Pharmacotherapy of Apnea by Cannabimimetic Enhancement, the PACE Clinical Trial: Effects of Dronabinol in Obstructive Sleep Apnea

[Can drug therapy for obstructive sleep apnea be expected after all?]

Obstructive sleep apnea (OSA) is a very common sleep disorder and is usually a chronic disease. Indications for treatment depend on the severity of the nocturnal breathing disorder; the specific symptoms, such as daytime sleepiness; and the comorbidities, which, together with the breathing disorder, constitute the risk of sleep apnea. Standard treatment is nocturnal positive airway pressure therapy or, especially for mild to moderate sleep apnea, a mandibular advancement device. Surgical measures are only carried out if indicated. A specific and effective sleep apnea medication does not yet exist. The first approved medication for obese OSA sufferers is tirzepatide, which leads to a reduction in nocturnal breathing disorders through effective weight reduction. Alternative and in some cases more specific medications are currently being researched. These include, for example, carbonic anhydrase inhibitors, anticholinergics, serotonin-noradrenaline reuptake inhibitors, sympathomimetics, and cannabinoids. Drug therapy for sleep apnea will enrich an individualized therapy in the future that is geared toward the phenotype of sleep apnea.

The impact of acetazolamide and dronabinol on the physiological endotypes responsible for obstructive sleep apnea

STUDY OBJECTIVES

To investigate the effect of differing doses of the combination of acetazolamide and dronabinol (Aceta-Dro) on the obstructive sleep apnea (OSA) endotypes and their relationship to OSA severity.

METHODS

We retrospectively analysed data from a double-blind, randomized, placebo-controlled trial of 3 different doses of Aceta-Dro [Low(125mg/2.5 mg), Medium(250mg/5 mg), High(500mg/10 mg)] in OSA patients. OSA endotypes (collapsibility [VPASSIVE], Loop gain [LG], Arousal threshold [ArTH], and muscle compensation [VCOMP]) were extracted from polysomnography signals using validated algorithms. Linear mixed models were employed to assess the impact of treatment condition on the endotypes. Linear regressions assessed the relationship between the changes in endotypes vs. apnea-hypopnea index (AHI) and to predict treatment response from baseline endotypes.

RESULTS

Relative to placebo, Aceta-Dro dose-dependently reduced LG by 11 % (p = 0.18), 18.5 % (p = 0.022) and 20.5 % (p = 0.016). The reduction in LG was associated with a decrease in AHI in only the high dose condition (R2 = 0.78, p = 0.004). Aceta-Dro improved VPASSIVE in the low dose condition (+13 %, p = 0.005) only, which was strongly associated with AHI reduction (R2 = 0.71, p = 0.005). Aceta-Dro had no impact on VCOMP or ArTH. A higher baseline LG predicted treatment response in the high dose (R2 = 0.56, p = 0.03), with a similar trend observed in the low dose group. More severe collapsibility (lower VPASSIVE) predicted treatment response to both low (R2 = 0.46, p = 0.07) and medium dose (R2 = 0.50, p = 0.03) conditions.

CONCLUSIONS

Mechanistically, our findings suggest that medium and high doses of Aceta-Dro primarily reduce OSA severity by lowering loop gain, while the efficacy of the low dose was due to improved airway collapsibility.

A randomized dose finding study of combination dronabinol and acetazolamide for the treatment of obstructive sleep apnea

STUDY OBJECTIVES

Current treatments for obstructive sleep apnea (OSA) are ineffective or not tolerated in a proportion of patients. Other therapeutic options are needed and pharmaceuticals may provide an alternative. This randomized, double-blind, placebo-controlled, crossover study examined the effect of a combination of acetazolamide and dronabinol (IHL-42X) at low, medium, and high doses on OSA severity.

METHODS

Participants with OSA (apnea-hypopnea index; AHI ≥15 events/hour) received 1 week of IHL-42X at each of three doses and placebo, each separated by a 1-week washout. The change from baseline in AHI, oxygen desaturation index (ODI), Epworth sleepiness score (ESS), and mood (profile of mood states) on the final night of each treatment arm relative to the change from baseline to placebo were the major endpoints. Adverse events (AEs) were monitored throughout.

RESULTS

Ten of 11 participants completed the final night of at least one treatment arm. IHL-42X demonstrated a greater reduction in AHI from baseline compared with placebo (low, -19.7 ± 27.1; medium, -17.5 ± 23.3; high, -16.4 ± 23.8 vs. placebo, -2.8 ± 21.0 events/hour; all p < .05). The change from baseline in ODI3% was greater for the medium IHL-42X dose when compared with placebo (-15.4 ± 19.0 vs. placebo, -2.8 ± 21.0 events/hour; p < .05) but not the low or high doses (low, -15.2 ± 24.8; high, -8.3 ± 13.2 events/hour). IHL-42X did not change ESS or mood. No serious AEs occurred; however, 35 mild-moderate possibly, probably, or treatment-related AEs occurred during IHL-42X dosing and 5 occurred during placebo.

CONCLUSIONS

One week of nightly IHL-42X at low, medium, and high doses was well tolerated, safe, and associated with significant reductions in OSA severity.

Treatable Traits-Based Pharmacologic Treatment of Sleep Apnea

Obstructive sleep apnea (OSA) is a heterogeneous condition characterized by diverse endotypic traits and clinical phenotypes. A recent randomized controlled trial evaluating a glucagon-like peptide-1 receptor agonist showed promising results, potentially making it the first on-label drug treatment for OSA. Phase II/III clinical trials investigating combinations of noradrenergic and antimuscarinic agents, as well as carbonic anhydrase inhibitors, are ongoing. Future drug treatments for OSA, either as monotherapy or combined with other treatment modalities, will be personalized and based on treatable traits to address underlying mechanisms, comorbid conditions, and patient-reported outcome measures.

Cannabinoids for obstructive sleep apnea: A systematic review

Cannabinoids have emerged as a potential treatment for obstructive sleep apnea (OSA). This systematic review aimed to summarize the efficacy and safety of cannabinoids to treat OSA. Databases including Ovid MEDLINE, EMBASE, Scopus, PsycINFO, and International Pharmaceutical Abstracts were searched; experimental and observational studies were eligible for inclusion. One-hundred seventy unique records were screened, and nine studies included: five full-text studies and four published abstracts. The five full-text studies were judged for quality appraisal: two studies deemed at low risk for bias, one study deemed to have some concerns for bias, and two studies deemed to have high risk for bias. Seven of nine total studies were experimental designs and evaluated dronabinol, and the other two studies were observational designs evaluating cannabis. The range of cannabinoid therapy duration spanned from 1 to 6 weeks, and the median duration was 3 weeks. Eight of nine total studies reported statistically significant, positive OSA outcomes due to cannabinoid therapy including reductions in the apnea hypopnea index and improvements in patient-reported daytime sleepiness scales. Between 70% and 80% of study participants reported neuropsychiatric and gastrointestinal adverse events attributable to cannabinoids. The American Academy of Sleep Medicine does not recommend using cannabinoids to treat OSA due to a lack of long-term safety and efficacy data. This systematic review found similar limitations, with the median cannabinoid treatment duration being only 3 weeks. Adequately powered experimental trials over longer time frames are necessary to more completely assess the long-term efficacy and safety of cannabinoids in the treatment of OSA and its effects on common comorbid conditions, such as obesity and cardiovascular disease.

Adverse events caused by cannabinoids in middle aged and older adults for all indications: a meta-analysis of incidence rate difference

BACKGROUND

Cannabinoid-based medicines (CBMs) are being used widely in older people. However, information on the incidence of adverse events (AEs) is limited.

OBJECTIVE

To quantify the incidence rate difference (IRD) of AEs in middle aged and older adults of age ≥50 years receiving CBMs and also examine associations with weekly doses.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, PubMed, EMBASE, CINAHL, PsychInfo, Cochrane Library and ClinicalTrials.gov (1st Jan 1990-12th June 2023).

METHODS

We included randomised clinical trials (RCTs) using CBMs with mean participant age ≥50 years for medicinal purposes for all clinical indications. Paired reviewers independently screened studies, extracted data and appraised risk of bias. We estimated pooled effect-sizes IRD under the random-effects model.

RESULTS

Data from 58 RCTs (37 moderate-high quality studies, pooled n = 6611, mean age range 50-87 years, 50% male, n = 3450 receiving CBMs) showed that compared with controls, the incidence of all-cause and treatment-related AEs attributable to delta-9-tetrahydrocannabinol (THC)-containing CBMs were: THC alone [IRD:18.83(95% Confidence Interval [CI], 1.47-55.79) and 16.35(95% CI, 1.25-48.56)] respectively; THC:cannabidiol (CBD) combination [IRD:19.37(95% CI, 4.24-45.47) and 11.36(95% CI, 2.55-26.48)] respectively. IRDs of serious AEs, withdrawals and deaths were not significantly greater for CBMs containing THC with or without CBD. THC dose-dependently increased the incidence of dry mouth, dizziness/lightheadedness, mobility/balance/coordination difficulties, dissociative/thinking/perception problems and somnolence/drowsiness. The interaction of weekly THC:CBD doses played a role in mostly neurological, psychiatric and cardiac side-effects.

CONCLUSIONS

Although CBMs in general are safe and acceptable in middle aged and older adults, one needs to be mindful of certain common dose-dependent side-effects of THC-containing CBMs.

Orexin receptor 2 agonist activates diaphragm and genioglossus muscle through stimulating inspiratory neurons in the pre-Bötzinger complex, and phrenic and hypoglossal motoneurons in rodents

Orexin-mediated stimulation of orexin receptors 1/2 (OX[1/2]R) may stimulate the diaphragm and genioglossus muscle via activation of inspiratory neurons in the pre-Bötzinger complex, which are critical for the generation of inspiratory rhythm, and phrenic and hypoglossal motoneurons. Herein, we assessed the effects of OX2R-selective agonists TAK-925 (danavorexton) and OX-201 on respiratory function. In in vitro electrophysiologic analyses using rat medullary slices, danavorexton and OX-201 showed tendency and significant effect, respectively, in increasing the frequency of inspiratory synaptic currents of inspiratory neurons in the pre-Bötzinger complex. In rat medullary slices, both danavorexton and OX-201 significantly increased the frequency of inspiratory synaptic currents of hypoglossal motoneurons. Danavorexton and OX-201 also showed significant effect and tendency, respectively, in increasing the frequency of burst activity recorded from the cervical (C3-C5) ventral root, which contains axons of phrenic motoneurons, in in vitro electrophysiologic analyses from rat isolated brainstem-spinal cord preparations. Electromyogram recordings revealed that intravenous administration of OX-201 increased burst frequency of the diaphragm and burst amplitude of the genioglossus muscle in isoflurane- and urethane-anesthetized rats, respectively. In whole-body plethysmography analyses, oral administration of OX-201 increased respiratory activity in free-moving mice. Overall, these results suggest that OX2R-selective agonists enhance respiratory function via activation of the diaphragm and genioglossus muscle through stimulation of inspiratory neurons in the pre-Bötzinger complex, and phrenic and hypoglossal motoneurons. OX2R-selective agonists could be promising drugs for various conditions with respiratory dysfunction.

Tackling obstructive sleep apnea with pharmacotherapeutics: expert guidance

INTRODUCTION

The efficacy of non-pharmacotherapeutic treatment of obstructive sleep apnea, a highly prevalent condition with serious cardiometabolic and neurocognitive health consequences, is well established. Supplementing traditional treatment strategies with medications can improve symptoms and reduce side effects. Efforts to identify medications that target the causes of sleep apnea have met with mixed success. However, this remains a worthwhile objective for researchers to pursue, given the potential benefit pharmacotherapy could bring to those patients who reject or struggle to adhere to existing treatments.

AREAS COVERED

This article presents the case for obstructive sleep apnea pharmacotherapy including drugs that reduce the occurrence of apnea events, such as weight loss agents, ventilation activators and muscle and nervous system stimulants, drugs that alleviate symptoms, such as wake-promoting agents for excessive daytime sleepiness, and drugs that improve adherence to existing treatments, such as hypnotics. Literature was accessed from PubMed between 1 March 2024 and 18 April 2024.

EXPERT OPINION

Exciting recent advances in both our understanding of obstructive sleep apnea pathology and in the techniques used to identify therapeutic agents and their targets combine to embolden a positive outlook for the expanded use of drugs in tackling this consequential disease.

Biphasic effects of cannabis and cannabinoid therapy on pain severity, anxiety, and sleep disturbance: a scoping review

INTRODUCTION

Cannabinoids are being used by patients to help with chronic pain management and to address the 2 primary chronic pain comorbidities of anxiety and sleep disturbance. It is necessary to understand the biphasic effects of cannabinoids to improve treatment of this symptom triad.

METHODS

A scoping review was conducted to identify whether biphasic effects of cannabinoids on pain severity, anxiolysis, and sleep disturbance have been reported. The search included the Embase, Biosis, and Medline databases of clinical literature published between 1970 and 2021. The inclusion criteria were (1) adults more than 18 years of age, (2) data or discussion of dose effects associated with U-shaped or linear dose responses, and (3) measurements of pain and/or anxiety and/or sleep disturbance. Data were extracted by 2 independent reviewers (with a third reviewer used as a tiebreaker) and subjected to a thematic analysis.

RESULTS

After the database search and study eligibility assessment, 44 publications met the final criteria for review. Eighteen publications that specifically provided information on dose response were included in the final synthesis: 9 related to pain outcomes, 7 measuring anxiety, and 2 reporting sleep effects.

CONCLUSIONS

This scoping review reports on biphasic effects of cannabinoids related to pain, sleep, and anxiety. Dose-response relationships are present, but we found gaps in the current literature with regard to biphasic effects of cannabinoids in humans. There is a lack of prospective research in humans exploring this specific relationship.

Synthesis and Evaluation of Natural and Unnatural Tetrahydrocannabiorcol for Its Potential Use in Neuropathologies

(-)-trans-Δ9-Tetrahydrocannabinol (trans-(-)-Δ9-THC) has shown neuroprotective potential, but its medicinal benefits are not fully exploited due to the limitations of psychoactive properties. The lower homologues are non-psychoactive in nature but lack comprehensive scientific validation regarding neuroprotective potential. The present study describes the synthesis of non-psychoactive lower homologues of THC-type compounds and their neuroprotective potential. Both natural tetrahydro-cannabiorcol (trans-(-)-Δ9-THCO) and unnatural Δ9-tetrahydrocannabiorcol (trans-(+)-Δ9-THCO) were successfully synthesized starting from R-limonene and S-limonene, respectively, and investigated for neuroprotective potential in cellular models. The structures of both enantiomers were confirmed by NMR, HMBC, HQSC, NOESY, and COSY experiments. Results indicated that both enantiomers were nontoxic to the cells treated up to 50 μM. Neuroprotective properties of the enantiomers showed that treatments could significantly reverse the corticosterone-induced toxicity in SH-SY5Y cells and simultaneously cause elevated expression of brain-derived neurotrophic factor (BDNF). It was also observed that unnatural trans-(+)-Δ9-THCO displayed better activity than the natural enantiomer and can be further explored for its potential use in neuropathological ailments.

Cannabinoid Use and Obstructive Sleep Apnea: A Retrospective Cohort Study

BACKGROUND

Obstructive sleep apnea (OSA) is a sleep disorder with no widely accepted pharmacological therapy. Cannabinoids have been suggested to reduce OSA severity in small human studies. The purpose of this retrospective cohort study was to explore the association of self-reported cannabis use on OSA severity and sleep parameters in a large cohort of adults undergoing in-laboratory polysomnography.

METHODS

Sleep and medication data were collected for all consecutive adults who completed diagnostic polysomnography at Sunnybrook Health Sciences Centre from 2010 to 2022. Multivariable linear regression models were employed that adjusted for age, sex, and BMI (minimally adjusted model), as well as medication and comorbidity data (maximally adjusted model). An exploratory subgroup analysis was additionally run in patients with moderate to severe OSA.

RESULTS

Of 6,958 individuals (mean age 54.7 ± 16.3, BMI 29.1 ± 6.8, 51.0% female), 71 reported cannabis use. In our minimally adjusted models, cannabis use predicted a reduced respiratory disturbance index (RDI) (β: -4.8 [95% CI: -9.4, -0.2]; p = 0.042); this association became nonsignificant in the fully adjusted models. In an exploratory analysis of patients with moderate to severe OSA (n = 613), cannabis use (n = 7) predicted increased stage N3 sleep (β: 33.5 [95% CI: 15.6, 51.4]; p < 0.001) and decreased REM sleep (β: 16.0 [95% CI: 0.3, 31.7]; p = 0.046).

CONCLUSION

Self-reported cannabis use was not associated with OSA severity after adjusting for confounders. In an exploratory subgroup analysis of patients with moderate to severe OSA, cannabis use impacted sleep architecture. Future studies should further explore these findings.

Thoughtfully Integrating Cannabis Products Into Chronic Pain Treatment

Cannabis products (CPs) and cannabis-based medicines (CBMs) are becoming increasingly available and are commonly used for pain management. The growing societal acceptance of cannabis and liberalization of cannabis laws allows patients to access CPs with minimal clinical oversight. While there is mechanistic plausibility that CPs and CBMs may be useful for pain management, the clinical trial literature is limited and does not refute or support the use of CBMs for pain management. Complicating matters, a large and growing body of observational literature shows that many people use CPs for pain management and in place of other medications. However, products and dosing regimens in existing trials are not generalizable to the current cannabis market, making it difficult to compare and reconcile these 2 bodies of literature. Given this complexity, clinicians need clear, pragmatic guidance on how to appropriately educate and work with patients who are using CBMs for pain management. In this review, we narratively synthesize the evidence to enable a clear view of current landscape and provide pragmatic advice for clinicians to use when working with patients. This advice revolves around 3 principles: (1) maintaining the therapeutic alliance; (2) harm reduction and benefit maximization; and (3) pragmatism, principles of patient-centered care, and use of best clinical judgment in the face of uncertainty. Despite the lack of certainty CPs and chronic pain management use, we believe that following these principles can make most of the clinical opportunity presented by discussions around CPs and also enhance the likelihood of clinical benefit from CPs.

Effect of cannabis and subproducts on anthropometric measures: a systematic review and meta-analysis

BACKGROUND

Obesity poses a significant public health challenge. Research has examined the impact of cannabis and subproducts on health but varying results have hindered a consensus.

AIM

This study aimed to evaluated the effects of cannabis and subproducts on body measurements.

METHODS

For searching randomized controlled trials evaluating cannabis and/or subproducts use and changes in anthropometric measures, a systematic search at MEDLINE, Embase, Cochrane Library and Web of Science was conducted until March 2023. The outcomes included changes in body weight, body mass index (BMI) and waist circumference (WC). Meta-analysis was realized using R software (version 4.2.1).

RESULTS

In general, cannabis use reduced weight by 1.87 kg (95% CI: -3.71 to -0.03) and WC (mean difference = -2.19, 95% CI: -4.44 to 0.06). When examining subgroups, longer follow-up periods were associated with a more pronounced BMI reduction (mean difference = -1.10, 95% CI: -2.23 to 0.03). Cannabinoid CB1 exhibited an increase in body fat (mean difference = 1.70, 95% CI: 0.66-2.74).

CONCLUSION

These findings suggest that cannabis and subproducts could be considered adjuncts in obesity treatment by helping to reduce relevant anthropometric measurements.

DMSO potentiates the suppressive effect of dronabinol on sleep apnea and REM sleep in rats

INTRODUCTION

Dimethyl sulfoxide (DMSO) is an amphipathic molecule with innate biological activity that also is used to dissolve both polar and nonpolar compounds in preclinical and clinical studies. Recent investigations of dronabinol, a cannabinoid, dissolved in DMSO demonstrated decreased sleep apnea frequency and time spent in REM sleep in rats. Here, we tested the effects of dronabinol dissolved in 25% DMSO diluted in phosphate-buffered saline (PBS) to rule out potentiating effects of DMSO.

METHODS

Sprague-Dawley rats were anesthetized and implanted with bilateral stainless steel screws into the skull for electroencephalogram recording and bilateral wire electrodes into the nuchal muscles for electromyogram recording. Each animal was recorded by polysomnography. The study was a fully nested, repeated measures crossover design, such that each rat was recorded following each of 8 intraperitoneal injections separated by three days: vehicle (25% DMSO/PBS); vehicle and CB₁ antagonist (AM 251); vehicle and CB₂ antagonist (AM 630); vehicle and CB₁/CB₂ antagonist; dronabinol (CB₁/CB₂ agonist); dronabinol and CB₁ antagonist; dronabinol and CB₂ antagonist; and dronabinol and CB₁/CB₂ antagonists. Sleep was manually scored into NREM and REM stages, and sleep apneas were quantified.

RESULTS

Dronabinol dissolved in 25% DMSO did not suppress sleep apneas or modify sleep efficiency compared to vehicle controls, in contrast to previously published results. However, dronabinol did suppress REM sleep, which is in line with previously published results.

CONCLUSIONS

Dronabinol in 25% DMSO partially potentiated dronabinol's effects, suggesting a concomitant biological effect of DMSO on breathing during sleep.

The combination of atomoxetine and dronabinol for the treatment of obstructive sleep apnea: a dose-escalating, open-label trial

STUDY OBJECTIVES

The potential sedative effect of dronabinol and the high expression of cannabinoid receptors on the hypoglossal motor nuclei makes this agent a good candidate for obstructive sleep apnea (OSA) pharmacotherapy to be tested with atomoxetine, a noradrenergic reuptake inhibitor that reduced OSA severity in combination with oxybutynin. Here we tested the effect of atomoxetine 80 mg plus dronabinol (Ato-Dro) at 2 different doses (5 and 10 mg) vs. baseline and atomoxetine alone in a 2-center, open-label, dose-escalating trial. The primary outcome was the effect of Ato-Dro vs. baseline on OSA severity (apnea-hypopnea index, hypopneas associated with 4% oxygen desaturation). Safety of the combination and self-reported outcomes were also assessed.

METHODS

Fifteen patients with OSA received progressively increasing Ato-Dro doses (dose escalation was performed every week, starting from Ato-Dro 40-2.5 mg, then 80-5 mg and finally 80-10 mg). A clinical, in-lab polysomnography was performed at baseline, on Ato-Dro 80-5 and Ato-Dro 80-10 mg.

RESULTS

Ato-Dro 80-10 mg did not significantly reduce apnea-hypopnea index, hypopneas associated with 4% oxygen desaturation, and hypoxic burden and yielded limited clinical benefit vs. baseline and atomoxetine alone. However, Ato-Dro 80-5 mg did improve OSA severity (Δapnea-hypopnea index = 8.3[0.3, 16.3] events/h; mean [confidence interval]; Δhypoxic burden = 37.7[12.5, 62.7] %min/h) and multiple self-reported outcomes vs. baseline and/or atomoxetine alone. Ato-Dro administration was characterized by several potentially harmful side effects and treatment discontinuation in 1/3 of cases.

CONCLUSIONS

Ato-Dro 80-5 mg might be useful to reduce OSA severity and lead to self-reported improvement in those who could tolerate the combination. However, given the numerous side effects and the exploratory nature of this open-label study, our results warrant further validation in larger trials.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Title: Study for Efficacy and Dose Escalation of AD313 + Atomoxetine (SEED) (SEED); URL: https://clinicaltrials.gov/ct2/show/NCT05101122; Identifier: NCT05101122.

CITATION

Messineo L, Norman D, Ojile J. The combination of atomoxetine and dronabinol for the treatment of obstructive sleep apnea: a dose-escalating, open-label trial. J Clin Sleep Med. 2023;19(7):1183-1190.

Cannabis use for Sleep Disturbance Among Older Patients in a Geriatrics Clinic

Cannabis use is growing among older adults to manage medical concerns including poor sleep. In this study, we characterized how patients seen at a geriatrics clinic use cannabis to address sleep disturbance. Specifically, we conducted an anonymous survey of 568 adults, including 83 who reported cannabis use within the past 3 years, to inquire about such use. We compared cannabis use characteristics between those using it for sleep disturbance versus all other conditions. We considered a p-value <.10 to be statistically significant. Among the cannabis users in our sample, 29% reported using cannabis for sleep disturbance (N = 24). They were more likely than other users to be female (p = .07), consume cannabis more frequently (p = .01), use products containing tetrahydrocannabinol (THC) (vs. cannabidiol [CBD]-only; p < .01), and use cannabis to target more symptoms (p < .01). As cannabis use continues to grow in older populations, it is essential to delineate better how cannabis may be used safely and effectively to improve older adults' sleep health.

The placebo effect in pharmacological treatment of obstructive sleep apnea, a systematic review and meta-analysis

OBJECTIVE

New drug treatments are under development in obstructive sleep apnea (OSA). The placebo effect is well recognized in various conditions, but its relevance in OSA is debated. In the current study we determined the influence of a placebo effect in studies of drug therapy in OSA.

METHODS

A systematic review and meta-analysis (PROSPERO CRD42021229410) with searches in MEDLINE, Scopus, Web of Science and Cochrane CENTRAL from inception to 2021-01-19. Inclusion criteria were (i) RCTs of adults with OSA, (ii) drug intervention with placebo baseline and follow-up sleep study (iii) outcomes: apnea hypopnea index (AHI), mean oxygen saturation (mSaO2), oxygen desaturation index (ODI) and/or Epworth Sleepiness Scale (ESS). Risk-of-bias was assessed with Cochrane RoB 2.

RESULTS

7436 articles were identified and 29 studies included (n = 413). Studies were generally small (median n = 14), with 78% men, baseline AHI range 9-74 events/h and treatment duration range 1-120 days. Meta-analyses were conducted for main outcomes. Mean change of the primary outcome, AHI, was -0.84 (95% CI -2.98 to 1.30); mSaO2 and ODI estimations were also non-significant. ESS showed a trend towards a reduction of -1 unit. Subgroup analysis did not show significant differences. Risk-of-bias assessment indicated mostly low risk but studies were small with wide confidence intervals.

CONCLUSIONS

In this meta-analysis we did not identify systematic placebo effects on the AHI, ODI or mSaO2 while ESS score showed a trend for a small reduction. These results have an impact on the design and interpretation of drug trials in OSA.

Cannabis and sleep disorders: not ready for prime time? A qualitative scoping review

STUDY OBJECTIVES

To perform a qualitative scoping literature review for studies involving the effects of cannabis on sleep and sleep disorders.

METHODS

Two electronic databases, MEDLINE and EMBASE, searched for comprehensive published abstracted studies that involved human participants. Inclusion criteria were article of any type, published in English, a target population of cannabis users, and reported data on cannabis effect on sleep and sleep disorders. The Joanna Briggs Institute's (JBI) approach was elected as the methodology framework guidance in the scoping review process.

RESULTS

A total of 40 unique publications were found. The majority (82.5%) were from the Americas with 60% published in the last decade. Of the 40 studies, only 25% were randomized control trials, and the sleep outcome measurements were similar and comparable in only 20%. Cannabis users studied were reported either 73% frequent users or 27% sporadic users. The utilization of cannabis showed improved sleep (21%), worse sleep (48%), mixed results (14%), or no impact at all (17%) in the studies published in the last 5 decades.

CONCLUSIONS

Our findings summarize the lack of robust evidence to support the use of cannabis for sleep disorders. The varied cannabis user-related characteristics may account for the inconsistent results identified. Further studies assessing cannabis and sleep are needed to discern what works in what context, how it works, and for whom.

CITATION

Amaral C, Carvalho C, Scaranelo A, Chapman K, Chatkin J, Ferreira I. Cannabis and sleep disorders: not ready for prime time? A qualitative scoping review. J Clin Sleep Med. 2023;19(5):975-990.

Molecular Pathology, Oxidative Stress, and Biomarkers in Obstructive Sleep Apnea

Obstructive sleep apnea syndrome (OSAS) is characterized by intermittent hypoxia (IH) during sleep due to recurrent upper airway obstruction. The derived oxidative stress (OS) leads to complications that do not only concern the sleep-wake rhythm but also systemic dysfunctions. The aim of this narrative literature review is to investigate molecular alterations, diagnostic markers, and potential medical therapies for OSAS. We analyzed the literature and synthesized the evidence collected. IH increases oxygen free radicals (ROS) and reduces antioxidant capacities. OS and metabolic alterations lead OSAS patients to undergo endothelial dysfunction, osteoporosis, systemic inflammation, increased cardiovascular risk, pulmonary remodeling, and neurological alterations. We treated molecular alterations known to date as useful for understanding the pathogenetic mechanisms and for their potential application as diagnostic markers. The most promising pharmacological therapies are those based on N-acetylcysteine (NAC), Vitamin C, Leptin, Dronabinol, or Atomoxetine + Oxybutynin, but all require further experimentation. CPAP remains the approved therapy capable of reversing most of the known molecular alterations; future drugs may be useful in treating the remaining dysfunctions.

Medical Cannabis Use Patterns for Sleep Disorders in Australia: Results of the Cross-Sectional CAMS-20 Survey

Introduction

Sleep disorders are the third most common indication for the prescription of medical cannabis products in Australia, after pain and anxiety. While the use of cannabis for medical purposes is growing in Australia, underlying consumer behaviours and patterns of use, particularly around sleep disorders, are poorly understood.

Methods

We conducted a subanalysis of the cross-sectional "Cannabis as Medicine Survey" 2020-2021 (CAMS-20) (N = 1600), to explore the characteristics of a sample of Australians who were using prescribed and/or illicit medical cannabis to treat a self-reported sleep disorder.

Results

When asked to specify up to seven different conditions they were treating with medical cannabis, a total of 1030 (64%) respondents [mean (SD) 44.9 (13.6) years] selected a sleep disorder, with "insomnia disorder" (85.5%), 'sleep-related movement disorders' (26%) and 'sleep-related breathing disorders' (11.1%) the most common subtypes. Only 165 (16.8%) respondents selected a self-reported sleep disorder as the main health condition being treated. Relative to other health conditions, use of medical cannabis for a self-reported sleep disorder was associated with younger age, increased likelihood of using both prescribed and illicit forms of medical cannabis, inhaled routes of administration, and THC-dominant products. Most respondents reported a reduction in the use of benzodiazepines and alcohol since starting medical cannabis. Binary logistic regression showed that respondents who predominantly used inhaled routes of administration, and concomitant use of medical cannabis for pain, mental health and/or substance use disorder, or a gastrointestinal disorder, were significantly more likely to also use medical cannabis to treat a self-reported sleep disorder.

Conclusion

Overall, these results suggest that self-reported sleep disorders are often being treated with medical cannabis alongside other health conditions (often pain or a mental health disorder) and that use of inhaled methods, THC-dominant products, and illicit sources of medical cannabis are common among people with self-reported sleep disorders in Australia.

Advances in Molecular Pathology of Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common syndrome that features a complex etiology and set of mechanisms. Here we summarized the molecular pathogenesis of OSA, especially the prospective mechanism of upper? airway dilator fatigue and the current breakthroughs. Additionally, we also introduced the molecular mechanism of OSA in terms of related studies on the main signaling pathways and epigenetics alterations, such as microRNA, long non-coding RNA, and DNA methylation. We also reviewed small molecular compounds, which are potential targets for gene regulations in the future, that are involved in the regulation of OSA. This review will be beneficial to point the way for OSA research within the next decade.

Cannabis dosing and administration for sleep: a systematic review

STUDY OBJECTIVES

As cannabis is increasingly used to treat sleep disorders, we performed a systematic review to examine the effects of cannabis on sleep and to guide cannabis prescribers in their recommendations to patients, specifically focusing on dosing.

METHODS

We searched EMBASE, Medline, and Web of Science and identified 4550 studies for screening. Five hundred sixty-eight studies were selected for full-text review and 31 were included for analysis. Study results were considered positive based on improvements in sleep architecture or subjective sleep quality. Bias in randomized controlled trials was assessed using Cochrane Risk of Bias tool 2.0.

RESULTS

Sleep improvements were seen in 7 out of 19 randomized studies and in 7 out of 12 uncontrolled trials. There were no significant differences between the effects of tetrahydrocannabinol and cannabidiol. Cannabis showed most promise at improving sleep in patients with pain-related disorders, as compared to those with neurologic, psychiatric, or sleep disorders, and showed no significant effects on healthy participants' sleep. While subjective improvements in sleep quality were often observed, diagnostic testing showed no improvements in sleep architecture. Adverse events included headaches, sedation, and dizziness, and occurred more frequently at higher doses, though no serious adverse events were observed.

CONCLUSION

High-quality evidence to support cannabis use for sleep remains limited. Heterogeneity in cannabis types, doses, timing of administration, and sleep outcome measures limit the ability to make specific dosing recommendations.

New pharmacologic agents for obstructive sleep apnoea: what do we know and what can we expect?

PURPOSE OF REVIEW

This review provides a condensed description of pharmacological remedies explored in patients with obstructive sleep apnoea (OSA) as well as projections of what we might expect in terms of clinical performance of these drugs.

RECENT FINDINGS

Conventional drug therapies explored in OSA have generally produced disappointing results and there is a shortage of pharmacological treatment alternatives in this disorder. Recent insights into pathophysiological mechanisms potentially involved in OSA suggest that the condition may be divided into distinct subgroups based on clusters or defined by means of unique functional endotypic criteria. In fact, positive outcomes in clinical trials have now resulted in several drug candidates that show a convincing reduction of sleep disordered breathing in both short and intermediate term. Such drugs may be particularly useful in certain variants of OSA but not in others. These insights have also raised the ambition to create personalized therapies in OSA. Another recent development is the insight that OSA-linked conditions such as obesity, daytime somnolence and various forms of cardiovascular/metabolic disease may provide drug-based targets. For instance, pharmacological obesity therapy may provide not only positive metabolic effects but may also be a way to eliminate the anatomic component in obese OSA patients.

SUMMARY

Recent insights into the pathophysiology of OSA have opened possibilities to develop personalized therapy. Drugs addressing fundamental aspects of the sleep and breathing disorder provide a particularly promising avenue for development of novel forms of treatment in OSA.

Review: Cannabinoids as Medicinals

PURPOSE OF REVIEW

There have been many debates, discussions, and published writings about the therapeutic value of cannabis plant and the hundreds of cannabinoids it contains. Many states and countries have attempted, are attempting, or have already passed bills to allow legal use of cannabinoids, especially cannabidiol (CBD), as medicines to treat a wide range of clinical conditions without having been approved by a regulatory body. Therefore, by using PubMed and Google Scholar databases, we have reviewed published papers during the past 30 years on cannabinoids as medicines and comment on whether there is sufficient clinical evidence from well-designed clinical studies and trials to support the use of CBD or any other cannabinoids as medicines.

RECENT FINDINGS

Current research shows that CBD and other cannabinoids currently are not ready for formal indications as medicines to treat a wide range of clinical conditions as promoted except for several exceptions including limited use of CBD for treating two rare forms of epilepsy in young children and CBD in combination with THC for treating multiple-sclerosis-associated spasticity.

SUMMARY

Research indicates that CBD and several other cannabinoids have potential to treat multiple clinical conditions, but more preclinical, and clinical studies and clinical trials, which follow regulatory guidelines, are needed to formally recommend CBD and other cannabinoids as medicines.

Endocannabinoid System and the Otolaryngologist

The endocannabinoid system is located throughout the central and peripheral nervous systems, endocrine system, gastrointestinal system, and within inflammatory cells. The use of medical cannabinoids has been gaining traction as a viable treatment option for varying illnesses in recent years. Research is ongoing looking at the effect of cannabinoids for treatment of common otolaryngologic pathologies. This article identifies common otolaryngologic pathologies where cannabinoids may have benefit, discusses potential drawbacks to cannabinoid use, and suggests future directions for research in the application of medical cannabinoids.

Review: Cannabinoids as Medicinals

Purpose of review

There have been many debates, discussions, and published writings about the therapeutic value of cannabis plant and the hundreds of cannabinoids it contains. Many states and countries have attempted, are attempting, or have already passed bills to allow legal use of cannabinoids, especially cannabidiol (CBD), as medicines to treat a wide range of clinical conditions without having been approved by a regulatory body. Therefore, by using PubMed and Google Scholar databases, we have reviewed published papers during the past 30 years on cannabinoids as medicines and comment on whether there is sufficient clinical evidence from well-designed clinical studies and trials to support the use of CBD or any other cannabinoids as medicines.

Recent findings

Current research shows that CBD and other cannabinoids currently are not ready for formal indications as medicines to treat a wide range of clinical conditions as promoted except for several exceptions including limited use of CBD for treating two rare forms of epilepsy in young children and CBD in combination with THC for treating multiple-sclerosis-associated spasticity.

Summary

Research indicates that CBD and several other cannabinoids have potential to treat multiple clinical conditions, but more preclinical, and clinical studies and clinical trials, which follow regulatory guidelines, are needed to formally recommend CBD and other cannabinoids as medicines.

Turning Over a New Leaf-Pharmacologic Therapy in Obstructive Sleep Apnea

Despite extensive research, there is currently no approved drug for obstructive sleep apnea (OSA) treatment. OSA is a heterogeneous condition that involves multiple dominating pathophysiological traits. Drug development in this field needs to address both pathophysiological mechanisms and associated comorbid conditions in order to meet requirements for long-term therapy in OSA. Several drug candidates have been proposed and ongoing phase II trials that target various forms of sleep-disordered breathing have been initiated. The field is moving toward tailored therapeutic approaches in patients with OSA.

Medical cannabinoids: a pharmacology-based systematic review and meta-analysis for all relevant medical indications

BACKGROUND

Medical cannabinoids differ in their pharmacology and may have different treatment effects. We aimed to conduct a pharmacology-based systematic review (SR) and meta-analyses of medical cannabinoids for efficacy, retention and adverse events.

METHODS

We systematically reviewed (registered at PROSPERO: CRD42021229932) eight databases for randomized controlled trials (RCTs) of dronabinol, nabilone, cannabidiol and nabiximols for chronic pain, spasticity, nausea /vomiting, appetite, ALS, irritable bowel syndrome, MS, Chorea Huntington, epilepsy, dystonia, Parkinsonism, glaucoma, ADHD, anorexia nervosa, anxiety, dementia, depression, schizophrenia, PTSD, sleeping disorders, SUD and Tourette. Main outcomes and measures included patient-relevant/disease-specific outcomes, retention and adverse events. Data were calculated as standardized mean difference (SMD) and ORs with confidence intervals (CI) via random effects. Evidence quality was assessed by the Cochrane Risk of Bias and GRADE tools.

RESULTS

In total, 152 RCTs (12,123 participants) were analysed according to the type of the cannabinoid, outcome and comparator used, resulting in 84 comparisons. Significant therapeutic effects of medical cannabinoids show a large variability in the grade of evidence that depends on the type of cannabinoid. CBD has a significant therapeutic effect for epilepsy (SMD - 0.5[CI - 0.62, - 0.38] high grade) and Parkinsonism (- 0.41[CI - 0.75, - 0.08] moderate grade). There is moderate evidence for dronabinol for chronic pain (- 0.31[CI - 0.46, - 0.15]), appetite (- 0.51[CI - 0.87, - 0.15]) and Tourette (- 1.01[CI - 1.58, - 0.44]) and moderate evidence for nabiximols on chronic pain (- 0.25[- 0.37, - 0.14]), spasticity (- 0.36[CI - 0.54, - 0.19]), sleep (- 0.24[CI - 0.35, - 0.14]) and SUDs (- 0.48[CI - 0.92, - 0.04]). All other significant therapeutic effects have either low, very low, or even no grade of evidence. Cannabinoids produce different adverse events, and there is low to moderate grade of evidence for this conclusion depending on the type of cannabinoid.

CONCLUSIONS

Cannabinoids are effective therapeutics for several medical indications if their specific pharmacological properties are considered. We suggest that future systematic studies in the cannabinoid field should be based upon their specific pharmacology.

Cannabinoids, Insomnia, and Other Sleep Disorders

Sleep disturbances are often cited as a primary reason for medicinal cannabis use, and there is increasing clinical interest in the therapeutic potential of cannabinoids in treating sleep disorders. Burgeoning evidence suggests a role of the endocannabinoid system in regulating the circadian sleep-wake cycle, highlighting a potential avenue for developing novel therapeutics. Despite widespread use of cannabis products as sleep aids globally, robustly designed studies verifying efficacy in sleep-disordered populations are limited. Although some study outcomes have suggested cannabinoid utility in insomnia disorder and sleep apnea, most studies to date are limited by small sample sizes, lack of rigorously controlled study designs, and high risk of bias. This critical review summarizes the current evidence for the use of cannabinoids as a treatment for sleep disorders and provides an overview of endocannabinoid modulation of sleep-wake cycles, as well as the sleep-modulating effects of plant-derived cannabinoids such as delta-9-tetrahydrocannbinol, cannabidiol, and cannabinol. The review also discusses practical considerations for clinicians regarding cannabinoid formulations, routes of administration, respiratory concerns, dosing, potential side effects, drug interactions, and effects relevant to driving, tolerance, and withdrawal. Although current interest in, and uptake of, medicinal cannabis use for sleep disorders may have surpassed the evidence base, there is a strong rationale for continued investigation into the therapeutic potential of cannabinoids.

[Progress in clinical research of REM-related obstructive sleep apnea]

REM-related obstructive sleep apnea （REM-OSA） refers to apneas and hypopneas in which most respiratory events occur during REM. The total AHI of REM-OSA is low compared to NREM-OSA, but the duration of apnea hypopnea events is longer and the oxygen saturation is lower. Only focusing on the total AHI value will miss the diagnosis of REM-OSA, and even some patients with severe hypoxemia cannot be effectively treated.REM-OSA may be an early manifestation of OSA, and active early recognition and intervention may benefit patients.The pathophysiology and mechanism of REM-OSA are still unclear. In this article, we reviewed the existing REM-OSA related research.

Considerations for Cannabinoids in Perioperative Care by Anesthesiologists

Increased usage of recreational and medically indicated cannabinoid compounds has been an undeniable reality for anesthesiologists in recent years. These compounds’ complicated pharmacology, composition, and biological effects result in challenging issues for anesthesiologists during different phases of perioperative care. Here, we review the existing formulation of cannabinoids and their biological activity to put them into the context of the anesthesia plan execution. Perioperative considerations should include a way to gauge the patient’s intake of cannabinoids, the ability to gain consent properly, and vigilance to the increased risk of pulmonary and airway problems. Intraoperative management in individuals with cannabinoid use is complicated by the effects cannabinoids have on general anesthetics and depth of anesthesia monitoring while simultaneously increasing the potential occurrence of intraoperative hemodynamic instability. Postoperative planning should involve higher vigilance to the risk of postoperative strokes and acute coronary syndromes. However, most of the data are not up to date, rending definite conclusions on the importance of perioperative cannabinoid intake on anesthesia management difficult.

Obstructive sleep apnea

Obstructive sleep apnea (OSA) is a disease that results from loss of upper airway muscle tone leading to upper airway collapse during sleep in anatomically susceptible persons, leading to recurrent periods of hypoventilation, hypoxia, and arousals from sleep. Significant clinical consequences of the disorder cover a wide spectrum and include daytime hypersomnolence, neurocognitive dysfunction, cardiovascular disease, metabolic dysfunction, respiratory failure, and pulmonary hypertension. With escalating rates of obesity a major risk factor for OSA, the public health burden from OSA and its sequalae are expected to increase, as well. In this chapter, we review the mechanisms responsible for the development of OSA and associated neurocognitive and cardiometabolic comorbidities. Emphasis is placed on the neural control of the striated muscles that control the pharyngeal passages, especially regulation of hypoglossal motoneuron activity throughout the sleep/wake cycle, the neurocognitive complications of OSA, and the therapeutic options available to treat OSA including recent pharmacotherapeutic developments.

Is There a Place for Medicinal Cannabis in Treating Patients with Sleep Disorders? What We Know so Far

The legalization of cannabis for medicinal, and in some countries, recreational, purposes in addition to growth in the cannabis industry has meant that cannabis use and interest in the area has increased rapidly over the past 20 years. Treatment of poor sleep and sleep disorders are two of the most common reasons for the current use of medicinal cannabis. However, evidence for the role of medical cannabis in the treatment of sleep disorders has not been clearly established, thus making it challenging for clinicians to make evidence-based decisions regarding efficacy and safety. This narrative review summarizes the highest quality clinical evidence currently available in relation to the use of medicinal cannabis for the treatment of sleep disorders including insomnia, obstructive sleep apnea, restless legs syndrome, rapid eye movement sleep behavior disorder, nightmare disorder and narcolepsy. A summary of the effect of cannabis on sleep quality and architecture is also presented. Currently, there is insufficient evidence to support the routine use of medicinal cannabis as an effective and safe treatment option for any sleep disorder. Nevertheless, emerging evidence is promising and warrants further investigation using standardized cannabinoid products and validated quantitative measurement techniques.

Recent cannabis use and nightly sleep duration in adults: a population analysis of the NHANES from 2005 to 2018

BACKGROUND

While popularly consumed for its perceived benefits as a sleeping aid, the impact of cannabis on sleep-wake regulation in clinical studies is inconclusive. The purpose of this study was to determine the relationship between cannabis use and nightly sleep duration in a nationally representative dataset.

METHODS

A cross-sectional analysis of adults was undertaken using the National Health and Nutrition Examination Survey data from 2005 to 2018. Respondents were dichotomized as recent users or non-users if they had used or not used cannabis in the past 30 days, respectively. The primary outcome was nightly sleep duration, categorized as short (<6 hours), optimal (6-9 hours), and long (>9 hours). Multinomial logistic regression was used to adjust for sociodemographic and health-related covariates, and survey sample weights were used in modeling.

RESULTS

From a sample representing approximately 146 million adults in the USA, 14.5% reported recent cannabis use. In an adjusted analysis, recent users were more likely than non-users to report both short sleep (OR 1.34, 95% CI 1.12 to 1.59, p<0.001) and long sleep (OR 1.56, 95% CI 1.25 to 1.96, p<0.001). Heavy users (≥20 of the past 30 days) were even more likely to be at the extremes of nightly sleep duration.

DISCUSSION

Recent cannabis use was associated with the extremes of nightly sleep duration in a nationally representative sample of adults, with suggestions of a dose-response relationship. Our findings highlight the need to further characterize the sleep health of regular cannabis users in the population.

The Management of Cancer Symptoms and Treatment-Induced Side Effects With Cannabis or Cannabinoids

Cannabis and cannabinoids are increasingly being accessed and used by patients with advanced cancer for various symptoms and general quality of life. Specific symptoms of pain, nausea and vomiting, loss of appetite and cachexia, anxiety, sleep disturbance, and medical trauma are among those that have prompted patients with cancer to use cannabis. This conference report from the National Cancer Institute's "Cannabis, Cannabinoid and Cancer Research Symposium" on the topic of "Cancer Symptom/Treatment Side Effect Management" is an expert perspective of cannabis intervention for cancer and cancer treatment-related symptoms. The purpose of the symposium was to identify research gaps, describe the need for high-quality randomized prospective studies of medical cannabis for palliative care in patients with cancer, and evaluate the impact of medical cannabis on cancer survivors' quality of life. Further, education of clinicians and affiliated health-care providers in guiding cancer patients in using cannabis for cancer care would benefit patients. Together, these steps will further aid in refining the use of cannabis and cannabinoids for symptom palliation and improve safety and efficacy for patients.

Novel avenues to approach non-CPAP therapy and implement comprehensive OSA care

Recent advances in obstructive sleep apnoea (OSA) pathophysiology and translational research have opened new lines of investigation for OSA treatment and management. Key goals of such investigations are to provide efficacious, alternative treatment and management pathways that are better tailored to individual risk profiles to move beyond the traditional, continuous positive airway pressure (CPAP)-focused, "one size fits all", trial and error approach which is too frequently inadequate for many patients. Identification of different clinical manifestations of OSA (clinical phenotypes) and underlying pathophysiological phenotypes (endotypes), that contribute to OSA have provided novel insights into underlying mechanisms and have underpinned these efforts. Indeed, this new knowledge has provided the framework for precision medicine for OSA to improve treatment success rates with existing non-CPAP therapies such as mandibular advancement devices and upper airway surgery, and newly developed therapies such as hypoglossal nerve stimulation and emerging therapies such as pharmacotherapies and combination therapy. These concepts have also provided insight into potential physiological barriers to CPAP adherence for certain patients. This review summarises the recent advances in OSA pathogenesis, non-CPAP treatment, clinical management approaches and highlights knowledge gaps for future research. OSA endotyping and clinical phenotyping, risk stratification and personalised treatment allocation approaches are rapidly evolving and will further benefit from the support of recent advances in e-health and artificial intelligence.

Review of the Management of Obstructive Sleep Apnea and Pharmacological Symptom Management

Nearly a billion adults around the world are affected by a disease that is characterized by upper airway collapse while sleeping called obstructive sleep apnea or OSA. The progression and lasting effects of untreated OSA include an increased risk of diabetes mellitus, hypertension, stroke, and heart failure. There is often a decrease in quality-of-life scores and an increased rate of mortality in these patients. The most common and effective treatments for OSA include continuous positive airway pressure (CPAP), surgical treatment, behavior modification, changes in lifestyle, and mandibular advancement devices. There are currently no pharmacological options approved for the standard treatment of OSA. There are, however, some pharmacological treatments for daytime sleepiness caused by OSA. Identifying and treating obstructive sleep apnea early is important to reduce the risks of future complications.

Cannabis related side effects in otolaryngology: a scoping review

BACKGROUND

Cannabis has been rapidly legalized in North America; however, limited evidence exists around its side effects. Health Canada defines side effect as a harmful and unintended response to a health product. Given drug safety concerns, this study's purpose was to review the unintended side effects of cannabis in otolaryngology.

METHODS

The Preferred Reporting Items For Systematic Reviews and Meta-analysis extension for Scoping Reviews (PRISMA-ScR) protocol was used to conduct a scoping review of the MEDLINE, EMBASE, CINAHL, and CENTRAL databases. (PROSPERO: CRD42020153022). English studies in adults were included from inception to the end of 2019. In-vitro, animal, and studies with n < 5 were excluded. Primary outcome was defined as unintended side effects (defined as any Otolaryngology symptom or diagnosis) following cannabis use. Oxford Centre for Evidence-Based Medicine: Levels of Evidence and risk of bias using the Risk of Bias in randomized trials (RoB 2) and Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tools were assessed.. Two authors independently reviewed all studies; the senior author settled any discrepancies.

RESULTS

Five hundred and twenty-one studies were screened; 48 studies were analysed. Subspecialties comprised: Head and Neck (32), Otology (8), Rhinology (5), Airway (5), Laryngology (1). Cannabis use was associated with unintended tinnitus, vertigo, hearing loss, infection, malignancy, sinusitis, allergic rhinitis, thyroid dysfunction, and dyspnea. About half (54.1%) of studies showed increased side effects, or no change in symptoms following cannabis use. Oxford Levels of Evidence was 2-4 with substantial heterogeneity. Risk of bias assessment with RoB2 was low to high and ROBINS-1 was moderate to critical.

CONCLUSION

This was the first comprehensive scoping review of unintended side effects of cannabis in Otolaryngology. The current literature is limited and lacks high-quality research Future randomized studies are needed to focus on therapeutic effects of cannabis in otolaryngology. Substantial work remains to guide clinicians to suggest safe, evidence-based choices for cannabis use.

Medical Cannabis and Cannabinoids for Impaired Sleep: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

STUDY OBJECTIVES

We conducted a systematic review to explore the effectiveness of medical cannabis for impaired sleep.

METHODS

We searched MEDLINE, EMBASE, CENTRAL and PsychINFO to January 2021 for randomized trials of medical cannabis or cannabinoids for impaired sleep vs. any non-cannabis control. When possible, we pooled effect estimates for all patient-important sleep-related outcomes and used the GRADE approach to appraise the certainty of evidence.

RESULTS

Thirty-nine trials (5,100 patients) were eligible for review, of which 38 evaluated oral cannabinoids and 1 administered inhaled cannabis. The median follow-up was 35 days, and most trials (33 of 39) enrolled patients living with chronic cancer or noncancer chronic pain. Among patients with chronic pain, moderate certainty evidence found that medical cannabis probably results in a small improvement in sleep quality versus placebo (modeled risk difference [RD] for achieving the minimally important difference [MID], 8% [95% CI, 3 to 12]). Moderate to high certainty evidence shows that medical cannabis vs. placebo results in a small improvement in sleep disturbance for chronic non-cancer pain (modeled RD for achieving the MID, 19% [95% CI, 11 to 28]) and a very small improvement in sleep disturbance for chronic cancer pain (WMD of -0.19cm [95%CI, -0.36 to -0.03cm]; interaction p=0.03). Moderate to high certainty evidence shows medical cannabis, versus placebo, results in a substantial increase in the risk of dizziness (RD 29% [95%CI, 16 to 50], for trials with ≥3 months follow-up), and a small increase in the risk of somnolence, dry mouth, fatigue, and nausea (RDs ranged from 6% to 10%).

CONCLUSION

Medical cannabis and cannabinoids may improve impaired sleep among people living with chronic pain, but the magnitude of benefit is likely small.

[(Daytime-)Sleepiness at the Wheel: Conceptual Basics for the Evaluation of the Fitness to Drive]

(Daytime-)Sleepiness at the Wheel: Conceptual Basics for the Evaluation of the Fitness to Drive Abstract. The number of accidents that are caused because the driver fell asleep is most likely underestimated. Clear signs of sleepiness are either misinterpreted or ignored. Independent of whether sleepiness is caused by behavior or a medical condition, the short-term and maybe even long-term fitness-to-drive is not given. Despite clear criteria for sleepiness from guidelines, medical reports and practice use a number of paraphrasing and thus misleading terms. To improve clarity in reports and to prepare future research projects, we present our understanding of such terms and suggest a more selective overall use.

Rapid eye movement related obstructive sleep apnea: Where do we stand?

Rapid eye movement (REM) related obstructive sleep apnea (OSA) is defined by the presence of episodes of apnea or hypopnea predominantly or exclusively during REM sleep. Epidemiology of this disorder shows a complex interaction with age, sex, and body mass index. The prevalence is variable and depends on the criteria used to define this disorder. Moreover, the clinical significance of this entity remains poorly defined. However, episodes of apnea or hypopnea encountered during REM sleep are longer and are associated with a more profound drop in oxygen saturation than non-REM sleep. Likewise, this disorder may be independently associated with hypertension and poor glycemic control. More importantly, positive airway pressure therapy as currently prescribed may not treat the majority of apnea episodes during REM sleep. The treatment is further complicated by the different definitions used for the diagnosis of this disorder and the lack of consensus if patients with this diagnosis should be treated if their overall apnea-hypopnea index does not meet the threshold for the clinical diagnosis of OSA. The definition and treatment used for the diagnosis and management of REM-related OSA needs to be standardized. Moreover, a consensus needs to be developed as to whether patients with this disorder should be treated if their overall apnea-hypopnea index does not meet the threshold for the clinical diagnosis of OSA. Further investigation may help answer if this disorder is independently associated with neurocognitive and cardiometabolic adverse outcomes and help guide the therapeutic approach.

Cannabinoids in Neurology - Position paper from Scientific Departments from Brazilian Academy of Neurology

Cannabinoids comprehend endocannabinoids, phytocannabinoids, and synthetic cannabinoids, with actions both in the central and peripherical nervous systems. A considerable amount of publications have been made in recent years, although cannabis has been known for over a thousand years. Scientific Departments from the Brazilian Academy of Neurology described evidence for medical use in their areas. Literature is constantly changing, and possible new evidence can emerge in the next days or months. Prescription of these substances must be discussed with patients and their families, with knowledge about adverse events and their efficacy.

The "respiratory REM sleep without atonia benefit" on coexisting REM sleep behavior disorder - obstructive sleep apnea

Rapid eye movement sleep behavior disorder (RBD) is a parasomnia characterized by dream-enactment behaviors that emerge during a loss of REM sleep atonia. In patients with RBD, obstructive sleep apneas syndrome (OSAS) frequently occurs as a comorbid entity. It has been reported that the presence of muscle tone during REM sleep (REM sleep without atonia-RSWA) could play a protective role in patients with OSAS RBD. In OSAS, recurrent episodes of complete or partial collapse of the upper airway occur during both, NREM and REM sleep. Particularly during sleep, the withdrawal of excitatory noradrenergic and serotoninergic inputs to the upper airway motor neurons deeply reduces the pharyngeal muscle activity, increasing the propensity for superior airway collapse. The present study compared for the first time the impact of OSAS in RBD patients with a subtype of OSAS patients with predominantly or isolated REM sleep-related OSAS (OSAS REM group) in the search of an adequate model to evaluate future therapeutic strategies. Our study found a significant lower nadir of oximetry values in OSAS RBD in comparison with the OSAS REM group. This reduction, that we called the “respiratory RSWA benefit”, is in accordance with the decrease of the nadir oximetry values observed in patients with Parkinson disease and OSAS with or without RBD. We suggest that the group of OSAS REM patients is a natural model to evaluate the respiratory protective role of RSWA in patients with coexisting RBD-OSAS and Parkinson’s disease.

Evaluation and Management of Adults with Obstructive Sleep Apnea Syndrome

Obstructive sleep apnea syndrome (OSAS) is a common and underdiagnosed medical condition characterized by recurrent sleep-dependent pauses and reductions in airflow. While a narrow, collapsible oropharynx plays a central role in the pathophysiology of OSAS, there are other equally important nonanatomic factors including sleep-stage dependent muscle tone, arousal threshold, and loop gain that drive obstructive apneas and hypopneas. Through mechanisms of intermittent hypoxemia, arousal-related sleep fragmentation, and intrathoracic pressure changes, OSAS impacts multiple organ systems. Risk factors for OSAS include obesity, male sex, age, specific craniofacial features, and ethnicity. The prevalence of OSAS is rising due to increasing obesity rates and improved sensitivity in the tools used for diagnosis. Validated questionnaires have an important but limited role in the identification of patients that would benefit from formal testing for OSA. While an in-laboratory polysomnography remains the gold standard for diagnosis, the widespread availability and accuracy of home sleep apnea testing modalities increase access and ease of OSAS diagnosis for many patients. In adults, the most common treatment involves the application of positive airway pressure (PAP), but compliance continues to be a challenge. Alternative treatments including mandibular advancement device, hypoglossal nerve stimulator, positional therapies, and surgical options coupled with weight loss and exercise offer possibilities of an individualized personal approach to OSAS. Treatment of symptomatic patients with OSAS has been found to be beneficial with regard to sleep-related quality of life, sleepiness, and motor vehicle accidents. The benefit of treating asymptomatic OSA patients, particularly with regard to cardiovascular outcomes, is controversial and more data are needed.

New frontiers in pharmacologic obstructive sleep apnea treatment: A narrative review

Obstructive sleep apnea (OSA) is the most common form of sleep-disordered breathing characterized by intermittent partial or complete closure of the upper airway during sleep. If left untreated, OSA is associated with adverse cardiovascular outcomes such as hypertension, coronary heart disease, heart failure, cardiac arrhythmia, stroke, and death. Positive airway pressure (PAP) is often considered the first-line treatment for OSA. While PAP can be very effective in reducing the number of obstructive apneas and hypopneas, its impact on prevention of adverse cardiovascular consequences remains controversial, and treatment adherence is often poor. Hence, the necessity for novel treatment options to help those who cannot adhere to positive airway pressure treatment. Different classes of medications have been tested with regards to their effect on OSA severity. This review 1) provides an update on the epidemiology and pathophysiology of OSA, 2) outlines the mechanistic rationale for medication classes tested as OSA treatment and 3) discusses the effects of these medications on OSA. Several wake-promoting medications are approved for management of persistent sleepiness despite OSA treatment; discussion of these symptomatic treatments is outside the scope of this review. Herein, the authors review the current evidence for pharmacological management of OSA and provide future directions.

Safety and tolerability of natural and synthetic cannabinoids in adults aged over 50 years: A systematic review and meta-analysis

BACKGROUND

Cannabinoid-based medicines (CBMs) are being used widely in the elderly. However, their safety and tolerability in older adults remains unclear. We aimed to conduct a systematic review and meta-analysis of safety and tolerability of CBMs in adults of age ≥50 years.

METHODS AND FINDINGS

A systematic search was performed using MEDLINE, PubMed, EMBASE, CINAHL PsychInfo, Cochrane Library, and ClinicalTrials.gov (1 January 1990 to 3 October 2020). Randomised clinical trials (RCTs) of CBMs in those with mean age of ≥50 years for all indications, evaluating the safety/tolerability of CBMs where adverse events have been quantified, were included. Study quality was assessed using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. Two reviewers conducted all review stages independently. Where possible, data were pooled using random-effects meta-analysis. Effect sizes were calculated as incident rate ratio (IRR) for outcome data such as adverse events (AEs), serious AEs (SAEs), and death and risk ratio (RR) for withdrawal from study and reported separately for studies using tetrahydrocannabinol (THC), THC:cannabidiol (CBD) combination, and CBD. A total of 46 RCTs were identified as suitable for inclusion of which 31 (67%) were conducted in the United Kingdom and Europe. There were 6,216 patients (mean age 58.6 ± 7.5 years; 51% male) included in the analysis, with 3,469 receiving CBMs. Compared with controls, delta-9-tetrahydrocannabinol (THC)-containing CBMs significantly increased the incidence of all-cause and treatment-related AEs: THC alone (IRR: 1.42 [95% CI, 1.12 to 1.78]) and (IRR: 1.60 [95% CI, 1.26 to 2.04]); THC:CBD combination (IRR: 1.58 [95% CI,1.26 to 1.98]) and (IRR: 1.70 [95% CI,1.24 to 2.33]), respectively. IRRs of SAEs and deaths were not significantly greater under CBMs containing THC with or without CBD. THC:CBD combination (RR: 1.40 [95% CI, 1.08 to 1.80]) but not THC alone (RR: 1.18 [95% CI, 0.89 to 1.57]) significantly increased risk of AE-related withdrawals. CBD alone did not increase the incidence of all-cause AEs (IRR: 1.02 [95% CI, 0.90 to 1.16]) or other outcomes as per qualitative synthesis. AE-related withdrawals were significantly associated with THC dose in THC only [QM (df = 1) = 4.696, p = 0.03] and THC:CBD combination treatment ([QM (df = 1) = 4.554, p = 0.033]. THC-containing CBMs significantly increased incidence of dry mouth, dizziness/light-headedness, and somnolence/drowsiness. Study limitations include inability to fully exclude data from those <50 years of age in our primary analyses as well as limitations related to weaknesses in the included trials particularly incomplete reporting of outcomes and heterogeneity in included studies.

CONCLUSIONS

This pooled analysis, using data from RCTs with mean participant age ≥50 years, suggests that although THC-containing CBMs are associated with side effects, CBMs in general are safe and acceptable in older adults. However, THC:CBD combinations may be less acceptable in the dose ranges used and their tolerability may be different in adults over 65 or 75 years of age.

Multitargeting the sleep-pain interaction with pharmacological approaches: A narrative review with suggestions on new avenues of investigation

The multimorbidity formed by sleep disturbances and pain conditions is highly prevalent and has a significant impact in global health and in the socioeconomic system. Although different approaches have been directed toward its management, evidence regarding an optimal treatment is lacking, and pharmacological options are often preferred. Health professionals (e.g., pain and sleep clinicians) tend to focus on their respective expertise, targeting a single symptom with a single drug. This may increase polypharmacy and the risk of drug interactions, adverse events, and mortality. Hence, the use of medications that can directly or indirectly improve sleep, pain, and other possible accompanying conditions without exacerbating them becomes especially relevant. The objectives of this comprehensive review are to: a) describe the beneficial or deleterious effects that some commonly used medications to manage pain have on sleep and sleep disorders; and b) describe the beneficial or deleterious effects that frequently prescribed medications for sleep may have on pain. Moreover, medications targeting some specific sleep-pain interactions will be suggested and future directions for improving sleep and alleviating pain of these patients will be provided with clinical and research perspectives.

Effects of Cannabinoids on Sleep and their Therapeutic Potential for Sleep Disorders

The recent trend for legalization of medicinal cannabis and cannabinoid-containing products, together with their soporific effects, has led to a surge of interest of their potential therapeutic role in the management of some common sleep disorders, such as insomnia, sleep disordered breathing, and restless legs syndrome, and less common disorders such as narcolepsy and parasomnias. Although much of the pre-clinical and clinical data were derived from studies with relatively small sample sizes and limited by biases in assessment, and in clinical trials lack of allocation concealment, as a whole, the results indicate a potential therapeutic role for cannabinoids in the management of some sleep disorders. Clinical trials are underway for insomnia and obstructive sleep apnea management, but there remains a substantial need for rigorous large multi-center studies to assess the dose, efficacy, and safety of the various types of cannabinoids on sleep disorders. This review aims to summarize the modulatory effects of cannabinoids on sleep physiology and provide a critical evaluation of the research on their potential therapeutic benefit in various sleep disorders.