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Manning B, Arkell TR, Hayley AC, Downey LA. A semi-naturalistic open-label study examining the effect of prescribed medical cannabis use on simulated driving performance. J Psychopharmacol 2024; 38:247-257. [PMID: 38332655 PMCID: PMC10944578 DOI: 10.1177/02698811241229524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
BACKGROUND Despite increasing medical cannabis use, research has yet to establish whether and to what extent products containing delta-9-tetrahydrocannabinol (THC) impact driving performance among patients. Stable doses of prescribed cannabinoid products during long-term treatment may alleviate clinical symptoms affecting cognitive and psychomotor performance. AIM To examine the effects of open-label prescribed medical cannabis use on simulated driving performance among patients. METHODS In a semi-naturalistic laboratory study, 40 adults (55% male) aged between 23 and 80 years, consumed their own prescribed medical cannabis product. Driving performance outcomes including standard deviation of lateral position (SDLP), the standard deviation of speed (SDS), mean speed and steering variability were evaluated using the Forum8 driving simulator at baseline (pre-dosing), 2.5 h and 5 -h (post-dosing). Perceived driving effort (PDE) was self-reported after each drive. Oral fluid and whole blood samples were collected at multiple timepoints and analysed for THC via liquid chromatography-mass spectrometry. RESULTS A significant main effect of time was observed for mean speed (p = 0.014) and PDE (p = 0.020), with patients displaying modest stabilisation of vehicle control, increased adherence to speed limits and reductions in PDE post-dosing, relative to baseline. SDLP (p = 0.015) and PDE (p = 0.043) were elevated for those who consumed oil relative to flower-based products. Detectable THC concentrations were observed in oral fluid at 6-h post-dosing (range = 0-24 ng/mL). CONCLUSIONS This semi-naturalistic study suggests that the consumption of medical cannabis containing THC (1.13-39.18 mg/dose) has a negligible impact on driving performance when used as prescribed.
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Affiliation(s)
- Brooke Manning
- Centre for Mental Health and Brain Sciences, Swinburne University of Technology, Hawthorn, VIC, Australia
| | - Thomas R Arkell
- Centre for Mental Health and Brain Sciences, Swinburne University of Technology, Hawthorn, VIC, Australia
| | - Amie C Hayley
- Centre for Mental Health and Brain Sciences, Swinburne University of Technology, Hawthorn, VIC, Australia
- Institute for Breathing and Sleep (IBAS), Austin Health, Melbourne, VIC, Australia
| | - Luke A Downey
- Centre for Mental Health and Brain Sciences, Swinburne University of Technology, Hawthorn, VIC, Australia
- Institute for Breathing and Sleep (IBAS), Austin Health, Melbourne, VIC, Australia
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2
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Hidding U, Mainka T, Buhmann C. Therapeutic use of medical Cannabis in neurological diseases: a clinical update. J Neural Transm (Vienna) 2024; 131:117-126. [PMID: 38015317 PMCID: PMC10791790 DOI: 10.1007/s00702-023-02719-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 10/31/2023] [Indexed: 11/29/2023]
Abstract
The use of medical Cannabis has increased in recent years due to changing legal circumstances in many countries. Approval exists only for a few neurological conditions such as rare forms of epilepsy or spasticity in multiple sclerosis. Beyond that, however, medical Cannabis is used for a wide range of neurological conditions and symptoms. In Germany, in parallel with new legislation that has simplified the prescription of medical Cannabis, an accompanying survey has been implemented for which initial data are now available. In this context, our review provides an overview of the evidence for the therapeutic use of medical Cannabis in neurology, the potential benefits, and side effects.
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Affiliation(s)
- Ute Hidding
- Department of Neurology, University Clinic Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Tina Mainka
- Department of Neurology and Experimental Neurology at the Charité, Charitéplatz 1, 10117, Berlin, Germany
- Berlin Institute of Health at Charité-BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Charitéplatz 1, 10117, Berlin, Germany
| | - Carsten Buhmann
- Department of Neurology, University Clinic Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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3
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Müller-Vahl KR, Pisarenko A, Ringlstetter R, Cimpianu CL, Fremer C, Weidinger E, Jenz EB, Musil R, Brunnauer A, Großhennig A. The Effect of Nabiximols on Driving Ability in Adults with Chronic Tic Disorders: Results of a Substudy Analysis of the Double-Blind, Randomized, Placebo-Controlled CANNA-TICS Trial. Cannabis Cannabinoid Res 2024. [PMID: 38265476 DOI: 10.1089/can.2023.0114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024] Open
Abstract
Background: The multicenter, randomized, double-blind, parallel-group, phase IIIb CANNA-TICS (CANNAbinoids in the treatment of TICS) trial showed clear trends for improvement of tics, depression, and quality of life with nabiximols versus placebo in adult patients with Gilles de la Tourette syndrome and other chronic tic disorders. Although in general nabiximols was well tolerated, it is unclear whether treatment using this cannabis extract influences driving skills in patients with chronic tic disorders. Methods: Here we report results of the "Fitness to Drive" substudy of the CANNA-TICS trial. The key endpoint was fitness to drive as a binary criterion with a computerized assessment at baseline and after 9 weeks of stable treatment (week 13) with nabiximols or placebo. A patient was considered unfit to drive according to the German Federal Highway Research Institute guidelines. Results: In the substudy, a total of 64 patients (76.6% men, mean±standard deviation of age: 36.8±13.9) were recruited at two study sites. The number of patients who were fit to drive increased from 24 (55.8%) at baseline to 28 (71.8%) at week 13 among 43 patients treated with nabiximols, and decreased from 14 (66.7%) to 10 (52.6%) among 21 patients who received placebo. The risk difference (nabiximols - placebo) was 0.17 (95% confidence interval=-0.08 to 0.43) in favor of nabiximols. Specifically, only 2 of 24 (8.3%) patients in the nabiximols, but 4 of 14 (28.6%) patients in the placebo group changed for the worse from fit (at baseline) to unfit (at week 13) to drive, whereas 8 of 19 (42.1%) patients in the nabiximols, and only 2 of 7 (28.6%) patients in the placebo group improved from unfit to fit. Conclusion: Treatment with nabiximols does not impair skills relevant to driving in those patients with tic disorders who were fit to drive at baseline and even improved fitness to drive in a subset of patients who were unfit to drive before start of treatment. EudraCT number: 2016-000564-42.
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Affiliation(s)
- Kirsten R Müller-Vahl
- Clinic of Psychiatry, Socialpsychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Anna Pisarenko
- Clinic of Psychiatry, Socialpsychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | | | - Camelia-Lucia Cimpianu
- Department of Forensic Psychiatry, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Carolin Fremer
- Clinic of Psychiatry, Socialpsychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Elif Weidinger
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Eva Beate Jenz
- Institute of Biostatistics, Hannover Medical School, Hannover, Germany
| | - Richard Musil
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Alexander Brunnauer
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University Munich, Munich, Germany
- Clinical Center for Psychiatry, Psychotherapy, Psychosomatic Medicine, Geriatrics and Neurology, kbo-Inn-Salzach-Klinikum, Wasserburg/Inn, Germany
| | - Anika Großhennig
- Institute of Biostatistics, Hannover Medical School, Hannover, Germany
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4
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Egloff L, Frei P, Gerlach K, Mercer-Chalmers-Bender K, Scheurer E. Effect of vaporizing cannabis rich in cannabidiol on cannabinoid levels in blood and on driving ability - a randomized clinical trial. Int J Legal Med 2023; 137:1713-1723. [PMID: 37626214 PMCID: PMC10567805 DOI: 10.1007/s00414-023-03076-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023]
Abstract
The aim of this prospective, placebo-controlled, double-blind, randomized, cross-over study was to determine cannabinoid levels in blood and driving-related ability after single (S1) and repetitive (S2) vaporization of cannabis rich in cannabidiol (CBD) containing < 1% Δ9-etrahydrocannabinol (THC). Healthy adult volunteers (Nsingle = 27, Nrepetitive = 20) with experience in smoking vapor-inhaled two low-THC/CBD-rich cannabis products both with < 1% THC (product 1: 38 mg CBD, 1.8 mg THC; product 2: 39 mg CBD, 0.6 mg THC) and placebo. Main outcomes were THC- and CBD-levels in whole blood and overall assessment of driving-related ability by computerized tests. Among 74 participants included, 27 (mean age ± SD, 28.9 ± 12.5 years) completed S1, and 20 (25.2 ± 4.0) completed S2. Peak concentrations and duration of detectability depended on the THC-content of the product. After single consumption THC dropped below 1.5 µg/L after 1.5 h, but was detected in some participants up to 5 h. Pairwise comparison of driving-related ability revealed no significant differences between low-THC/CBD-rich products (P1, P2) and placebo. Detection of THC after consumption of low-THC/CBD-rich cannabis might have legal consequences for drivers. Regarding overall driving-related ability, no significant differences were observed between the interventional products. This trial was registered with the German Clinical Trials Register (DRKS00018836) on 25.10.2019 and with the Coordination Office for Human Research (kofam) which is operated by the Federal Office of Public Health (FOPH) (SNCTP000003294).
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Affiliation(s)
- Laura Egloff
- Institute of Forensic Medicine, Department of Biomedical Engineering, University of Basel, Pestalozzistrasse 22, 4056 Basel, Switzerland
| | - Priska Frei
- Institute of Forensic Medicine, Department of Biomedical Engineering, University of Basel, Pestalozzistrasse 22, 4056 Basel, Switzerland
| | - Kathrin Gerlach
- Institute of Forensic Medicine, Department of Biomedical Engineering, University of Basel, Pestalozzistrasse 22, 4056 Basel, Switzerland
| | - Katja Mercer-Chalmers-Bender
- Institute of Forensic Medicine, Department of Biomedical Engineering, University of Basel, Pestalozzistrasse 22, 4056 Basel, Switzerland
| | - Eva Scheurer
- Institute of Forensic Medicine, Department of Biomedical Engineering, University of Basel, Pestalozzistrasse 22, 4056 Basel, Switzerland
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5
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Dykukha I, Essner U, Schreiber H, Raithel LM, Penner IK. Effects of Sativex Ⓡ on cognitive function in patients with multiple sclerosis: A systematic review and meta-analysis. Mult Scler Relat Disord 2022; 68:104173. [PMID: 36174323 DOI: 10.1016/j.msard.2022.104173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 09/05/2022] [Accepted: 09/08/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cognitive impairment is a common manifestation of multiple sclerosis (MS). OBJECTIVE To assess by systematic review and meta-analysis available evidence regarding the impact of nabiximols oromucosal spray on cognition in patients with MS. METHODS A systematic literature search of clinical studies (all types, any comparator) that measured cognitive function in patients with MS spasticity treated with nabiximols. Meta-analysis for cognitive endpoints was not possible due to heterogenous measurement instruments and outcomes. Meta-analysis was performed for adverse events (AEs) of special interest (cognition disorders) reported in randomized controlled trials (RCTs) of nabiximols versus placebo in patients with MS (with or without spasticity). Certainty of evidence and risk of bias were assessed. RESULTS Seven clinical studies (three RCTs) directly assessing cognitive function were included in the qualitative analysis. There was no consistent evidence to suggest that nabiximols causes cognitive impairment as assessed by a range of specific psychometric instruments across cognitive domains. Thirteen double-blind, placebo-controlled RCTs (nabiximols, n = 964; placebo, n = 904) were included in the meta-analysis of cognitive AEs. Most cognitive AEs (30 of 32 events, 93.8%) reported with nabiximols in MS patients occurred with not in-label use, i.e., dosage >12 sprays per day and/or not administered primarily for treatment of spasticity. CONCLUSIONS Within the limitations of the review, we can conclude that no detrimental effects of nabiximols on cognitive function were observed in patients with MS spasticity during up to 12 months follow-up and that cognitive AEs were rare and occurred only when nabiximols was not used according to its approved label.
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Affiliation(s)
- Igor Dykukha
- Medical Affairs, Almirall Hermal GmbH, Reinbek, Germany
| | - Ute Essner
- O. Meany Consultancy GmbH, Hamburg, Germany
| | - Herbert Schreiber
- Neurological Practice Center, Neuropoint Academy, NTD & Neurosys, Ulm, Germany
| | - Lina Marie Raithel
- COGITO Center for Applied Neurocognition and Neuropsychological Research, Düsseldorf, Germany
| | - Iris-Katharina Penner
- Department of Neurology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany.
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6
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Creta A, Gilio L, Centonze D, Fantozzi R. Usability of an application device for nabiximols oromucosal spray in patients with upper limb impaired multiple sclerosis. Neurodegener Dis Manag 2022; 12:195-201. [PMID: 35707977 DOI: 10.2217/nmt-2022-0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: This study aimed to assess the usability of a specific EU-available application device for Sativex® (USA adopted name: nabiximols) cannabinoid-based oromucosal spray in patients with multiple sclerosis (MS) and spasticity-related upper limb and hand impairment in routine daily practice. Methods: MS patients with upper limb and hand impairment evaluated the usability of the device using an ad hoc 18-item questionnaire. Results: 60 patients were included. The comprehensibility of the instructions for use, practical handling and ergonomics of the device were rated as optimal (mean scores ≥8.9/10 across questions). Assisting trained nurses also rated the device as easy to use and helpful for drug administration (mean scores 10/10). Conclusion: The application device may assist MS patients with upper limb impairment self-administer nabiximols oromucosal spray.
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Affiliation(s)
| | - Luana Gilio
- Unit of Neurology, IRCCS Neuromed, Pozzilli, Italy
| | - Diego Centonze
- Unit of Neurology, IRCCS Neuromed, Pozzilli, Italy.,Multiple Sclerosis Clinical & Research Unit, Department of Systems Medicine, Tor Vergata University, Rome, Italy
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7
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Chan A, Silván CV. Evidence-based management of multiple sclerosis spasticity with nabiximols oromucosal spray in clinical practice: a 10-year recap. Neurodegener Dis Manag 2022; 12:141-154. [PMID: 35377770 DOI: 10.2217/nmt-2022-0002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Effective symptomatic management of multiple sclerosis (MS) spasticity remains an unmet need for many patients. The second-line option nabiximols is the most widely investigated of the noninvasive antispasticity medications in this patient population. Clinical evidence accumulated with nabiximols since it was first approved in Europe in 2010 suggests that about 40% of initial responders (i.e., those with ≥20% improvement in their baseline 0-10 Numerical Rating Scale score) may expect to achieve clinically meaningful (≥30% Numerical Rating Scale response) and durable symptomatic improvement in MS spasticity. During 10 years' routine use of nabiximols, no new safety signals have emerged. Nabiximols-associated improvement in MS spasticity-related symptoms such as pain and sleep disruption suggests a need to track possible therapeutic effects beyond muscle tone control.
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Affiliation(s)
- Andrew Chan
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
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8
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Perkins D, Brophy H, McGregor IS, O'Brien P, Quilter J, McNamara L, Sarris J, Stevenson M, Gleeson P, Sinclair J, Dietze P. Medicinal cannabis and driving: the intersection of health and road safety policy. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 97:103307. [PMID: 34107448 DOI: 10.1016/j.drugpo.2021.103307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/26/2021] [Accepted: 05/12/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Recent shifting attitudes towards the medical use of cannabis has seen legal access pathways established in many jurisdictions in North America, Europe and Australasia. However, the positioning of cannabis as a legitimate medical product produces some tensions with other regulatory frameworks. A notable example of this is the so-called 'zero tolerance' drug driving legal frameworks, which criminalise the presence of THC (tetrahydrocannabinol) in a driver's bodily fluids irrespective of impairment. Here we undertake an analysis of this policy issue based on a case study of the introduction of medicinal cannabis in Australia. METHODS We examine the regulatory approaches used for managing road safety risks associated with potentially impairing prescription medicines and illicit drugs in Australian jurisdictions, as well as providing an overview of evidence relating to cannabis and road safety risk, unintended impacts of the 'zero-tolerance' approach on patients, and the regulation of medicinal cannabis and driving in comparable jurisdictions. RESULTS Road safety risks associated with medicinal cannabis appear similar or lower than numerous other potentially impairing prescription medications. The application of presence-based offences to medicinal cannabis patients appears to derive from the historical status of cannabis as a prohibited drug with no legitimate medical application. This approach is resulting in patient harms including criminal sanctions when not impaired and using the drug as directed by their doctor, or the forfeiting of car use and related mobility. Others who need to drive are excluded from accessing a needed medication and associated therapeutic benefit. 'Medical exemptions' for medicinal cannabis in comparable jurisdictions and other drugs included in presence offences in Australia (e.g. methadone) demonstrate a feasible alternative approach. CONCLUSION We conclude that in medical-only access models there is little evidence to justify the differential treatment of medicinal cannabis patients, compared with those taking other prescription medications with potentially impairing effects.
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Affiliation(s)
- Daniel Perkins
- Office of Medicinal Cannabis, Department of Health, Melbourne, VIC 3000, Australia; School of Social and Political Science, University of Melbourne, Parkville, VIC 3010, Australia.
| | - Hugh Brophy
- Office of Medicinal Cannabis, Department of Health, Melbourne, VIC 3000, Australia
| | - Iain S McGregor
- The Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW 2050, Australia. Faculty of Science, School of Psychology, The University of Sydney, Sydney, NSW 2006, Australia
| | - Paula O'Brien
- Melbourne Law School, University of Melbourne, Parkville, VIC 3010, Australia
| | - Julia Quilter
- School of Law, University of Wollongong, Northfields Ave, Wollongong, NSW 2522, Australia
| | - Luke McNamara
- Centre for Crime, Law and Justice, Faculty of Law and Justice, University of New South Wales, Sydney, NSW 2052, Australia
| | - Jerome Sarris
- NICM Health Research institute, Western Sydney University, Westmead, NSW 2145, Australia; Professorial Unit, The Melbourne Clinic, Department of Psychiatry, University of Melbourne, Melbourne, 130 Church St, Richmond, VIC 3121, Australia
| | - Mark Stevenson
- Urban Transport and Public Health, University of Melbourne, Parkville, VIC 3000, Australia
| | - Penny Gleeson
- Deakin Law School, Deakin University, Burwood, VIC 3125, Australia
| | - Justin Sinclair
- NICM Health Research institute, Western Sydney University, Westmead, NSW 2145, Australia
| | - Paul Dietze
- Behaviours and Health Risks Program, Burnet Institute, Melbourne, VIC 3004, Australia. National Drug Research Institute, Curtin University, Melbourne, VIC 3004, Australia
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9
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Prieto González JM, Vila Silván C. Safety and tolerability of nabiximols oromucosal spray: a review of real-world experience in observational studies, registries, and case reports. Expert Rev Neurother 2021; 21:547-558. [PMID: 33749480 DOI: 10.1080/14737175.2021.1904896] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION : Nabiximols oromucosal spray,a cannabis-based medicine containing a balanced ratio of Δ-9-tetrahydrocannabinol and cannabidiol, is approved widely as an add-on therapy for symptomatic relief of spasticity in people with multiple sclerosis (MS). Most safety data for nabiximols derive from use in MS spasticity, with some data available from the analgesia area. AREAS COVERED : This review compiles safety and tolerability data from all published observational studies, registry analyses, and case reports identified in systematic searches in which nabiximols oromucosal spray was investigated for spasticity (n = 20) and/or chronic non-cancer pain (n = 4). Aligning with the known safety profile of nabiximols as demonstrated in randomized controlled trials, common adverse events reported consistently across studies conducted under clinical practice conditions were dizziness, fatigue and somnolence. The serious adverse event (SAE) rate with nabiximols in MS spasticityobservational studies was 3.1% (137/4351). A total of 39 treatment-related SAEs were reported in 32 patients with spasticity, all of which (where specified) were resolved. No treatment-related SAEs were recorded in nabiximols pain studies. EXPERT OPINION : Real-world experience with nabiximols oromucosal spray in treating spasticity and chronic pain indicates that, overall, it is well tolerated and has a good safety profile.
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Affiliation(s)
- José María Prieto González
- Jefe Del Servicio De Neurología/Neurology Service Head, Hospital Clínico Universitario, Santiago De Compostela, Spain
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10
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Eadie L, Lo LA, Christiansen A, Brubacher JR, Barr AM, Panenka WJ, MacCallum CA. Duration of Neurocognitive Impairment With Medical Cannabis Use: A Scoping Review. Front Psychiatry 2021; 12:638962. [PMID: 33790818 PMCID: PMC8006301 DOI: 10.3389/fpsyt.2021.638962] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/18/2021] [Indexed: 12/12/2022] Open
Abstract
While the recreational use of cannabis has well-established dose-dependent effects on neurocognitive and psychomotor functioning, there is little consensus on the degree and duration of impairment typically seen with medical marijuana use. Compared to recreational cannabis users, medical cannabis patients have distinct characteristics that may modify the presence and extent of impairment. The goal of this review was to determine the duration of acute neurocognitive impairment associated with medical cannabis use, and to identify differences between medical cannabis patients and recreational users. These findings are used to gain insight on how medical professionals can best advise medical cannabis patients with regards to automobile driving or safety-sensitive tasks at work. A systematic electronic search for English language randomized controlled trials (RCTs), clinical trials and systematic reviews (in order to capture any potentially missed RCTs) between 2000 and 2019 was conducted through Ovid MEDLINE and EMBASE electronic databases using MeSH terms. Articles were limited to medical cannabis patients using cannabis for chronic non-cancer pain or spasticity. After screening titles and abstracts, 37 relevant studies were subjected to full-text review. Overall, seven controlled trials met the inclusion/exclusion criteria and were included in the qualitative synthesis: six RCTs and one observational clinical trial. Neurocognitive testing varied significantly between all studies, including the specific tests administered and the timing of assessments post-cannabis consumption. In general, cognitive performance declined mostly in a THC dose-dependent manner, with steady resolution of impairment in the hours following THC administration. Doses of THC were lower than those typically reported in recreational cannabis studies. In all the studies, there was no difference between any of the THC groups and placebo on any neurocognitive measure after 4 h of recovery. Variability in the dose-dependent relationship raises the consideration that there are other important factors contributing to the duration of neurocognitive impairment besides the dose of THC ingested. These modifiable and non-modifiable factors are individually discussed.
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Affiliation(s)
- Lauren Eadie
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Lindsay A Lo
- Department of Psychology, Queens University, Kingston, ON, Canada
| | - April Christiansen
- Centre for Neuroscience Studies, Queens University, Kingston, ON, Canada
| | - Jeffrey R Brubacher
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Alasdair M Barr
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
| | - William J Panenka
- British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada.,Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,British Columbia Provincial Neuropsychiatry Program, Vancouver, BC, Canada
| | - Caroline A MacCallum
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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11
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Jakubovski E, Pisarenko A, Fremer C, Haas M, May M, Schumacher C, Schindler C, Häckl S, Aguirre Davila L, Koch A, Brunnauer A, Cimpianu CL, Lutz B, Bindila L, Müller-Vahl K. The CANNA-TICS Study Protocol: A Randomized Multi-Center Double-Blind Placebo Controlled Trial to Demonstrate the Efficacy and Safety of Nabiximols in the Treatment of Adults With Chronic Tic Disorders. Front Psychiatry 2020; 11:575826. [PMID: 33324255 PMCID: PMC7725747 DOI: 10.3389/fpsyt.2020.575826] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 11/02/2020] [Indexed: 01/13/2023] Open
Abstract
Background: Gilles de la Tourette syndrome (TS) is a chronic neuropsychiatric disorder characterized by motor and vocal tics. First-line treatments for tics are antipsychotics and tic-specific behavioral therapies. However, due to a lack of trained therapists and adverse events of antipsychotic medication many patients seek alternative treatment options including cannabis. Based on the favorable results obtained from case studies on different cannabis-based medicines as well as two small randomized controlled trials using delta-9-tetrahydrocannabinol (THC), we hypothesize that the cannabis extract nabiximols can be regarded as a promising new and safe treatment strategy in TS. Objective: To test in a double blind randomized clinical trial, whether treatment with the cannabis extract nabiximols is superior to placebo in patients with chronic tic disorders. Patients and Methods: This is a multicenter, randomized, double-blind, placebo controlled, parallel-group, phase IIIb trial, which aims to enroll 96 adult patients with chronic tic disorders (TS or chronic motor tic disorder) across 6 centers throughout Germany. Patients will be randomized with a 2:1 ratio into a nabiximols and a placebo arm. The primary efficacy endpoint is defined as tic reduction of at least 30% (compared to baseline) according to the Total Tic Score of the Yale Global Tic Severity Scale (YGTSS-TTS) after 13 weeks of treatment. In addition, several secondary endpoints will be assessed including changes in different psychiatric comorbidities, quality of life, driving ability, and safety assessments. Discussion: This will be the first large, controlled study investigating efficacy and safety of a cannabis-based medicine in patients with TS. Based on available data using different cannabis-based medicines, we expect not only a reduction of tics, but also an improvement of psychiatric comorbidities. If the cannabis extract nabiximols is proven to be safe and effective, it will be a valuable alternative treatment option. The results of this study will be of high health-economic relevance, because a substantial number of patients uses cannabis (illegally) as self-medication. Conclusion: The CANNA-TICS trial will clarify whether nabiximols is efficacious and safe in the treatment of patients with chronic tic disorders. Clinical Trial Registration: This trial is registered at clinicaltrialsregister.eu (Eudra-CT 2016-000564-42) and clinicaltrials.gov (NCT03087201).
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Affiliation(s)
- Ewgeni Jakubovski
- Clinic of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Anna Pisarenko
- Clinic of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Carolin Fremer
- Clinic of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Martina Haas
- Clinic of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Marcus May
- Clinical Research Center Core Facility, Hannover Medical School, Hannover, Germany
| | - Carsten Schumacher
- Clinical Research Center Core Facility, Hannover Medical School, Hannover, Germany
| | - Christoph Schindler
- Clinical Research Center Core Facility, Hannover Medical School, Hannover, Germany.,Center for Pharmacology and Toxicology, Hannover Medical School, Hannover, Germany
| | - Sebastian Häckl
- Hannover Medical School, Institute for Biostatistics, Hannover, Germany
| | - Lukas Aguirre Davila
- Hannover Medical School, Institute for Biostatistics, Hannover, Germany.,Section Biostatistics, Paul-Ehrlich-Institute, Langen, Germany
| | - Armin Koch
- Hannover Medical School, Institute for Biostatistics, Hannover, Germany
| | - Alexander Brunnauer
- Department of Neuropsychology, Kbo-Inn-Salzach-Klinikum, Psychiatric Hospital, Wasserburg am Inn, Germany.,Department of Psychiatry and Psychotherapy, Ludwig-Maximilians University Munich, Munich, Germany
| | - Camelia Lucia Cimpianu
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians University Munich, Munich, Germany
| | - Beat Lutz
- Institute of Physiological Chemistry, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Laura Bindila
- Institute of Physiological Chemistry, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Kirsten Müller-Vahl
- Clinic of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
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12
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Akgün K, Essner U, Seydel C, Ziemssen T. Daily Practice Managing Resistant Multiple Sclerosis Spasticity With Delta-9-Tetrahydrocannabinol: Cannabidiol Oromucosal Spray: A Systematic Review of Observational Studies. J Cent Nerv Syst Dis 2019; 11:1179573519831997. [PMID: 30886530 PMCID: PMC6413425 DOI: 10.1177/1179573519831997] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 01/21/2019] [Indexed: 11/23/2022] Open
Abstract
Background/purpose: Spasticity is one of the most common symptoms in people with multiple
sclerosis (MS). Conventional anti-spasticity agents have limitations in
their efficacy and tolerability. Delta-9-tetrahydrocannabinol: cannabidiol
(THC:CBD) spray, a cannabinoid-based medicine, is approved as an add-on
therapy for MS spasticity not adequately controlled by other anti-spasticity
medications. The results from randomized controlled trials (RCTs) have
demonstrated a reduction in the severity of spasticity and associated
symptoms. However, RCTs do not always reflect real-life outcomes. We
systematically reviewed the complementary evidence from non-interventional
real-world studies. Methods: A systematic literature review was conducted to identify all non-RCT
publications on THC:CBD spray between 2011 and 2017. Data on study design,
patient characteristics, effectiveness, and safety outcomes were extracted
from those publications meeting our inclusion criteria. Results: In total, we reviewed 14 real-world publications including observational
studies and treatment registries. The proportion of patients reaching the
threshold of minimal clinical important difference (MCID), with at least a
20% reduction of the spasticity Numeric Rating Scale (NRS) score after
4 weeks ranged from 41.9% to 82.9%. The reduction in the mean NRS spasticity
score after 4 weeks was maintained over 6-12 months. The average daily dose
was five to six sprays. Delta-9-tetrahydrocannabinol: cannabidiol was well
tolerated in the evaluated studies in the same way as in the RCTs. No new or
unexpected adverse events or safety signals were reported in everyday
clinical practice. Conclusions: The data evaluated in this systematic review provide evidence for the
efficacy and safety of THC:CBD in clinical practice and confirm results
obtained in RCTs.
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Affiliation(s)
- Katja Akgün
- Department of Neurology, Center of Clinical Neuroscience, University Hospital Dresden, Dresden, Germany
| | - Ute Essner
- O.MEANY Consultancy GmbH, Hamburg, Germany
| | | | - Tjalf Ziemssen
- Department of Neurology, Center of Clinical Neuroscience, University Hospital Dresden, Dresden, Germany
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13
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Patti F. Newest evidence for tetrahydrocannabinol:cannabidiol oromucosal spray from postapproval pragmatic studies. Neurodegener Dis Manag 2019; 9:3-7. [PMID: 30657027 DOI: 10.2217/nmt-2018-0049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Postapproval studies have an essential role in demonstrating that an intervention is effective and well tolerated during use in daily clinical practice. Numerous large observational and registry studies of tetrahydrocannabinol (THC):cannabidiol (CBD) oromucosal spray have been conducted subsequent to its approval in Europe in 2011. Collectively, these studies provide valuable insight into various aspects of THC:CBD spray during real-world use in patients with multiple sclerosis spasticity, including its long-term effectiveness and tolerability. The Italian Medicines Agency's web-based registry is the largest observational study of THC:CBD oromucosal spray conducted to date, reporting on more than 1600 patients prescribed THC:CBD spray since it was introduced in Italy in 2013, and further supporting its effectiveness and tolerability profile.
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Affiliation(s)
- Francesco Patti
- Department 'GF Ingrassia', Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
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14
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Celius EG, Vila C. The influence of THC:CBD oromucosal spray on driving ability in patients with multiple sclerosis-related spasticity. Brain Behav 2018; 8:e00962. [PMID: 29761015 PMCID: PMC5943754 DOI: 10.1002/brb3.962] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 02/09/2018] [Accepted: 02/18/2018] [Indexed: 01/24/2023] Open
Abstract
Background Driving ability is a key function for the majority of patients with multiple sclerosis (MS) to help maintain daily interactions. Both physical and cognitive disability, as well as treatments, may affect the ability to drive. Spasticity is a common symptom associated with MS, and it may affect driving performance either directly or via the medications used to treat it. In this article, we review the evidence relating the antispasticity medicine, Δ9-tetrahydrocannabinol:cannabidiol (THC:CBD) oromucosal spray (Sativex®), and its potential impact on driving performance. Methods Articles were identified by searching PubMed from 1/1/2000 to 30/6/2017 using a specified list of search terms. The articles identified using these search terms were augmented with relevant references from these papers and other articles known to the authors. Results The results from THC:CBD oromucosal spray driving studies and real-world registries did not show any evidence of an increase in motor vehicle accidents associated with THC:CBD oromucosal spray. The majority of patients reported an improvement in driving ability after starting THC:CBD oromucosal spray, and it was speculated that this may be related to reduced spasticity and/or better cognitive function. It should be noted that THC blood levels are significantly lower than the levels associated with recreational use of herbal cannabis. Conclusions THC:CBD oromucosal spray was shown not to impair driving performance. However, periodic assessment of patients with MS driving ability is recommended, especially after relapses and changes in treatment. Blood THC measurements might be above authorized thresholds for some countries following administration of THC:CBD oromucosal spray, thus specific knowledge of each country's driving regulations and a medical certificate are recommended.
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Affiliation(s)
- Elisabeth G. Celius
- Department of NeurologyOslo University Hospital, and Institute of Health and SocietyUniversity of OsloOsloNorway
| | - Carlos Vila
- Almirall Neurology Global Medical AffairsBarcelonaSpain
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15
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Linker R. What's new in multiple sclerosis spasticity research? Poster session highlights. Neurodegener Dis Manag 2017; 7:51-53. [PMID: 29143588 DOI: 10.2217/nmt-2017-0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Each year at the Multiple Sclerosis Experts Summit, relevant research in the field of multiple sclerosis spasticity is featured in poster sessions. The main studies presented at this year's meeting are summarized herein.
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Affiliation(s)
- Ralf Linker
- Department of Neurology, Friedrich-Alexander-University, Schwabachanlage 6, 91054 Erlangen, Germany
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16
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Keating GM. Delta-9-Tetrahydrocannabinol/Cannabidiol Oromucosal Spray (Sativex ®): A Review in Multiple Sclerosis-Related Spasticity. Drugs 2017; 77:563-574. [PMID: 28293911 DOI: 10.1007/s40265-017-0720-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Delta-9-tetrahydrocannabinol (THC)/cannabidiol (CBD) oromucosal spray (THC/CBD, Sativex®, nabiximols) is available in numerous countries worldwide for the treatment of multiple sclerosis (MS)-related moderate to severe spasticity in patients who have not responded adequately to other anti-spasticity medication and who demonstrate clinically significant improvement in spasticity-related symptoms during an initial trial of therapy. Twelve weeks' therapy with THC/CBD improved MS-related spasticity in patients with an inadequate response to other anti-spasticity agents who had undergone a successful initial trial of THC/CBD therapy, according to the results of a pivotal phase 3 trial. Improvements in spasticity were maintained in the longer term with THC/CBD with no evidence of dose tolerance, and results of real-world studies confirm the effectiveness of THC/CBD in everyday clinical practice. Improvements in health-related quality of life and activities of daily living were also seen with THC/CBD. THC/CBD is generally well tolerated; adverse effects such as dizziness may occur whilst the THC/CBD dosage is being optimized. THC/CBD has low abuse potential and a low risk of psychoactive effects. In conclusion, THC/CBD oromucosal spray is a useful option for the treatment of MS-related spasticity not completely relieved with current anti-spasticity medication.
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Affiliation(s)
- Gillian M Keating
- Springer, Private Bag 65901, Mairangi Bay, 0754, Auckland, New Zealand.
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17
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Carotenuto A, Iodice R, Petracca M, Inglese M, Cerillo I, Cocozza S, Saiote C, Brunetti A, Tedeschi E, Manganelli F, Orefice G. Upper motor neuron evaluation in multiple sclerosis patients treated with Sativex ®. Acta Neurol Scand 2017; 135:442-448. [PMID: 27500463 DOI: 10.1111/ane.12660] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Spasticity in multiple sclerosis (MS) results from an imbalance of inputs from descending pathways to the spinal motor circuits, as well as from a damage of the corticospinal tract (CST). OBJECTIVES To assess CST impairment in MS patients with and without spasticity and to evaluate its evolution under Sativex® treatment. METHODS Ten MS patients with spasticity ("cases") underwent clinical (EDSS, 9-hole Peg, Ashworth scale, Timed 25-Foot Walk, and NRS for spasticity), MRI (CST fractional anisotropy [FA]), and electrophysiological (central motor conduction time [CMCT] and H/M ratio) evaluations at baseline and after 12 months. We selected 20 MS patients without spasticity as control group at baseline. RESULTS At baseline, cases showed a lower CST FA (0.492±0.045 vs 0.543±0.047; P=.01) and a higher CMCT (P=.001) compared to the control group. No correlations were found between clinical, electrophysiological, and MRI features. After 12 months, cases showed a decrease in non-prevalent degree of impairment (PDI) side FA (0.502±0.023 vs 0.516±0.033; P=.01) without differences for electrophysiological features compared to baseline. Treatment with Sativex® resulted in a reduction of NRS for spasticity (P=.01). CONCLUSIONS We confirm the presence of CST impairment in MS patients with spasticity. We did not identify structural/electrophysiological correlates that could explain Sativex® clinical effect.
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Affiliation(s)
- A. Carotenuto
- Department of Neurosciences, Reproductive and Odontostomatological Sciences; Federico II University of Naples; Naples Italy
| | - R. Iodice
- Department of Neurosciences, Reproductive and Odontostomatological Sciences; Federico II University of Naples; Naples Italy
| | - M. Petracca
- Department of Neurosciences, Reproductive and Odontostomatological Sciences; Federico II University of Naples; Naples Italy
- Department of Neurology, Radiology, Neuroscience; Icahn School of Medicine; Mount Sinai NY USA
| | - M. Inglese
- Department of Neurology, Radiology, Neuroscience; Icahn School of Medicine; Mount Sinai NY USA
| | - I. Cerillo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences; Federico II University of Naples; Naples Italy
| | - S. Cocozza
- Department of Advanced Biomedical Sciences; Federico II University of Naples; Naples Italy
| | - C. Saiote
- Department of Neurology; Icahn School of Medicine; Mount Sinai NY USA
| | - A. Brunetti
- Department of Advanced Biomedical Sciences; Federico II University of Naples; Naples Italy
| | - E. Tedeschi
- Department of Advanced Biomedical Sciences; Federico II University of Naples; Naples Italy
| | - F. Manganelli
- Department of Neurosciences, Reproductive and Odontostomatological Sciences; Federico II University of Naples; Naples Italy
| | - G. Orefice
- Department of Neurosciences, Reproductive and Odontostomatological Sciences; Federico II University of Naples; Naples Italy
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18
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Maccarrone M, Maldonado R, Casas M, Henze T, Centonze D. Cannabinoids therapeutic use: what is our current understanding following the introduction of THC, THC:CBD oromucosal spray and others? Expert Rev Clin Pharmacol 2017; 10:443-455. [PMID: 28276775 DOI: 10.1080/17512433.2017.1292849] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The complexity of the endocannabinoid (eCB) system is becoming better understood and new drivers of eCB signaling are emerging. Modulation of the activities of the eCB system can be therapeutic in a number of diseases. Research into the eCB system has been paralleled by the development of agents that interact with cannabinoid receptors. In this regard it should be remembered that herbal cannabis contains a myriad of active ingredients, and the individual cannabinoids have quite distinct biological activities requiring independent studies. Areas covered: This article reviews the most important current data involving the eCB system in relation to human diseases, to reflect the present (based mainly on the most used prescription cannabinoid medicine, THC/CBD oromucosal spray) and potential future uses of cannabinoid-based therapy. Expert commentary: From the different therapeutic possibilities, THC/CBD oromucosal spray has been in clinical use for approximately five years in numerous countries world-wide for the management of multiple sclerosis (MS)-related moderate to severe resistant spasticity. Clinical trials have confirmed its efficacy and tolerability. Other diseases in which different cannabinoids are currently being investigated include various pain states, Alzheimer's disease, Parkinson's disease, Huntington's disease and epilepsy. The continued characterization of individual cannabinoids in different diseases remains important.
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Affiliation(s)
- Mauro Maccarrone
- a Department of Medicine , Campus Bio-Medico University of Rome , Rome , Italy.,b Laboratory of Lipid Neurochemistry, European Center for Brain Research/IRCCS Santa Lucia Foundation , Rome , Italy
| | - Rafael Maldonado
- c Laboratori de Neurofarmacologia, Departament de Ciències Experimentals i de la Salut (CEXS), Facultat de Ciències de la Salut i de la Vida , Universitat Pompeu Fabra , Barcelona , Spain
| | - Miguel Casas
- d Servicio de Psiquiatría , Hospital Universitari Vall d'Hebron , Barcelona , Spain.,e Departamento de Psiquiatría y Medicina Legal , Universitat Autònoma de Barcelona , Barcelona , Spain.,f CIBERSAM , Barcelona , Spain
| | - Thomas Henze
- g Passauer Wolf Reha-Zentrum Nittenau , Nittenau , Germany
| | - Diego Centonze
- h Multiple Sclerosis Clinical and Research Center, Tor Vergata University, Rome & Unit of Neurology , IRCCS Istituto Neurologico Mediterraneo Neuromed , Pozzilli , Italy
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19
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Etges T, Karolia K, Grint T, Taylor A, Lauder H, Daka B, Wright S. An observational postmarketing safety registry of patients in the UK, Germany, and Switzerland who have been prescribed Sativex ® (THC:CBD, nabiximols) oromucosal spray. Ther Clin Risk Manag 2016; 12:1667-1675. [PMID: 27956834 PMCID: PMC5113923 DOI: 10.2147/tcrm.s115014] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The global exposure of Sativex® (Δ9-tetrahydrocannabinol [THC]:cannabidiol [CBD], nabiximols) is estimated to be above 45,000 patient-years since it was given marketing approval for treating treatment-resistant spasticity in multiple sclerosis (MS). An observational registry to collect safety data from patients receiving THC:CBD was set up following its approval in the UK, Germany, and Switzerland, with the aim of determining its long-term safety in clinical practice. Twice a year, the Registry was opened to prescribing physicians to voluntarily report data on patients' use of THC:CBD, clinically significant adverse events (AEs), and special interest events. The Registry contains data from 941 patients with 2,213.98 patient-years of exposure. Within this cohort, 60% were reported as continuing treatment, while 83% were reported as benefiting from the treatment. Thirty-two percent of patients stopped treatment, with approximately one third citing lack of effectiveness and one quarter citing AEs. Psychiatric AEs of clinical significance were reported in 6% of the patients, 6% reported falls requiring medical attention, and suicidality was reported in 2%. Driving ability was reported to have worsened in 2% of patients, but improved in 7%. AEs were more common during the first month of treatment. The most common treatment-related AEs included dizziness (2.3%) and fatigue (1.7%). There were no signals to indicate abuse, diversion, or dependence. The long-term risk profile from the Registry is consistent with the known (labeled) safety profile of THC:CBD, and therefore supports it being a well-tolerated and beneficial medication for the treatment of MS spasticity. No evidence of new long-term safety concerns has emerged.
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20
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Bespalov A, Mus L, Zvartau E. Preclinical models of muscle spasticity: valuable tools in the development of novel treatment for neurological diseases and conditions. Naunyn Schmiedebergs Arch Pharmacol 2016; 389:457-66. [PMID: 26861550 DOI: 10.1007/s00210-016-1215-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 02/01/2016] [Indexed: 01/08/2023]
Abstract
Poor validity of preclinical animal models is one of the most commonly discussed explanations for the failures to develop novel drugs in general and in neuroscience in particular. However, there are several areas of neuroscience such as injury-induced spasticity where etiological factor can be adequately recreated and models can focus on specific pathophysiological mechanisms that likely contribute to spasticity syndrome in humans (such as motoneuron hyperexcitability and spinal hyperreflexia). Methods used to study spasticity in preclinical models are expected to have a high translational value (e.g., electromyogram (EMG)-based electrophysiological tools) and can efficiently assist clinical development programs. However, validation of these models is not complete yet. First, true predictive validity of these models is not established as clinically efficacious drugs have been used to reverse validate preclinical models while newly discovered mechanisms effective in preclinical models are yet to be fully explored in humans (e.g., 5-HT2C receptor inverse agonists, fatty acid amid hydrolase inhibitors). Second, further efforts need to be invested into cross-laboratory validation of study protocols and tools, adherence to the highest quality standards (blinding, randomization, pre-specified study endpoints, etc.), and systematic efforts to replicate key sets of data. These appear to be readily achievable tasks that will enable development not only of symptomatic but also of disease-modifying therapy of spasticity, an area that seems to be currently not in focus of research efforts.
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Affiliation(s)
- Anton Bespalov
- Institute of Pharmacology, Pavlov Medical University, St. Petersburg, Russia.
- Partnership for Assessment and Accreditation of Scientific Practice, Heidelberg, Germany.
| | - Liudmila Mus
- Institute of Pharmacology, Pavlov Medical University, St. Petersburg, Russia
| | - Edwin Zvartau
- Institute of Pharmacology, Pavlov Medical University, St. Petersburg, Russia
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21
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Zettl UK, Rommer P, Hipp P, Patejdl R. Evidence for the efficacy and effectiveness of THC-CBD oromucosal spray in symptom management of patients with spasticity due to multiple sclerosis. Ther Adv Neurol Disord 2016; 9:9-30. [PMID: 26788128 PMCID: PMC4710104 DOI: 10.1177/1756285615612659] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Spasticity, one of the main symptoms of multiple sclerosis (MS), can affect more than 80% of MS patients during the course of their disease and is often not treated adequately. δ-9-Tetrahydrocannabinol-cannabidiol (THC-CBD) oromucosal spray is a plant-derived, standardized cannabinoid-based oromucosal spray medicine for add-on treatment of moderate to severe, resistant multiple sclerosis-induced spasticity. This article reviews the current evidence for the efficacy and safety, with dizziness and fatigue as the most common treatment-related adverse events, being mostly mild to moderate in severity. Results from both randomized controlled phase III studies involving about,1600 MS patients or 1500 patient-years and recently published studies on everyday clinical practice involving more than 1000 patients or more than,1000 patient-years are presented.
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Affiliation(s)
- Uwe K. Zettl
- Department of Neurology, University of Rostock, Gehlsheimer Straße 20, D-18147 Rostock, Germany
| | - Paulus Rommer
- Department of Neurology, University of Rostock, Germany
- Department of Neurology, Medical University of Vienna, Austria
| | | | - Robert Patejdl
- Department of Neurology, University of Rostock, Germany Oscar-Langendorff-Institute of Physiology, University of Rostock, Germany
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