research, Santos, Brazil
| | - Adriana Carra
- MS Section, Hospital Británico De CABA, Buenos Aires, Argentina
| | - Miguel Angel Macias
- Departamento De Neurociencias Y Doctorado De Farmacologia, CUCS, Universidad De Guadalajara, Mexico
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17
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Chisari CG, Sgarlata E, Arena S, D’Amico E, Toscano S, Patti F. An update on the pharmacological management of pain in patients with multiple sclerosis. Expert Opin Pharmacother 2020; 21:2249-2263. [DOI: 10.1080/14656566.2020.1757649] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Clara G. Chisari
- Department “GF Ingrassia”, Section of Neurosciences, University of Catania, Catania, Italy
| | - Eleonora Sgarlata
- Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
- Stroke Unit, Department of Medicine, Umberto I Hospital, Siracusa, Italy
| | - Sebastiano Arena
- Department “GF Ingrassia”, Section of Neurosciences, University of Catania, Catania, Italy
| | - Emanuele D’Amico
- Department “GF Ingrassia”, Section of Neurosciences, University of Catania, Catania, Italy
| | - Simona Toscano
- Department “GF Ingrassia”, Section of Neurosciences, University of Catania, Catania, Italy
| | - Francesco Patti
- Department “GF Ingrassia”, Section of Neurosciences, University of Catania, Catania, Italy
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18
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Maayah ZH, Takahara S, Ferdaoussi M, Dyck JRB. The anti-inflammatory and analgesic effects of formulated full-spectrum cannabis extract in the treatment of neuropathic pain associated with multiple sclerosis. Inflamm Res 2020; 69:549-558. [PMID: 32239248 DOI: 10.1007/s00011-020-01341-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/12/2020] [Accepted: 03/16/2020] [Indexed: 12/16/2022] Open
Abstract
PURPOSE Cannabis has been used for thousands of years in many cultures for the treatment of several ailments including pain. The benefits of cannabis are mediated largely by cannabinoids, the most prominent of which are tetrahydrocannabinol (THC) and cannabidiol (CBD). As such, THC and/or CBD have been investigated in clinical studies for the treatment of many conditions including neuropathic pain and acute or chronic inflammation. While a plethora of studies have examined the biochemical effects of purified THC and/or CBD, only a few have focused on the effects of full-spectrum cannabis plant extract. Accordingly, studies using purified THC or CBD may not accurately reflect the potential health benefits of full-spectrum cannabis extracts. Indeed, the cannabis plant produces a wide range of cannabinoids, terpenes, flavonoids, and other bioactive molecules which are likely to contribute to the different biological effects. The presence of all these bioactive molecules in cannabis extracts has garnered much attention of late especially with regard to their potential role in the treatment of neuropathic pain associated with multiple sclerosis. METHODS Literature review was performed to further understand the effect of clinically used full-spectrum cannabis extract in patients with multiple sclerosis. RESULTS Herein, the current knowledge about the potential beneficial effects of existing products of full-spectrum cannabis extract in clinical studies involving patients with multiple sclerosis is extensively reviewed. In addition, the possible adverse effects associated with cannabis use is discussed along with how the method of extraction and the delivery mechanisms of different cannabis extracts contribute to the pharmacokinetic and biological effects of full-spectrum cannabis extracts.Herein, the current knowledge about the potential beneficial effects of existing products of full-spectrum cannabis extract in clinical studies involving patients with multiple sclerosis is extensively reviewed. In addition, the possible adverse effects associated with cannabis use is discussed along with how the method of extraction and the delivery mechanisms of different cannabis extracts contribute to the pharmacokinetic and biological effects of full-spectrum cannabis extracts.
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Affiliation(s)
- Zaid H Maayah
- Cardiovascular Research Centre, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Shingo Takahara
- Cardiovascular Research Centre, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.,Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Mourad Ferdaoussi
- Cardiovascular Research Centre, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Jason R B Dyck
- Cardiovascular Research Centre, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada. .,Heritage Medical Research Centre, University of Alberta, Edmonton, AB, T6G 2S2, Canada.
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19
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Maayah ZH, Takahara S, Ferdaoussi M, Dyck JRB. The molecular mechanisms that underpin the biological benefits of full-spectrum cannabis extract in the treatment of neuropathic pain and inflammation. Biochim Biophys Acta Mol Basis Dis 2020; 1866:165771. [PMID: 32201189 DOI: 10.1016/j.bbadis.2020.165771] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 03/09/2020] [Accepted: 03/17/2020] [Indexed: 02/07/2023]
Abstract
Cannabis has been shown to be beneficial in the treatment of pain and inflammatory diseases. The biological effect of cannabis is mainly attributed to two major cannabinoids, tetrahydrocannabinol and cannabidiol. In the majority of studies to-date, a purified tetrahydrocannabinol and cannabidiol alone or in combination have been extensively examined in many studies for the treatment of numerous disorders including pain and inflammation. However, few studies have investigated the biological benefits of full-spectrum cannabis plant extract. Given that cannabis is known to generate a large number of cannabinoids along with numerous other biologically relevant products including terpenes, studies involving purified tetrahydrocannabinol and/or cannabidiol do not consider the potential biological benefits of the full-spectrum cannabis extracts. This may be especially true in the case of cannabis as a potential treatment of pain and inflammation. Herein, we review the pre-clinical physiological and molecular mechanisms in biological systems that are affected by cannabis.
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Affiliation(s)
- Zaid H Maayah
- Cardiovascular Research Centre, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Shingo Takahara
- Cardiovascular Research Centre, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Mourad Ferdaoussi
- Cardiovascular Research Centre, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Jason R B Dyck
- Cardiovascular Research Centre, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
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20
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Carotenuto A, Costabile T, De Lucia M, Moccia M, Falco F, Petruzzo M, De Angelis M, Russo CV, Saccà F, Lanzillo R, Brescia Morra V. Predictors of Nabiximols (Sativex®) discontinuation over long-term follow-up: a real-life study. J Neurol 2020; 267:1737-1743. [DOI: 10.1007/s00415-020-09739-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 11/30/2022]
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21
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The Role of Cannabidiol (CBD) in Chronic Pain Management: An Assessment of Current Evidence. Curr Pain Headache Rep 2020; 24:4. [PMID: 31980957 DOI: 10.1007/s11916-020-0835-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Given the growing challenges in chronic pain management coupled with the ongoing consequences of the opioid epidemic, pain management practitioners are looking into more effective, innovative, and safer alternatives to treat pain. Cannabis-based medicine had been described for hundreds of years but only recently have we seen the more scientific, evidence-based approach to its use, and ongoing investigations continue to explore its potential medical benefits. While historically more attention has been paid to the psychoactive component of the cannabis plant Δ9-tetrahydrocannabinol (THC), there have been fewer scientific studies on the medical use of the cannabidiol (CBD) - a non-psychoactive component of the cannabis plant. RECENT FINDINGS By examining recent literature, we investigated the use of CBD and its potential role in pain management. Since there are currently no approved pharmaceutical products that contain CBD alone for the management of pain, this review focused on nabiximols (which is a combined product of THC/CBD in a 1:1 ratio) as the only pharmaceutical product available that contains CBD and is being used for the management of pain. It is difficult to definitely attribute the therapeutic properties to CBD alone since it is always administered with THC. Based on the available literature, it is difficult to make a recommendation for the use of CBD in chronic pain management. It is also important to note that there are many CBD products currently available as supplements, but these products are non-pharmaceuticals and lack the appropriate clinical studies to support their efficacy claims.
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Hutchison KE, Hagerty SL, Galinkin J, Bryan AD, Bidwell LC. Cannabinoids, Pain, and Opioid Use Reduction: The Importance of Distilling and Disseminating Existing Data. Cannabis Cannabinoid Res 2019; 4:158-164. [PMID: 31579833 PMCID: PMC6757236 DOI: 10.1089/can.2018.0052] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The high prevalence of chronic pain conditions combined with an over-reliance on opioid prescriptions has resulted in an opioid epidemic and a desperate need for solutions. There is some debate about whether cannabis might play a role in addressing chronic pain conditions as well as the opioid epidemic. Recent surveys suggest that a large number of people are using cannabis as a treatment for pain and to reduce use of opioids, and cannabis-derived products demonstrate at least modest efficacy in the treatment of pain in randomized controlled trials. In addition, surveillance studies from countries that have approved the use of Sativex, which is a cannabis-based product, have demonstrated that a combination of Δ9-tetrahydrocannabinol and cannabidiol has low potential for harm, is well tolerated, and is helpful to patients. Given the number of people in the United States who are already using cannabis to manage pain and opioid use in state-regulated markets, it is imperative to conduct additional research in these areas, and to disseminate information on how to minimize harm and maximize any benefits of using cannabinoids to mitigate pain and reduce opioid use. The purpose of this article is to call attention to the fact that cannabis is being used in the management of chronic pain. Thus, this article also provides a set of guidelines on how to approach using cannabis to treat pain.
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Affiliation(s)
- Kent E. Hutchison
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, Colorado
| | - Sarah L. Hagerty
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, Colorado
| | - Jeffrey Galinkin
- Pediatric Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Angela D. Bryan
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, Colorado
| | - L. Cinnamon Bidwell
- Institute of Cognitive Science, University of Colorado Boulder, Boulder, Colorado
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23
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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.
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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
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Abstract
Cannabis users have long reported therapeutic properties of the plant for a variety of conditions, some of which include nausea, emesis, seizures, cancer, neurogenic diseases and pain control. Research has elucidated many cannabinoid pharmacodynamic and pharmacokinetic properties, expanding the potential use of cannabinoids as a medical therapy. Due to the inconsistent delivery and control of the active components involved with smoking, pharmaceutical companies are investigating and prioritizing routes other than smoke inhalation for therapeutic use of cannabinoids. In this relatively new field of pharmaceutical development, ongoing drug development promises great benefit from targeted endocannabinoid receptor agonism. Available in Canada and Europe, nabiximols, a specific extract from the Cannabis plant, has demonstrated great benefit in the treatment of pain related to spasticity in multiple sclerosis, cancer and otherwise chronic pain conditions. The cannabidiol oral solution Epidiolex®, which is available in the USA, is indicated for management of refractory epilepsy but may offer therapeutic relief to chronic pain conditions as well. Current investigative drugs, such as those developed by Cara Therapeutics and Zynerba Pharmaceuticals, are synthetic cannabinoids which show promise to specifically target neuropsychiatric conditions and chronic pain symptoms such as neuropathy and allodynia. The objective of this review is to provide clinicians with an update of currently available and promising developmental cannabis pharmaceutical derivatives which may stand to greatly benefit patients with otherwise difficult-to-treat chronic conditions.
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Rock EM, Limebeer CL, Parker LA. Effect of cannabidiolic acid and ∆ 9-tetrahydrocannabinol on carrageenan-induced hyperalgesia and edema in a rodent model of inflammatory pain. Psychopharmacology (Berl) 2018; 235:3259-3271. [PMID: 30225659 DOI: 10.1007/s00213-018-5034-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 09/07/2018] [Indexed: 12/19/2022]
Abstract
RATIONALE Cannabidiol (CBD), a non-intoxicating component of cannabis, or the psychoactive Δ9-tetrahydrocannabiol (THC), shows anti-hyperalgesia and anti-inflammatory properties. OBJECTIVES The present study evaluates the anti-inflammatory and anti-hyperalgesia effects of CBD's potent acidic precursor, cannabidiolic acid (CBDA), in a rodent model of carrageenan-induced acute inflammation in the rat hind paw, when administered systemically (intraperitoneal, i.p.) or orally before and/or after carrageenan. In addition, we assess the effects of oral administration of THC or CBDA, their mechanism of action, and the efficacy of combined ineffective doses of THC and CBDA in this model. Finally, we compare the efficacy of CBD and CBDA. RESULTS CBDA given i.p. 60 min prior to carrageenan (but not 60 min after carrageenan) produced dose-dependent anti-hyperalgesia and anti-inflammatory effects. In addition, THC or CBDA given by oral gavage 60 min prior to carrageenan produced anti-hyperalgesia effects, and THC reduced inflammation. The anti-hyperalgesia effects of THC were blocked by SR141716 (a cannabinoid 1 receptor antagonist), while CBDA's effects were blocked by AMG9810 (a transient receptor potential cation channel subfamily V member 1 antagonist). In comparison to CBDA, an equivalent low dose of CBD did not reduce hyperalgesia, suggesting that CBDA is more potent than CBD for this indication. Interestingly, when ineffective doses of CBDA or THC alone were combined, this combination produced an anti-hyperalgesia effect and reduced inflammation. CONCLUSION CBDA or THC alone, as well as very low doses of combined CBDA and THC, has anti-inflammatory and anti-hyperalgesia effects in this animal model of acute inflammation.
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Affiliation(s)
- Erin M Rock
- Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, ON, N1G2W1, Canada
| | - Cheryl L Limebeer
- Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, ON, N1G2W1, Canada
| | - Linda A Parker
- Department of Psychology and Collaborative Neuroscience Program, University of Guelph, Guelph, ON, N1G2W1, Canada.
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Maurya N, Velmurugan BK. Therapeutic applications of cannabinoids. Chem Biol Interact 2018; 293:77-88. [PMID: 30040916 DOI: 10.1016/j.cbi.2018.07.018] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 07/10/2018] [Accepted: 07/20/2018] [Indexed: 12/12/2022]
Abstract
The psychoactive property of cannabinoids is well known and there has been a continuous controversy regarding the usage of these compounds for therapeutic purposes all over the world. Their use for medical and research purposes are restricted in various countries. However, their utility as medications should not be overshadowed by its negative physiological activities. This review article is focused on the therapeutic potential and applications of phytocannabinoids and endocannabinoids. We further highlights their mode of action, overall effects on physiology, various in vitro and in vivo studies that have been done so far and the extent to which these compounds can be useful in different disease conditions such as cancer, Alzheimer's disease, multiple sclerosis, pain, inflammation, glaucoma and many others. Thus, this work is an attempt to make the readers understand the positive implications of these compounds and indicates the significant developments of utilizing cannabinoids as therapeutic agents.
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Affiliation(s)
- Nancy Maurya
- School of Biotechnology, Rajiv Gandhi Proudyogiki Vishwavidyalaya, Bhopal, India
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Turri M, Teatini F, Donato F, Zanette G, Tugnoli V, Deotto L, Bonetti B, Squintani G. Pain Modulation after Oromucosal Cannabinoid Spray (SATIVEX ®) in Patients with Multiple Sclerosis: A Study with Quantitative Sensory Testing and Laser-Evoked Potentials. MEDICINES 2018; 5:medicines5030059. [PMID: 29933552 PMCID: PMC6163235 DOI: 10.3390/medicines5030059] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 06/15/2018] [Accepted: 06/19/2018] [Indexed: 12/12/2022]
Abstract
Background. Delta-9-tetrahydrocannabinol (THC)/cannabidiol (CBD) (nabiximols or Sativex®) is an oromucosal spray formulation containing THC and CBD at an approximately 1:1 fixed ratio. Its administration for the treatment of pain in patients with multiple sclerosis (MS) has been established. MS patients generally complain of different kinds of pain, including spasticity-related and neuropathic pain. In this study, we compared and evaluated pain modulation and thermal/pain threshold of MS patients before and after THC/CBD administration. Methods. 19 MS patients underwent clinical examination, numerical rating scale (NRS), quantitative sensory testing (QST), and laser-evoked potentials (LEPs) before and after 1 month of therapy. Psychophysiological and neurophysiological data were compared to sex- and age-matched controls. Results. Patients reported a significant reduction in pain. We found statistically significant differences in LEP parameters between patients and controls but no significant change in LEP measures after THC/CBD therapy. Cold and heat detection thresholds were altered in patients but did not change after THC/CBD therapy. There was a significant increase in cold pain threshold by hand stimulation and a significant reduction in abnormal cold perception thresholds. Conclusions. Our results indicate that Sativex® therapy provides pain relief in MS patients and suggest that it might modulate peripheral cold-sensitive TRP channels.
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Affiliation(s)
- Mara Turri
- Department of Neurology, Central Hospital of Bolzano, 39100 Bolzano, Italy.
| | - Francesco Teatini
- Department of Neurology, Central Hospital of Bolzano, 39100 Bolzano, Italy.
| | - Francesco Donato
- Department of Neurology, SS Giovanni e Paolo Hospital, 30122 Venice, Italy.
| | - Giampietro Zanette
- Department of Neurology, Casa di Cura Pederzoli, 37019 Peschiera del Garda, VR, Italy.
| | - Valeria Tugnoli
- Neurology Unit, Department of Neuroscience and Rehabilitation, S. Anna Hospital, 44124 Ferrara, Italy.
| | - Luciano Deotto
- Neurology Unit, Department of Neuroscience, AOUI Verona, 37126 Verona, Italy.
| | - Bruno Bonetti
- Neurology Unit, Department of Neuroscience, AOUI Verona, 37126 Verona, Italy.
| | - Giovanna Squintani
- Neurology Unit, Department of Neuroscience, AOUI Verona, 37126 Verona, Italy.
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Suryadevara U, Bruijnzeel DM, Nuthi M, Jagnarine DA, Tandon R, Bruijnzeel AW. Pros and Cons of Medical Cannabis use by People with Chronic Brain Disorders. Curr Neuropharmacol 2018; 15:800-814. [PMID: 27804883 PMCID: PMC5652027 DOI: 10.2174/1570159x14666161101095325] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Revised: 08/26/2016] [Accepted: 10/28/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Cannabis is the most widely used illicit drug in the world and there is growing concern about the mental health effects of cannabis use. These concerns are at least partly due to the strong increase in recreational and medical cannabis use and the rise in tetrahydrocannabinol (THC) levels. Cannabis is widely used to self-medicate by older people and people with brain disorders such as amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), Alzheimer's disease (AD), Parkinson's disease (PD), bipolar disorder, and schizophrenia. OBJECTIVE This review provides an overview of the perceived benefits and adverse mental health effects of cannabis use in people with ALS, MS, AD, PD, bipolar disorder, and schizophrenia. RESULTS The reviewed studies indicate that cannabis use diminishes some symptoms associated with these disorders. Cannabis use decreases pain and spasticity in people with MS, decreases tremor, rigidity, and pain in people with PD, and improves the quality of life of ALS patients by improving appetite, and decreasing pain and spasticity. Cannabis use is more common among people with schizophrenia than healthy controls. Cannabis use is a risk factor for schizophrenia which increases positive symptoms in schizophrenia patients and diminishes negative symptoms. Cannabis use worsens bipolar disorder and there is no evidence that bipolar patients derive any benefit from cannabis. In late stage Alzheimer's patients, cannabis products may improve food intake, sleep quality, and diminish agitation. CONCLUSION Cannabis use diminishes some of the adverse effects of neurological and psychiatric disorders. However, chronic cannabis use may lead to cognitive impairments and dependence.
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Affiliation(s)
- Uma Suryadevara
- Department of Psychiatry, University of Florida, Gainesville, FL, United States
| | - Dawn M Bruijnzeel
- Department of Psychiatry, University of Florida, Gainesville, FL, United States
| | - Meena Nuthi
- Department of Psychiatry, University of Florida, Gainesville, FL, United States
| | - Darin A Jagnarine
- Department of Psychiatry, University of Florida, Gainesville, FL, United States
| | - Rajiv Tandon
- Department of Psychiatry, University of Florida, Gainesville, FL, United States
| | - Adriaan W Bruijnzeel
- University of Florida, College of Medicine, Department of Psychiatry, 1149 Newell Dr. Gainesville, FL, United States
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Giacoppo S, Bramanti P, Mazzon E. Sativex in the management of multiple sclerosis-related spasticity: An overview of the last decade of clinical evaluation. Mult Scler Relat Disord 2017; 17:22-31. [DOI: 10.1016/j.msard.2017.06.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 06/20/2017] [Accepted: 06/25/2017] [Indexed: 01/28/2023]
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30
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Afkar A, Ashouri A, Rahmani M, Emami Sigaroudi A. Effect of exercise therapy on quality of life of patients with multiple sclerosis in Iran: a systematic review and meta-analysis. Neurol Sci 2017; 38:1901-1911. [DOI: 10.1007/s10072-017-3047-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 06/21/2017] [Indexed: 01/26/2023]
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31
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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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32
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Maccarrone M, Maldonado R, Casas M, Henze T, Centonze D. Cannabinoids therapeutic use: what is our current understanding following the introduction of THC, THC:CBD oromucosal spray and others? Expert Rev Clin Pharmacol 2017; 10:443-455. [PMID: 28276775 DOI: 10.1080/17512433.2017.1292849] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The complexity of the endocannabinoid (eCB) system is becoming better understood and new drivers of eCB signaling are emerging. Modulation of the activities of the eCB system can be therapeutic in a number of diseases. Research into the eCB system has been paralleled by the development of agents that interact with cannabinoid receptors. In this regard it should be remembered that herbal cannabis contains a myriad of active ingredients, and the individual cannabinoids have quite distinct biological activities requiring independent studies. Areas covered: This article reviews the most important current data involving the eCB system in relation to human diseases, to reflect the present (based mainly on the most used prescription cannabinoid medicine, THC/CBD oromucosal spray) and potential future uses of cannabinoid-based therapy. Expert commentary: From the different therapeutic possibilities, THC/CBD oromucosal spray has been in clinical use for approximately five years in numerous countries world-wide for the management of multiple sclerosis (MS)-related moderate to severe resistant spasticity. Clinical trials have confirmed its efficacy and tolerability. Other diseases in which different cannabinoids are currently being investigated include various pain states, Alzheimer's disease, Parkinson's disease, Huntington's disease and epilepsy. The continued characterization of individual cannabinoids in different diseases remains important.
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Affiliation(s)
- Mauro Maccarrone
- a Department of Medicine , Campus Bio-Medico University of Rome , Rome , Italy.,b Laboratory of Lipid Neurochemistry, European Center for Brain Research/IRCCS Santa Lucia Foundation , Rome , Italy
| | - Rafael Maldonado
- c Laboratori de Neurofarmacologia, Departament de Ciències Experimentals i de la Salut (CEXS), Facultat de Ciències de la Salut i de la Vida , Universitat Pompeu Fabra , Barcelona , Spain
| | - Miguel Casas
- d Servicio de Psiquiatría , Hospital Universitari Vall d'Hebron , Barcelona , Spain.,e Departamento de Psiquiatría y Medicina Legal , Universitat Autònoma de Barcelona , Barcelona , Spain.,f CIBERSAM , Barcelona , Spain
| | - Thomas Henze
- g Passauer Wolf Reha-Zentrum Nittenau , Nittenau , Germany
| | - Diego Centonze
- h Multiple Sclerosis Clinical and Research Center, Tor Vergata University, Rome & Unit of Neurology , IRCCS Istituto Neurologico Mediterraneo Neuromed , Pozzilli , Italy
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Advances in clinical neurology through the journal "Neurological Sciences" (2015-2016). Neurol Sci 2017; 38:9-18. [PMID: 28093657 DOI: 10.1007/s10072-017-2815-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Ghezzi A. What is new in multiple sclerosis spasticity research? Poster session highlights. Neurodegener Dis Manag 2016; 6:45-47. [PMID: 27874498 DOI: 10.2217/nmt-2016-0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Each year at the MS Experts Summit, relevant research in the field of multiple sclerosis spasticity is featured in poster sessions. In 2016, six new studies were presented.
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Affiliation(s)
- Angelo Ghezzi
- Neurologia 2, Centro Studi Sclerosi Multipla, Gallarate Hospital, Gallarate, Italy
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35
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Ligresti A, De Petrocellis L, Di Marzo V. From Phytocannabinoids to Cannabinoid Receptors and Endocannabinoids: Pleiotropic Physiological and Pathological Roles Through Complex Pharmacology. Physiol Rev 2016; 96:1593-659. [DOI: 10.1152/physrev.00002.2016] [Citation(s) in RCA: 253] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Apart from having been used and misused for at least four millennia for, among others, recreational and medicinal purposes, the cannabis plant and its most peculiar chemical components, the plant cannabinoids (phytocannabinoids), have the merit to have led humanity to discover one of the most intriguing and pleiotropic endogenous signaling systems, the endocannabinoid system (ECS). This review article aims to describe and critically discuss, in the most comprehensive possible manner, the multifaceted aspects of 1) the pharmacology and potential impact on mammalian physiology of all major phytocannabinoids, and not only of the most famous one Δ9-tetrahydrocannabinol, and 2) the adaptive pro-homeostatic physiological, or maladaptive pathological, roles of the ECS in mammalian cells, tissues, and organs. In doing so, we have respected the chronological order of the milestones of the millennial route from medicinal/recreational cannabis to the ECS and beyond, as it is now clear that some of the early steps in this long path, which were originally neglected, are becoming important again. The emerging picture is rather complex, but still supports the belief that more important discoveries on human physiology, and new therapies, might come in the future from new knowledge in this field.
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Affiliation(s)
- Alessia Ligresti
- Endocannabinoid Research Group, Institute of Biomolecular Chemistry, Consiglio Nazionale delle Ricerche, Comprensorio Olivetti, Pozzuoli, Italy
| | - Luciano De Petrocellis
- Endocannabinoid Research Group, Institute of Biomolecular Chemistry, Consiglio Nazionale delle Ricerche, Comprensorio Olivetti, Pozzuoli, Italy
| | - Vincenzo Di Marzo
- Endocannabinoid Research Group, Institute of Biomolecular Chemistry, Consiglio Nazionale delle Ricerche, Comprensorio Olivetti, Pozzuoli, Italy
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36
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Patti F, Messina S, Solaro C, Amato MP, Bergamaschi R, Bonavita S, Bruno Bossio R, Brescia Morra V, Costantino GF, Cavalla P, Centonze D, Comi G, Cottone S, Danni M, Francia A, Gajofatto A, Gasperini C, Ghezzi A, Iudice A, Lus G, Maniscalco GT, Marrosu MG, Matta M, Mirabella M, Montanari E, Pozzilli C, Rovaris M, Sessa E, Spitaleri D, Trojano M, Valentino P, Zappia M. Efficacy and safety of cannabinoid oromucosal spray for multiple sclerosis spasticity. J Neurol Neurosurg Psychiatry 2016; 87:944-51. [PMID: 27160523 PMCID: PMC5013116 DOI: 10.1136/jnnp-2015-312591] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 03/05/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The approval of 9-δ-tetrahydocannabinol and cannabidiol (THC:CBD) oromucosal spray (Sativex) for the management of treatment-resistant multiple sclerosis (MS) spasticity opened a new opportunity for many patients. The aim of our study was to describe Sativex effectiveness and adverse events profile in a large population of Italian patients with MS in the daily practice setting. METHODS We collected data of all patients starting Sativex between January 2014 and February 2015 from the mandatory Italian medicines agency (AIFA) e-registry. Spasticity assessment by the 0-10 numerical rating scale (NRS) scale is available at baseline, after 1 month of treatment (trial period), and at 3 and 6 months. RESULTS A total of 1615 patients were recruited from 30 MS centres across Italy. After one treatment month (trial period), we found 70.5% of patients reaching a ≥20% improvement (initial response, IR) and 28.2% who had already reached a ≥30% improvement (clinically relevant response, CRR), with a mean NRS score reduction of 22.6% (from 7.5 to 5.8). After a multivariate analysis, we found an increased probability to reach IR at the first month among patients with primary and secondary progressive MS, (n=1169, OR 1.4 95% CI 1.04 to 1.9, p=0.025) and among patients with >8 NRS score at baseline (OR 1.8 95% CI 1.3-2.4 p<0.001). During the 6 months observation period, 631(39.5%) patients discontinued treatment. The main reasons for discontinuation were lack of effectiveness (n=375, 26.2%) and/or adverse events (n=268, 18.7%). CONCLUSIONS Sativex can be a useful and safe option for patients with MS with moderate to severe spasticity resistant to common antispastic drugs.
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Affiliation(s)
- F Patti
- Department of Medical, Surgical Science and Advanced Technology "GF Ingrassia", University of Catania, Catania, Italy
| | - S Messina
- Department of Medical, Surgical Science and Advanced Technology "GF Ingrassia", University of Catania, Catania, Italy
| | - C Solaro
- Neurology Unit, Department Head and Neck, ASL3 Genova, Genova, Italy
| | - M P Amato
- Department NEUROFARBA, University of Florence, Florence, Italy
| | - R Bergamaschi
- Department of Neurology, Neurology Institute C Mondino, Pavia, Italy
| | - S Bonavita
- I Clinic Neurology, II University of Naples, Naples, Italy
| | - R Bruno Bossio
- Neurology Operating Unit, Multiple Sclerosis Center, Provincial Health Authority of Cosenza, Cosenza, Italy
| | - V Brescia Morra
- Multiple Sclerosis Centre, University Federico II, Naples, Italy
| | - G F Costantino
- Demyelinating Diseases Centre, Foggia Hospital, Foggia, Italy
| | - P Cavalla
- Multiple Sclerosis Centre, S. Giovanni Battista, Molinette Hospital, Turin, Italy
| | - D Centonze
- Department of Systems Medicine, Multiple Sclerosis Clinical and Research Center, Tor Vergata University, Rome, Italy Unit of Neurology and of Neurorehabilitation, IRCCS Neuromed, Pozzilli (IS), Italy
| | - G Comi
- Department of Neurology, San Raffaele Hospital, Milan, Italy
| | - S Cottone
- Neuroimmunology Unit, Villa Sofia-Cervello Hospital, Palermo, Italy
| | - M Danni
- Neurology Clinic, Ancona Hospital, Ancona, Italy
| | - A Francia
- Department Neurol Psich, Multiple Sclerosis Center, Sapienza University, Rome, Italy
| | - A Gajofatto
- Multiple Sclerosis Centre, University of Verona, Verona, Italy
| | - C Gasperini
- Neurology Division, San Camillo Hospital, Rome, Italy
| | - A Ghezzi
- Multiple Sclerosis Centre, Sant'Antonio Abate Hospital, Gallarate, Italy
| | - A Iudice
- Multiple Sclerosis Centre, University Hospital Pisa, Pisa, Italy
| | - G Lus
- Multiple Sclerosis Center, Second University of Naples, Naples, Italy
| | - G T Maniscalco
- Multiple Sclerosis Centre, Cardarelli Hospital, Naples, Italy
| | - M G Marrosu
- Department of Medical Sciences, University of Cagliari, Cagliari, Italy
| | - M Matta
- Multiple Sclerosis Centre (CRESM), San Luigi Gonzaga Hospital, Orbassano, Italy
| | - M Mirabella
- Multiple Sclerosis Centre, Cattolica University, Rome, Italy
| | - E Montanari
- Multiple Sclerosis Centre, Vaio Hospital, Fidenza, Italy
| | - C Pozzilli
- Multiple Sclerosis Centre, S. Andrea Hospital, Rome, Italy
| | - M Rovaris
- Multiple Sclerosis Centre, IRCCS Don Gnocchi Foundation, Milan, Italy
| | - E Sessa
- Multiple Sclerosis Centre, IRCCS-Bonino Pulejo Centre, Messina, Italy
| | - D Spitaleri
- Multiple Sclerosis Centre, San G. Moscati Hospital, Avellino, Italy
| | - M Trojano
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Bari, Italy
| | - P Valentino
- Department of Medical Sciences, Institute of Neurology, University "Magna Graecia", Catanzaro, Italy
| | - M Zappia
- Department of Medical, Surgical Science and Advanced Technology "GF Ingrassia", University of Catania, Catania, Italy
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