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Nonopioid and Adjuvant Analgesic Agents
Published in Pamela E. Macintyre, Stephan A. Schug, Acute Pain Management, 2021
Pamela E. Macintyre, Stephan A. Schug
In chronic pain conditions (including neuropathic pain, fibromyalgia, and arthritis), cannabinoids have only minimal effects with regard to pain relief and no benefits with regard to physical and emotional functioning (Stockings et al, 2018). There are only modest effects on spasticity and neuropathic pain in multiple sclerosis (Nielsen et al, 2018); nabiximols (an oromucosal spray containing THC and CBD in a 1:1 ratio) is the only registered cannabinoid with the sole indication of spasticity in multiple sclerosis
Cannabis and Cannabinoids
Published in Dilip Ghosh, Pulok K. Mukherjee, Natural Medicines, 2019
In 2010 nabiximols was first approved in the United Kingdom for the treatment of spasticity associated with multiple sclerosis (Tanasescu et al. 2011). In a pooled analysis of three trials investigating nabiximols or nabilone, Whiting et al. (2015) found that the cannabinoids decreased the patient self-reported spasticity score and improvement of a global impression of change score also favoured nabiximols over placebo. In the previous year, Koppel et al. (2014) also concluded that nabiximols and oral THC were ‘probably effective’ and oral cannabis extract was ‘established as effective’ in reducing patient reported spasticity scores. Considering these two favourable systematic reviews, the NASEM report concluded that there is substantial evidence that oral cannabinoids are effective for improving patient reported multiple sclerosis spasticity symptoms.
Use of Cannabinoids in Palliative Nutrition Care
Published in Victor R. Preedy, Handbook of Nutrition and Diet in Palliative Care, 2019
Of the 120-plus phytocannabinoids, only a small number have been well researched. Table 33.1 lists the most abundant and commonly studied phytocannabinoids and noted physiologic effects of cannabinoids. The most widely known cannabinoids are Δ-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). Noted therapeutic properties of THC include analgesic, anti-emetic, anti-inflammatory, anti-spasmodic, orexigenic and sedative effects (Russo and Guy 2006). Noted therapeutic properties of CBD include analgesia, anti-convulsant, antipsychotic, anxiolytic and anti-emetic effects. When used concurrently with THC (from 2:1 to 1:2 of THC to CBD), CBD reduces the undesirable effects of THC such as anxiety, sedation and tachycardia (Russo and Guy 2006). Cannabinoid medicines include synthetic or semi-synthetic single-molecule pharmaceuticals, liquid cannabis extracts and whole cannabis, also referred to as a phytocannabinoid dense botanical (Aggarwal et al. 2009). Table 33.2 summarizes the various types of cannabinoid medicines, their active compounds and clinical usage status. Dronabinol and nabilone are prescribed to manage chemotherapy-induced nausea and vomiting; dronabinol is also used for anorexia accompanied by weight loss in AIDS patients. Nabiximols is prescribed for muscle spasticity in multiple sclerosis and pain in advanced cancer, while Epidiolex is prescribed for treating certain refractory seizure syndromes (Vemuri and Makriyannis 2015; US Food and Drug Administration 2018). Availability of both prescription and non-prescription forms of cannabis will vary by country.
Cannabis as a potential compound against various malignancies, legal aspects, advancement by exploiting nanotechnology and clinical trials
Published in Journal of Drug Targeting, 2022
Nazeer Hasan, Mohammad Imran, Afsana Sheikh, Suma Saad, Gaurav Chaudhary, Gaurav Kumar Jain, Prashant Kesharwani, Farhan J. Ahmad
Additionally, this study also demonstrated that THC showed a superior analgesic effect than codeine at the higher dose. However, its sedative effects may restrict the application of THC. A placebo-controlled, randomised, and double-blind study of nabiximols, an oromucosal spray combined with CBD and THC (1:1). This study was conducted on 360 patients against opioid-refractory pain and advanced cancer [88]. Patients received either the dose of nabiximols or placebo at high dose (11–16 sprays/day), medium dose (6–10 sprays/day), and low dose (1–4 sprays/day). The outcome of this study revealed that the medium and low doses of nabiximols exhibited better analgesic effects as compared to placebo after 5 weeks of treatment, while nabiximols at higher doses did not show any significant effects. The reason is subjects were not able to tolerate such a higher dose. Hence, nabiximol in required and optimised doses could be efficacious for advanced cancer and offer high-end therapeutic results in refractory pain associated with poorly ill patients. Another study was conducted by Johnson et al. [89] on 177 subjects with advanced cancer and uncontrolled cancer pain despite long-term opioid therapy. The study was conducted in various parts; placebo (59 patients), THC: CBD extract (60 patients), and THC extract (58 patients). The investigation exhibited that the pain was significantly reduced by THC: CBD, in which ∼30% reduction in pain was reported compared to the placebo group. Hence, many studies have already shown promising outcomes in cancer pain with the use of CBD.
A systematic review of European regional and national guidelines: a focus on the recommended use of nabiximols in the management of spasticity in multiple sclerosis
Published in Expert Review of Neurotherapeutics, 2022
Francisco Javier Carod-Artal, Peyman Adjamian, Carlos Vila Silván, Makarand Bagul, Claudio Gasperini
This analysis focussed on European guidelines, to reflect the more widespread regulatory approval of nabiximols in this region. Nabiximols is approved in several non-European countries including Israel, Colombia, Brazil, Chile, Peru, Canada, Australia, and New Zealand. To the best of our knowledge, these countries have not yet published any national guidelines covering the clinical use of nabiximols. One published guideline document from the USA recommended that ‘clinicians might offer Sativex oromucosal cannabinoid spray (nabiximols), where available, to reduce symptoms of spasticity, pain, or urinary frequency’ with a recommendation level of B (the second highest level) [36]. This is despite nabiximols not yet being approved in the USA [36]. Comparison of the similarities and differences between European guidelines and those published in other global regions is outside the scope of this review but may form the basis for future investigation.
Safety and tolerability of nabiximols oromucosal spray: a review of more than 15 years” accumulated evidence from clinical trials
Published in Expert Review of Neurotherapeutics, 2021
José María Prieto González, Carlos Vila Silván
Many early studies of nabiximols allowed dosages of up to 48 sprays/24 hours (equivalent to 129.6 mg THC/120 mg CBD) [3,4,19,20,27,32–34,42,44,47,48,52], possibly influencing the type (e.g. psychiatric symptoms, application site reactions) and incidence of AEs experienced by patients on initial exposure to a novel cannabis-based medication and novel route of administration. The incidence of psychiatric AEs in the active medication arm of the most recent large RCT was <1% [25]. In order to limit the risk of AEs (especially dizziness) at first exposure to nabiximols, current dosing recommendations advise titration over 14 days to a maximum dose of 12 sprays/day (equivalent to 32.4 mg THC/30 mg CBD) [2]. Other strategies to decrease the intensity of or alleviate an AE are dose reduction, treatment interruption [2], and slower rate of up-titration to the maximum recommended dose. Our analysis indicated that, although psychiatric symptoms or cognitive impairments can occur during nabiximols treatment, they are not common. Unlike the risks associated with prolonged use of inhaled or ingested cannabis [57], there is no evidence to suggest that long-term treatment with nabiximols associates with cognitive dysfunction [10]. Nevertheless, in the event of psychiatric symptoms during treatment with nabiximols, treatment should be discontinued immediately and the patient monitored closely until symptoms have resolved completely [2].