Real-world, long-term evaluation of the tolerability and therapy retention of Epidiolex® (cannabidiol) in patients with refractory epilepsy

Real-world experience of cannabidiol in conjunction with clobazam for the treatment of seizures associated with Lennox-Gastaut syndrome and Dravet syndrome: Results from a retrospective multicentre chart review in Germany

BACKGROUND

Lennox-Gastaut syndrome (LGS) and Dravet syndrome (DS) are rare and debilitating forms of epilepsy, characterised by recurrent, severe, drug-resistant seizures and neurodevelopmental impairments. A non-euphoric, plant-derived, highly purified formulation of cannabidiol (CBD; Epidyolex®, 100 mg/mL oral solution) is approved in the European Union and United Kingdom for use in patients aged ≥2 years for the adjunctive treatment of seizures associated with LGS or DS in conjunction with clobazam (CLB), and for the adjunctive treatment of seizures associated with tuberous sclerosis complex in patients aged ≥2 years.

METHODS

We performed a retrospective chart review of patients with treatment-resistant epilepsies who were treated with adjunctive CBD at six epilepsy centres in Germany. We analysed patient and treatment characteristics, seizure outcomes, treatment retention rates (i.e. the proportion of patients remaining on CBD treatment at time of assessment and retention as estimated by Kaplan-Meier [KM] analyses), physician-rated Clinical Global Impression of Change (CGI-C), and adverse events (AEs) for up to 12 months. Here, we report data from this chart review for those patients with LGS or DS receiving adjunctive treatment with concomitant CBD and CLB.

RESULTS

We identified 126 patients (102 LGS; 24 DS) receiving CBD and CLB, with a mean (standard deviation [SD]) age of 23.2 (15.8) years and a mean (SD) age of epilepsy onset of 3 (3.7) years. Patients had received a median (range) number of prior antiseizure medications (ASMs) of 6 (1-24) and concomitant ASMs of 3 (1-7). The median target CBD dose was 11.1 mg/kg/day in the total population (17.8, 15.8, and 9.7 mg/kg/day in the <6 years, 6-17 years, and ≥18 years subgroups, respectively). The median time to the target dose was 21-22 days across age groups. The median concomitant CLB dose was 0.14 mg/kg/day (0.38, 0.22, and 0.10 mg/kg/day in the respective age groups). A ≥50% reduction in total seizures was observed in 47.5% of patients at 3 months (35.7-52.6% across age groups) and 45.5% of patients at 12 months (44.4-46.2% across age groups). For generalised tonic-clonic seizures, a ≥50% reduction was observed in 63.0% of patients at 3 months (60.7-66.7% across age groups) and 56.9% of patients at 12 months (50.0-75.0% across age groups). Median seizure days per month significantly decreased from 30 (range: 0.5-30) at baseline to 15 (range: 0-30) at the last follow-up (p <0.001). Overall, 89.7%, 80.7%, and 69.8% patients remained on CBD at 3, 6, and 12 months, respectively. KM estimated treatment retention was similar across paediatric and adult groups, according to earlier or later initiation (e.g. ≤4 vs ≥15 prior and concomitant ASMs) and according to the syndrome (LGS and DS). Physicians rated 66% of patients demonstrated a CGI-C improvement and 67% demonstrated a CGI-C behaviour improvement. The most common AEs (≥5%) were sedation (n = 30, 23.8%), diarrhoea (n = 13, 10.3%) and psycho-behavioural AEs (n = 9, 7.1%).

CONCLUSION

In this chart review of patients with severe treatment refractory LGS or DS receiving adjunctive CBD and CLB concomitantly, a reduction in seizure frequency and sustained treatment retention was observed for up to 12 months across age groups in real-world clinical practice. CBD discontinuations exclusively due to AEs were infrequent and the AE profile was generally aligned to that previously observed.

Persistent behavioural consequences of chronic adolescent cannabidiol (CBD) in a mouse model with increased susceptibility to Δ9-tetrahydrocannabinol and schizophrenia

Increasingly, the cannabis sativa plant compound cannabidiol (CBD) is used to treat various psychiatric and neurological health conditions which occur in early life or adolescence, including schizophrenia and autism spectrum disorder. However, behavioural effects CBD during adolescence have received limited attention, and the long-lasting behavioural consequences of adolescent CBD treatment are unknown. Thus, this study investigated the effects of chronic CBD in adolescence on behaviours in adulthood, in a mouse model of susceptibility to cannabinoid drugs and schizophrenia, i.e. Neuregulin 1 transmembrane domain heterozygous (Nrg1 TM HET) and wildtype-like (WT) controls. We also assessed if adolescent CBD may affect behavioural responses to acute low dose Δ9-tetrahydrocannabinol (THC) in adulthood. Male Nrg1 TM HET mice and WT controls were administered 30 mg/kg CBD daily intraperitoneally for 3 weeks in adolescence, and then at 5-6 months of age were tested for locomotion, social behaviour, sensorimotor gating and cognition, as well as sensitivity to acute THC-induced behaviours. Adolescent CBD supressed locomotion, exploration, and social behaviours, and reduced anxiety-like behaviours in adult mice. An acute THC challenge in adulthood suppressed social behaviours and acoustic startle in all mice, and adolescent CBD exacerbated THC-induced suppression of acoustic startle in Nrg1 mutant mice. CBD did not alter schizophrenia-relevant behaviours in Nrg1 TM HET mice. To conclude, adolescent CBD exposure had persistent effects on behavioural domains in adulthood including anxiety, locomotion and social behaviours. Furthermore, CBD exposure early in life affected behavioural responses to acute THC in the presence of a risk gene which enhances cannabinoid sensitivity.

Cognitive and behavioral impact of antiseizure medications, neuromodulation, ketogenic diet, and surgery in Lennox-Gastaut syndrome: A comprehensive review

Lennox-Gastaut syndrome (LGS) is a severe developmental and epileptic encephalopathy marked by drug-resistant seizures and profound cognitive and behavioral impairments, with nearly 95% of individuals affected by moderate to severe intellectual disability. This review comprehensively explores the cognitive and behavioral impacts of current treatment options for LGS, including antiseizure medications (ASMs), neuromodulation strategies, the ketogenic diet, and surgical interventions. Given the limited availability of LGS-specific data for several ASMs, the evidence base is supplemented with findings from general epilepsy populations and individuals with epilepsy and intellectual disabilities. The evidence reveals that ASMs exert varied cognitive and behavioral effects in LGS. Medications such as valproate, lamotrigine, cannabidiol, fenfluramine, levetiracetam, brivaracetam, felbamate, and rufinamide generally support cognitive stability, while topiramate and zonisamide are associated with cognitive challenges. Behavioral outcomes also vary: stability is observed with valproate, lamotrigine, rufinamide, cannabidiol, and fenfluramine, whereas medications like levetiracetam, perampanel, brivaracetam, clobazam, and zonisamide can increase aggression or irritability. Nonpharmacological therapies, particularly when they reduce seizure frequency, typically provide greater cognitive and behavioral stability, with some offering improvement. Early intervention-especially through surgical options-appears most beneficial for preserving cognitive function. Additionally, therapies such as the ketogenic diet and neuromodulation may provide independent cognitive benefits beyond seizure control. This review emphasizes the importance of personalized treatment strategies, integrating cognitive and behavioral evaluations in therapy selection. Key components include baseline cognitive and behavioral assessments, followed by regular follow-up evaluations, particularly after therapy changes. Consideration of minimizing ASM polytherapy, careful evaluation of drug-drug interactions, pharmacogenomic implications, and the need for therapeutic drug monitoring in cases of cognitive adverse effects is essential. Future research should focus on developing assessment tools tailored to the unique needs of individuals with LGS, utilizing connectivity measures to assess intervention impacts, and advancing precision therapeutics to improve cognitive and behavioral outcomes.

Cannabidiol Toxicity Driven by Hydroxyquinone Formation

Oxidative byproducts of cannabidiol (CBD) are known to be cytotoxic. However, CBD susceptibility to oxidation and resulting toxicity dissolved in two common solvents, ethanol (EtOH) and dimethyl sulfoxide (DMSO), is seldom discussed. Furthermore, CBD products contain a wide range of concentrations, making it challenging to link general health risks associated with CBD cytotoxicity. Here, we report on the effect of CBD and CBD analogues dissolved in EtOH or DMSO at various concentrations. The cells used in these studies were human umbilical vascular endothelial cells (HUVECs). Our findings show significant CBD oxidation to cannabidiol-quinone (CBD-Q) and subsequent cytotoxicity, occurring at 10 μM concentration, regardless of the solution delivery vehicle. Moreover, a new analogue of CBD, cannabidiol-diacetate (CBD-DA), exhibits significantly more stability and reduced toxicity compared with CBD or CBD-Q, respectively. This knowledge is important for determining concentration-dependent health risks of complex cannabinoid mixtures and establishing legal limits.

Efficiency and safety of cannabinoid medical use: an analysis of discussions and observed trends on Instagram

Background

Cannabis and its derivatives show encouraging therapeutic effects in the treatment of various diseases. However, further studies are needed to better assess their efficacy and safety. A promising base for research in the field of medicine and additional pharmacovigilance is social networks, in which experience and knowledge are exchanged between researchers, doctors, and patients, as well as information about the potential risks and benefits of using drugs for medical purposes is disseminated. The aim of this study was to investigate the reported efficiency and safety of medical use of cannabinoids in patients using posts on the social media Instagram and analyze the observed trends.

Methods

Social media listening platform Apify was used to collect data with hashtags as of June 4, 2024, including posts from 2023 and 2024, with some data extending into later periods, in compliance with a systematic approach to data collection. The analysis of the data obtained from the research was conducted using the RStudio platform.

Results

The analysis covered 1,466 posts containing hashtags related to cannabinoids. The posts studied were categorized as follows: 33.08% focused on advertising and commercialization, 25.58% on personal experience, 21.35% on other topics, and 19.99% contained educational content. An analysis of overall content relevance found that the majority of Instagram posts (81.79%) related to cannabis and cannabinoid hashtags are relevant. Most of the Instagram posts studied were posters, followed by personal photos and videos. The analysis shows that English dominates the studied category (70.74% of posts), while German, French, Spanish, and other languages also occupy a significant place, emphasizing the importance of a multilingual approach in content analysis. It has been revealed that organizations publish a larger percentage of posts under this study, with a higher percentage of relevance. Personal experience stories receive a significant number of "likes" indicating a strong emotional connection between audience and content. Instagram discussions about cannabinoid treatment support evidence from scientific studies about their effectiveness in treating a range of diseases, such as epilepsy with Lennox-Gastaut and Dravet syndromes, multiple sclerosis, cancer, and HIV-cachexia, nausea and vomiting caused by chemotherapy. At the same time, they emphasize the need for further clinical studies to better assess safety, side effects, and optimal dosages. Advertising and commercial posts can contribute to increased cannabis use, highlighting the need to raise awareness of risks and strengthen preventive measures.

Conclusion

Analysis of content on the social media Instagram can complement traditional scientific research by providing information on the real use of cannabis and its derivatives, contributing to the development of safe and effective recommendations for its use.

Evolving treatment strategies for early-life seizures in Tuberous Sclerosis Complex: A review and treatment algorithm

Tuberous sclerosis Complex (TSC) is a genetic disorder characterized by multisystem involvement, with epilepsy affecting 80-90% of patients, often beginning in infancy. Early-life seizures in TSC are associated with poor neurodevelopmental outcomes, underscoring the importance of timely and effective management. This review explores the evolving treatment landscape for TSC-associated seizures in young children, focusing on three recently approved or license-expanded therapies: vigabatrin, everolimus, and cannabidiol. The efficacy and safety profiles of these treatments are examined based on clinical trials and real-world evidence, with a focus on their use in treating seizures in young children. The preemptive use of vigabatrin in clinical studies has also been carefully reviewed. A treatment algorithm is proposed, emphasizing early diagnosis, prompt initiation of appropriate therapy, and a stepwise approach to managing both infantile spasms and focal seizures. The algorithm incorporates these newer therapies alongside traditional antiseizure medications and non-pharmacological approaches. Challenges in optimizing treatment strategies, minimizing side effects, and improving long-term outcomes are discussed. This review aims to guide clinicians in navigating the complex landscape of early-life seizures associated with TSC, ultimately striving for improved seizure control and better developmental outcomes in this vulnerable population.

Current and Potential Use of Biologically Active Compounds Derived from Cannabis sativa L. in the Treatment of Selected Diseases

Cannabis sativa L. contains numerous compounds with antioxidant and anti-inflammatory properties, including the flavonoids and the cannabinoids, particularly Δ-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). Cannabinoids have an effect on the endocannabinoid system (ECS), a cellular communication network, and are, hence, widely studied for medical applications. Epidiolex®, a 99% pure oral CBD extract, has been approved by the FDA for the treatment of epilepsy. Nabiximols (Sativex) is an oromucosal spray containing equal volume of THC and CBD, and it is commonly used as an add-on treatment for unresponsive spasticity in multiple sclerosis (MS) patients. Several in vitro and in vivo studies have also shown that cannabinoids can be used to treat various types of cancer, such as melanoma and brain glioblastoma; the first positive clinical trials on the anticancer effect of a THC:CBD blend with temozolomide (TMZ) in the treatment of highly invasive brain cancer are very promising. The cannabinoids exert their anticancer properties in in vitro investigations by the induction of cell death, mainly by apoptosis and cytotoxic autophagy, and the inhibition of cell proliferation. In several studies, cannabinoids have been found to induce tumor regression and inhibit angiogenic mechanisms in vitro and in vivo, as well as in two low-numbered epidemiological studies. They also exhibit antiviral effects by inhibiting ACE2 transcription, blocking viral replication and fusion, and acting as anti-inflammatory agents; indeed, prior CBD consumption (a study of 93,565 persons in Chicago) has also been associated with a much lower incidence of SARS-CoV-2 infections. It is postulated that cannabis extracts can be used in the treatment of many other diseases such as systemic lupus erythematosus, type 1 diabetes, or various types of neurological disorders, e.g., Alzheimer's disease. The aim of this review is to outline the current state of knowledge regarding currently used medicinal preparations derived from C. sativa L. in the treatment of selected cancer and viral diseases, and to present the latest research on the potential applications of its secondary metabolites.

Cannabidiol Treatment for Adult Patients with Drug-Resistant Epilepsies: A Real-World Study in a Tertiary Center

BACKGROUND AND PURPOSE

Around 30% of patients with epilepsy show drug-resistant epilepsy (DRE). While cannabidiol has demonstrated efficacy as an adjunctive treatment in Dravet syndrome (DS), Lennox-Gastaut Syndrome (LGS), and epilepsy related to tuberous sclerosis complex (TSC), its more global effectiveness in adult patients with DRE apart from these three specific contexts needs to be clarified.

METHODS

We conducted a retrospective study at the epilepsy unit of Pitié Salpêtrière Hospital. Patients initiating pharmaceutical cannabidiol treatment and followed for at least 1 year were included. Patients were categorized into "authorized" (LGS, DS, or TSC) and "off-label" groups. Cannabidiol effectiveness and tolerance were compared between groups, and characteristics of responders (patients with >50% reduction in seizure frequency) in the off-label group were examined.

RESULTS

Ninety-one patients, followed by a median duration of 24 months, were included. A total of 35.2% of the patients were in the authorized group. No significant differences were observed in responder rates between groups (31.3% vs. 35.6%, p = 0.85) and retention rates at 1 year (75.0% vs. 74.6%, p = 0.97). Sleepiness was more commonly reported in the authorized group (50.0% vs. 22.0%, p = 0.01), with no other significant differences. Among off-label patients (n = 59), clobazam co-prescription was more prevalent in responders (71.4% vs. 28.9%, p = 0.002).

CONCLUSION

Our findings suggest that cannabidiol may benefit all adult patients with DRE, particularly those already receiving clobazam. Randomized controlled trials are warranted in off-label patients to validate these observational findings.

The Fundamentals of Antiseizure Medications: A Through Z

Since bromides were first used in 1857 to treat epilepsy, numerous antiseizure medications (ASM) have been developed. Many of these are available for the treatment of epilepsy and status epilepticus today. With so many ASM available, questions arise as to whether all of these medications are needed and when should they be used. As precision medicine begins to play a larger role in determining targeted treatments for specific types of epilepsy, a complete understanding of various medications is needed. Additionally, access to several of these medications can be limited in the United States and are especially limited globally. All these factors can make proper selection of ASM challenging and difficult for clinicians. This review highlights important aspects of older and newer medications, developments in precision medicine for epilepsy, increasing understanding of effective treatments for status epileptics, and a global perspective on ASM availability.

Minor Cannabinoids as Inhibitors of Skin Inflammation: Chemical Synthesis and Biological Evaluation

Despite millennia of therapeutic plant use, deliberate exploitation of Cannabis's diverse biomedical potential has only recently gained attention. Bioactivity studies focus mainly on cannabidiol (CBD) and tetrahydrocannabinol (THC) with limited information about the broader cannabinome's "minor phytocannabinoids". In this context, our research targeted the synthesis of minor cannabinoids containing a lateral chain with 3 or 4 carbon atoms, focusing on cannabigerol (CBG) and cannabichromene (CBC) analogues. Using known and innovative strategies, we achieved the synthesis of 11 C3 and C4 analogues, five of which were inhibitors of skin inflammation, with the CBG-C4 ester derivative emerging as the most potent compound.

Polycaprolactone microparticles for the subcutaneous administration of cannabidiol: in vitro and in vivo release

Cannabidiol (CBD) has become a highly attractive entity in therapeutics. However, its low aqueous solubility, instability and handling problems limit the development of effective CBD formulations. Subcutaneously administered CBD-loaded polycaprolactone microparticles (MP) represent an interesting strategy to overcome these challenges. This work focuses on evaluating the pharmacokinetics of CBD formulated in polymer microparticles for subcutaneous administration and characterising its release. The mean release time (MRLT) parameter is used to compare the release of CBD from two microparticle formulations in vitro and in a mouse model. After the administration of CBD in solution, a bicompartmental distribution is observed due to the extensive diffusion to the brain, being the brain/blood AUC ratio 1.29. The blood and brain mean residence time (MRT) are 0.507 ± 0.04 and 0.257 ± 0.0004 days, respectively. MP prepared with two drug/polymer ratios (15/150-MP and 30/150-MP) are designed, showing similar in vitro dissolution profiles (similarity factor (f2) is 63.21), without statistically significant differences between MRLTin vitro values (4.68 ± 0.63 and 4.32 ± 0.05 days). However, considerable differences in blood and brain profiles between both formulations are detected. The blood and brain MRT values of 15/150-MP are 6.44 ± 0.3 days and 6.15 ± 0.25 days, respectively, whereas significantly lower values 3.91 ± 0.29 days and 2.24 ± 0.64 days are obtained with 30/150-MP. The extended release of CBD during 10 days after a single subcutaneous administration is achieved.

Medicinal plants for epileptic seizures: Phytoconstituents, pharmacology and mechanisms revisited

ETHNOPHARMACOLOGICAL RELEVANCE

Epilepsy is a neurological disorder that presents with recurring and spontaneous seizures. It is prevalent worldwide, affecting up to 65 million people, with 80% of cases found in lower-income countries. Medicinal plants are commonly employed for managing and treating epilepsy and convulsions due to their unique therapeutic properties. With increasing research and clinical application, medicinal plants are gaining attention globally due to their potent therapeutic effects and fewer side effects. The development of new plant-based antiepileptic/anticonvulsant agents has become a major focus in the pharmaceutical industry.

AIM OF THE REVIEW

This article summarizes recent research on medicinal plants with reported antiepileptic/anticonvulsant effects. It provides pharmacological and molecular mechanism of action information for the crude extracts and related active constituents evaluated in preclinical research for the treatment of epilepsy and convulsions, and offers a reference for the development of future related studies in this area.

MATERIALS AND METHODS

Articles related to ethnopharmacological and antiepileptic studies on plants or natural products from 2018 to 2023 were collected from PubMed, Web of Science and Scopus, etc. using keywords related to epilepsy, medicinal plants, and natural products, etc. RESULTS: Eighty plant species are commonly used to treat epilepsy and convulsions in African and Asian countries. Sixty natural products showing potential for antiepileptic/anticonvulsant effects have been identified from these medicinal plants. These products can be broadly classified as alkaloids, coumarins, flavonoids, saponins, terpenoids and other compounds. The antiepileptic action of plant extracts and their active ingredients can be classified according to their abilities to modulate the GABAergic and glutamatergic systems, act as antioxidants, exhibit anti-neuroinflammatory effects, and provide neuroprotection. In addition, we highlight that some medicinal plants capable of pharmacologically relieving epilepsy and cognition may be therapeutically useful in the treatment of refractory epilepsy.

CONCLUSIONS

The review highlights the fact that herbal medicinal products used in traditional medicine are a valuable source of potential candidates for antiepileptic drugs. This confirms and encourages the antiepileptic/anticonvulsant activity of certain medicinal plants, which could serve as inspiration for further development. However, the aspects of structural modification and optimization, metabolism, toxicology, mechanisms, and clinical trials are not fully understood and need to be further explored.

Adherence and discontinuation of prescription cannabidiol for the management of seizure disorders at an integrated care center

OBJECTIVE

Evaluate adherence, discontinuation rates, and reasons for non-adherence and discontinuation of prescription CBD during the 12-months post-initiation period at an integrated care center.

METHODS

This was a prospective study of patients prescribed CBD by a neurology clinic provider with initial prescription fulfillment through the center's specialty pharmacy from January 2019 through April 2020. Baseline demographics and reasons for non-adherence and/or discontinuation were collected from the electronic health record and pharmacy claims history was used to calculate adherence using proportion of days covered (PDC). Patients were included in the PDC analysis if they had at least 3 fills during the study period. Non-adherence was defined as a PDC < 0.8. Descriptive statistics were used to summarize data with categorical variables represented as frequencies and percentages and continuous variables as medians and interquartile ranges (IQRs).

RESULTS

We included 136 patients with a median age of 14 years (IQR 9 - 21). Most patients were white (n = 115, 85%), with a diagnosis of intractable epilepsy (n = 100, 74%). Among the 128 patients with 3 or more fills, the median PDC was 0.99 (IQR 0.95 - 1.00) with non-adherence seen in 6% (n = 8) of patients. The most common reason for non-adherence was side effects (n = 2, 25%). Prescription CBD was discontinued by 23% (n = 31) of patients with a median time to discontinuation of 117 days (IQR 68 - 216). The most common reason for discontinuation was major side effects (n = 12, 39%). The most common side effects leading to discontinuation were agitation/irritability (n = 4), mood changes (n = 4), aggressive behavior (n = 3), and increased seizure frequency (n = 3).

CONCLUSION

Adherence to prescription CBD at an integrated care center was high with approximately 94% of patients considered adherent. Providers and pharmacists may improve adherence and discontinuation rates by educating patients on the timeline of response, potential side effects, and potential for dose adjustments.

Characterising people with focal drug-resistant epilepsy: A retrospective cohort study

OBJECTIVES

To describe the demographics, clinical characteristics, drug treatment outcomes, healthcare resource utilization, and injuries among people with focal drug-resistant epilepsy (F-DRE) analysed separately for six European countries.

METHODS

We used electronic medical record data from six European (Belgium, Spain, Italy, France, UK and Germany) primary care/specialist care databases to identify antiseizure medication (ASM) treatment-naïve people (aged ≥ 18 years at F-DRE diagnosis). They were followed from their epilepsy diagnosis until death, the date of last record available, or study end. We used descriptive analyses to characterise the F-DRE cohort, and results were reported by country.

RESULTS

One-thousand-seventy individuals with F-DRE were included (mean age 52.5 years; 55.4 % female). The median follow-up time from the first diagnosis to the end of the follow-up was 95.5 months across all countries. The frequency of F-DRE diagnosis in 2021 ranged from 8.8 % in Italy to 18.2 % in Germany. Psychiatric disorders were the most common comorbidity across all countries. Frequently reported psychiatric disorders were depression (26.7 %) and anxiety (11.8 %). The median time from epilepsy diagnosis to the first ASM failure ranged from 5.9 (4.2-10.2) months in France to 12.6 (5.8-20.4) months in Spain. Levetiracetam and lamotrigine were the most commonly used ASM monotherapies in all countries. Consultation with a general practitioner is sought more frequently after F-DRE diagnosis than after epilepsy diagnosis, except in the UK.

SIGNIFICANCE

No one ASM is optimal for all people with F-DRE, and the risks and benefits of the ASM must be considered. Comorbidities must be an integral part of the management strategy and drive the choice of drugs.

Real-world evidence on the use of cannabidiol for the treatment of drug resistant epilepsy not related to Lennox-Gastaut syndrome, Dravet syndrome or Tuberous Sclerosis Complex

INTRODUCTION

Highly purified cannabidiol (CBD) has a broad spectrum of action and could be useful for the treatment of drug resistant epilepsy regardless of etiology or syndrome.

MATERIALS AND METHODS

Multicenter retrospective study that evaluated the efficacy and safety of CBD for the treatment of drug resistant epilepsy of different etiologies in patients >2 years of age.

RESULTS

Seventy-eight patients with a median age of 24 years and a wide spectrum of mainly structural and genetic etiologies were included. Patients were using a median of 3 antiseizure drugs (IQR=2-4) and had a median of 30 monthly seizures (IQR=12-100) before starting CBD. The median treatment time with CBD was 14 months (IQR=10-17). The efficacy analysis at the last available visit showed that mean percent reduction in seizures, ≥50% reduction in seizure frequency and seizure freedom was 67.8%, 68.8% and 11.5% respectively. We found no significant impact of concomitant clobazam use on the efficacy and safety of CBD. In the safety analysis, 28.2% (n = 22) of patients presented adverse events related to CBD and drug-retention rate was 78.2%.

CONCLUSIONS

In a real-world setting, highly purified CBD has been shown to be safe and effective for the treatment of drug resistant epilepsy not related to Lennox-Gastaut syndrome, Dravet syndrome or Tuberous Sclerosis Complex. Based on these findings, highly purified CBD should be considered as an adjuvant therapy for drug resistant epilepsy, regardless of its underlying cause or specific syndrome. Nevertheless, this assumption should be validated through further controlled trials.

Therapy outcomes associated with prescription cannabidiol use at 12 months post-initiation

OBJECTIVE

This study evaluated prescription cannabidiol (CBD) outcomes during the first 12 months of therapy.

METHODS

A single-center, prospective cohort study was performed including patients prescribed CBD from January 2019 - April 2020, excluding clinical trial patients and those using external specialty pharmacy services. The primary outcome wasepilepsy-related emergency healthcare service (EHS) use within 12 months of initation. Secondary outcomes included prescription CBD discontinuation rate and reason and concomitant anti-seizure medication (ASM) use. A multiple logistic regression model evaluated the odds of EHS use, adjusting for initial concomitant ASM count, age, and insurance type.

RESULTS

The 136 patients included were 85% white, 50% female, and 68% pediatric. EHS utilization occurred in 37% (n = 50) of patients; 29 patients (21%, n = 20 pediatric, n = 9 adult) had at least one emergency department (ED) visit, 9 patients (7%) had two or more; 30 patients (22%, n = 22 pediatric, n = 8 adult) had at least one hospitalizaion. Median time to first ED and hospitalization was 69 (IQR 31-196) and 104 (IQR 38-179) days, respectively. Prescription CBD was discontinued in 31 patients (23%, n = 18 pediatric, n = 13 adult), due to major side effects (n = 12, 39%), common side effects (n = 11, 36%), and unsatisfactory response (n = 11, 36%). There was no significant change in concomitant ASM use.

CONCLUSION

Despite potential benefits of prescription CBD, many patients utilize EHSs in the first 12 months of treatment with minimal changes in concomitant ASM use.

Highly purified cannabidiol in the treatment of drug-resistant epilepsies: A real-life impact on seizure frequency, quality of life, behavior, and sleep patterns from a single Italian center

Seizure frequency in treatment-resistant epilepsies seems to be decreased by cannabidiol (CBD), but contrasting data are available on its effect on sleep, behavior, and quality of life (QoL), and no data is reported on its effect on parental stress in patients with epilepsy (PWE). Thus, we conducted a retrospective study on a cohort of children and adults with drug-resistant epilepsy (DRE) who had been treated with highly purified, pharmaceutical-grade CBD to evaluate its effects on seizure frequency, QoL, behavior, parental stress, and sleep. Eighteen patients (12 adults and 6 children) were included in the cohort and followed for a median of 9 months. At the last follow-up (Tn), nine patients (50%) were considered CBD responders with at least a 50% decrease in seizure frequency. No serious adverse effects were found. No statistically significant differences were found concerning sleep, including daytime sleepiness, and no statistically significant effect was found on parental stress at Tn. An improvement was found for social interaction in quality of life (p < 0.05) for all patients. Our results demonstrate that CBD is a safe and effective antiseizure medication (ASM). CBD doesn't seem to affect sleep measures in adults and children or worsen daytime sleepiness. However, CBD improves specific QoL measures, which could indicate a possible use of CBD for other childhood disabilities. No impact of CBD was seen on parental stress, which could possibly be due to the limited follow-up or could mean that parental stress is not dependent on seizure frequency.

The therapeutic potential of purified cannabidiol

The use of cannabidiol (CBD) for therapeutic purposes is receiving considerable attention, with speculation that CBD can be useful in a wide range of conditions. Only one product, a purified form of plant-derived CBD in solution (Epidiolex), is approved for the treatment of seizures in patients with Lennox-Gastaut syndrome, Dravet syndrome, or tuberous sclerosis complex. Appraisal of the therapeutic evidence base for CBD is complicated by the fact that CBD products sometimes have additional phytochemicals (like tetrahydrocannabinol (THC)) present, which can make the identification of the active pharmaceutical ingredient (API) in positive studies difficult. The aim of the present review is to critically review clinical studies using purified CBD products only, in order to establish the upcoming indications for which purified CBD might be beneficial. The areas in which there is the most clinical evidence to support the use of CBD are in the treatment of anxiety (positive data in 7 uncontrolled studies and 17 randomised controlled trials (RCTs)), psychosis and schizophrenia (positive data in 1 uncontrolled study and 8 RCTs), PTSD (positive data in 2 uncontrolled studies and 4 RCTs) and substance abuse (positive data in 2 uncontrolled studies and 3 RCTs). Seven uncontrolled studies support the use of CBD to improve sleep quality, but this has only been verified in one small RCT. Limited evidence supports the use of CBD for the treatment of Parkinson's (3 positive uncontrolled studies and 2 positive RCTs), autism (3 positive RCTs), smoking cessation (2 positive RCTs), graft-versus-host disease and intestinal permeability (1 positive RCT each). Current RCT evidence does not support the use of purified oral CBD in pain (at least as an acute analgesic) or for the treatment of COVID symptoms, cancer, Huntington's or type 2 diabetes. In conclusion, published clinical evidence does support the use of purified CBD in multiple indications beyond epilepsy. However, the evidence base is limited by the number of trials only investigating the acute effects of CBD, testing CBD in healthy volunteers, or in very small patient numbers. Large confirmatory phase 3 trials are required in all indications.