Cannabis in Epilepsy – Part II

Recently there have been several large, well-controlled studies of the use of Cannabidiol in children and adolescents but it was used as an adjunctive therapy, not in a standalone way. What would happen if patients were only taking a cannabinoid as some activists for the legalization of Cannabis are vociferously demanding in many American state capitals?

Emily Stockings et al., researchers at the National and Alcohol Research Centre at the University of South Wales in Sydney, reviewed the data of several clinical trials of Cannabidiol, focusing on 36 studies that studied the use of the drug in drug-resistant Epilepsy. Two double blind studies on the use of CBD—one with 120 patients with the Drayet syndrome and the other with 171 patients with Lenox-Gastaut syndrome—showed that CBD was 75% more likely than the placebo to reduce the number of seizures by more than half. In the largest pool of almost a thousand patients that were observed, almost half of them got some significant reduction of their seizure frequency.

The researchers admitted that the quality of the data was mixed as there is no reliable evidence of which preparation of Cannabis—either Cannabis sativa or CBD-THC extracts or oral cannabis extracts—is more suitable. Three randomized clinical trials studied the possibility of seizure-free by just taking CBD compared to placebo; even though they found an encouraging six-fold increase in the number of patients that ended up seizure-free, their data is not completely reliable. Half of the patients treated with CBD reported that the quality of their daily activities had improved. The overall data suggested that almost half of the patients reported some significant improvement.

The greatest gains were observed in patients with Drayet syndrome or Severe Myoclonic Epilepsy of Childhood (SMEC), a tragic condition that begins in the first year of life and produces constant seizures; we can understand the relief experienced by those parents when they noticed a change. However, all the studies with Drayet syndrome were case series with a 100% response, which should be interpreted with extreme caution. The Sydney researchers also studied the number of participants that dropped off the study, which could be an indicator of their tolerance to the drug; they found no real difference between the participants receiving CBD and those with placebo.

There was a significant increase in the rate of adverse events in patients receiving CBD compared to placebo, including the dangerous status epilepticus and elevated aminotransferase levels. The most common adverse effects were drowsiness, diarrhea, fatigue and lack of appetite. This fact should make clinicians ponder whether the addition of CBD is warranted in the med schedule. The use of Cannabis should not be taken lightly or “to see what happens. What’s there to lose anyway?”

Many policy pundits and media charlatans are jumping in the bandwagon of the medical benefits of Cannabis in the American states that have long approved it like Colorado and those like Florida that are just beginning to regulate its use. We should fund serious studies in prestigious centers; moreover, the parents of children with grave, chronic neurological diseases should have priority access to them. There is a fine blue line between the medical benefits of Cannabis and its purely recreational use. But sick children should not be taken as hostages by the perpetrators of this media driven-frenzy.

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Farmacia Homeopatica Italiana

When the dirt-poor, half-literate and dazed Italian immigrants arrived at the ports of entry of Montevideo and Buenos Aires in the beginning of the Twentieth Century they found two very prosperous (due to their commodities’ export bonanza) yet sparsely populated countries that needed their arms to work in the fields, storage silos, meatpacking plants, leather factories and even in their offices and homes. But the native population was not really interested in their social welfare and health. So these savvy survivors decided to band together in “mutual associations” that provided some basic social services, primary health care facilities, temporary lodging for new arrivals, labour placement, legal advice and even funeral services for the long-term residents.

My dear grandfather Morizio arrived as a child with his whole family from Piemonte and prospered as a winemaker in Uruguay; but he never made it back to his “piccolo paese” in Ricaldone. Neither did the parents from my dear grandmother Yolanda who aldo arrived with their whole families from Salerno in Campania. Their humungous sacrifice enabled their descendants to live, work and study in the host countries.

The peasants from the Mezzogiorno (despectively nicknamed “terrones” by the more wealthy Italians up North) had “fame di terra” and ventured en masse to the hinterlands where they toiled in the fertile plains, the grain storage facilities, the meatpacking and fish processing plants, the cargo facilities in the ports of Rosario and Bahia Blanca. The city of Mar del Plata is located in the Atlantic coastline in the state of Buenos Aires, close to the agricultural centers and with a good harbor to host a fishing fleet. They worked tirelessly for long hours and started large families in that blessed city. But initially they did not have spare money to seek medical care for their families, let alone medication.

The “Farmacia Homeopatica Italiana” was founded in 1914 by concerned professionals that had studied the herbal medicine and natural products that the nascent Homeopathy was promoting at the time. Even with the present worldwide controversies swirling around that healing school, the natural products of this pharmacy have continued to sell very well as their customers value them. When you enter their cozy, downtown location , you are immediately transported into another more genteel age as you gawk at the shelves filled with glass flasks containing natural products and potions. We have been a loyal customer for many years and at present we are using three of their products.

In the mornings we take a solution of “Magnesium Chloride” mixed with some orange juice, before leaving for work we rub either the cream or liquid form of “Arnica” on the knees, and if we happen to eat too much meat or a hearty meal, we take a lemon tea with a few drops of the “Liver Drainer.” This is not a commercial or professional endorsement of their products but the honest testimony of a satisfied customer that values their work.

In our next blogging season we will discuss some of these marvelous natural products plus some others from the milennary Chinese and Ayurvedic Medicine as well; we will take advantage of the upcoming summer break to study in earnest before writing. If you happen to be in Mar del Plata, please do not forget to visit this place and chat with the informed pharmacists who are always ready to discuss the indications for their products.

Farmacia Homeopatica Italiana

20 de Setiembre 1678, Mar del Plata

Tel.: (0223) 473-0178, 473-4845, 473-8354

farmaciahitaliana@yahoo.com.ar

 

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Pain and Mindfulness in Multiple Sclerosis

Chronic pain is one of the most crippling, and oftentimes intractable to treatment, symptoms of patients with Multiple Sclerosis, many of them young people in the prime of their lifetimes. Given that most pharmacological schedules eventually bring collateral effects that intoxicate or limit the wakefulness of patients with good jobs, paths in Alternative Medicine have been explored.

Almost two thirds of MS patients experience some kind of severe pain in their daily demeanor. Patients experience different types of pain, which can be grouped in the following categories:

  1. Central neuropathic pain: dysesthetic extremity pain, tonic muscle spasm, trigeminal neuralgia.
  2. Musculoskeletal pain: cervical or lumbar radiculopathies.
  3. Mixed Neuropathies and nonneuropathic forms of pain: headaches.

Jon Kabat-Zinn initiated the practice of “mindfulness” in 1982 as a behavioral cure for pain. He wrote that it constitutes as “paying attention in a particular way; on purpose, in the present moment, and non-judgmentally.” It is as if the patient could detach himself/herself from the suffering condition and observe it in “an objective way” without expressing any judgements. It strives to let go of natural defensive mechanisms and to start the process of acceptance of pain. Various meditation practices like focused attention or open monitoring are being used, which activate some unique neural networks that modify the pain experience integrated in the CNS.

Angela Senders et al. designed a cross-sectional survey of MS patients followed in the outpatient clinic of the Oregon Health and Science University that completed several questionnaires during one study visit; patients that had a relapse or exacerbation in the previous 90 days were excluded. As a measurement device they use “pain interference”, which is “how much pain” limits the patient’s ability to perform the occupational and social tasks; they used the “Patient-reported Outcomes Measurement Information System (PROMIS) as the dependent variable in the study.

One hundred and fifty patients participated in the study, the majority were women (78%) and the mean age was 50.45 +/- 12.85 years; the majority of patients had the relapsing-remitting variant of the disease (74%) and two-thirds of them were taking MS DMT like interferon beta-1b. in the study model for every 18-point increase in the mindfulness score, the Pain-interference score was expected to decrease by 2.88 points. Six demographic features (age, sex, level of disability, type of MS, DMT and education) were studied for their interaction with mindfulness.

The study showed that the relationship between pain and mindfulness was very significant (t=-5.52, P less than .0001) For every 18-point increase in the mindfulness score, the pain interference score decreased by 3.96 points (Beta=-0.227, P less than .0001) In sum, there is a significant correlation between the practice of mindfulness and the amelioration of MS pain.

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Cannabis in Lennox-Gastaut Syndrome

One of the most painfully frustrating events in our practice of Neurology since the times of residency training has been the encounter with a refractory Epilepsy syndrome in a young patient. Not only we witness the suffering of the disgraced patients, who are losing intellectual capacity and the promise of a fruitful future, but also the terrible frustration of their parents and loved ones. Lenox-Gastaut syndrome is exactly that: an epilepsy variant that attacks young patients with “drop seizures” that are resilient to effective, long-term and non-toxic pharmacologic treatment.

A multi-center study that enrolled 171 patients form 24 clinical centers form the United States, the Netherlands and Poland studied the effects of the administration of Epidiolex, a CBD purified drug that does not contain any of the psychoactive components of Cannabis. Patients from the age of 2 and 55 years old who had failed to show improvement with at least two anti-epileptic drugs were eligible to participate; their mean age was 15 years old with six drug failures. They all had to have slow (less than 3 hertz) spike and wave patterns in their electroencephalogram, more than one type of seizure for at least six months and at least two drop seizures per week.

The participants were randomized to receive 20 mg/kg purified CBD oil daily (divided twice daily) or a matched placebo for 14 weeks. Their families actively participated as they helped them record the number of drop seizures and related events during the study. They were evaluated four times in their respective medical clinics and twice with a special telephone interview. The investigators studied the percentage change of drop seizures during the treatment period of 86 patients that received the drug and the 85 patients who were part of the placebo group. We must point out that all patients continued to receive their properly prescribed anti-epileptic treatment.

The median percent reduction in monthly drop seizures from baseline to the end of the study was 43.9% in the group receiving Epidiolex compared to 21.8% in the placebo group. Some patients receiving the drug even had a 50% reduction in seizures and three patients were even seizure-free during the whole study; nobody in the placebo group had a seizure-free period. There were some adverse events in both groups, including diarrhea, fatigue, fever and vomiting. Amongst the noted drug interactions, the patients taking Clobazam had an increase in its active metabolite, which led to higher sedation. Thirty-six treated patients that were also taking Valproic Acid had an increase in liver enzymes, which resolved after the CBD was stopped.

After the study was stopped in October 2015, an open-label extension study was started.

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Clinical challenges in Transitioning

There is a dearth of clinical knowledge and expertise in the slowly yet surely evolving field of Transgender Medicine as only lately most practicing physicians have honestly  acknowledged that they know little or next to nothing about Transitioning for these patients. But many enthusiastic and honest professionals are starting to study the clinical challenges posed by these patients and trying some specific, practical steps.

Considering that Transgender people are usually receiving treatment with exogenous hormones that alter their metabolism, the established treatment protocols might not be entirely appropriate and they must be adjusted. Moreover since the hormonal schedules are often changed in composition and dosage, the treatment of chronic ailments must be adjusted accordingly.

The use of Testosterone in the female to male transitioning schedule could worsen a previously existing endometrial neoplasia. The use of estrogens in the male to female transitioning schedule can stimulate the appearance of blood clots. The use of hormones can affect chronic neurological diseases like Epilepsy. Some studies have suggested that there is negative interaction of Estrogen with antiepileptic drugs but its extent has not been established. The control of seizures becomes more difficult as new hormones are added.Transgender people have a higher rate of HIV infections and use retro-viral medication, which can interact with the hormones in still unforeseen ways.

Sadly one of the commonest reactions of clinicians who encounter treatment difficulties in their Transgender patients is that they must immediately stop the use of hormones until further notice. The subconscious in their minds still resists the idea that Transgender people are different and they need their hormonal treatments to become fully identified with their gender of choice. The only way to surpass this obstacle is to maintain good communications between the clinicians and the experts managing the hormonal treatments. Trans patients occasionally complain that some drugs are promoting a faster metabolic degradation of the hormones in their livers, for which they cannot benefit from their full metabolic effects in their Transitioning protocols. Instead of just dismissing those complaints, physicians should find solutions.

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Arnica

The name of “Arnica” comes from a Latin deformation of the Greek term “pragmique”, which is related to “pragmos” and it refers to its capacity to induce cough. It is a very ancient remedy that became very popular in the Middle Ages in Europe and then reached the Americas with the arrival of the colonists.

Arnica belongs to the genus of Asteraceae, the sunflower family of plants. It is an aromatic plant measuring 20-60 of height with simple stems and with bright yellow flowers in a star or sunflower distribution that bloom from June through august in the Northern Hemisphere. There are two original plants from Eurasia but “Arnica Montana’ is the most widely distributed. It prefers the temperate zones of sub-alpine regions and avoids strong winds; it avoids the soils with too much clay and is a fixture of the spring meadows.

Its flowers contain between o.3% and 1.5/6% of Sespquiterpene lactones that are useful in the treatment of cardiovascular diseases and neoplasia. Helenalin, one of the main sesquiterpenes found in Arnica Montana has strong anti-inflammatory properties, for which it has been used to treat the osteo-articular pain and limitation of movements for hundreds of years; it is very effective in stimulating the tissue regeneration in local inflammatory processes like arthritis or trauma. It is not an edible plant as it can be very toxic in large quantities. It is used as the main ingredient of creams and tinctures that are applied topically to skin; it is found in many homeopathic preparations. A scientific study found that applied topically it can have the same curative effect as Ibuprofen, a strong anti-inflammatory medication.

A few weeks ago I was suffering badly from my injured left knee—I had fallen from a horse almost twenty years ago and the resulting trauma has produced arthrosis of the joint—and I was limping badly. Blanca, a gentle nurse form Peru that works in my office saw my distress and offered help. She asked me to lay my bare knee on top of my desk and proceeded to apply a tincture of Arnica that her husband had recently brought from Lima. I cannot fully explain the almost instantaneous relief that I felt with it; its balsamic properties extended to my irascible mood at the time. The curative effect lasted for at least 5-6 hours, which enabled me to function adequately. Thank you dear Blanca.

Alleluia!

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Cannabis in Parkinson’s Disease – Part II

Physicians’ reports, patient surveys and clinical studies have indicated that Cannabis may help alleviate the motor and non-motor symptoms in chronic Parkinson’s Disease as we have discussed in a previous post.However the lack of properly designed clinical trials for Cannabis, and its derivatives like CBD, has limited its acceptance by the medical community.

Two big studies presented in the “21st International Congress of Parkinson’s Disease and Movement Disorders” evaluated the effects of oral cannabidiol (CBD) and inhaled Cannabis in patients that had Parkinson’s Disease.

Dr. Maureen A. Leehey et al. from the University of Colorado in Aurora carried on a phase II, open-label, dose –escalation study to determine the safety and efficacy of Epidiolex (a commercial form of CBD) in humans. The study included 13 volunteers—without a history of drug or alcohol dependence or took cannabinoids in the previous 30 days—who were treated with 5, 7.5, 10, 15 and 20 mg/kg/day doses of CBD for 31 days; they ere evaluated at triage, baseline and 31-days treatment. The adverse effects were usually mild to moderate: fatigue, diarrhea, somnolence, rising liver enzymes and dizziness. Only seven patients finally completed the treatment.

The “Unified Parkinson’s Disease rating scale” (whose acronym is UPDRS) is a comprehensive rating scale for patients with PD that includes:

  1. alterations of intellectual function
  2. alrerations of cognitive function
  3. depression
  4. motivation-initiative
  5. language
  6. salivary function
  7. swallowing
  8. writing
  9. cut the food and handling cutlery
  10. personal grooming
  11. personal hygiene
  12. behavior in bed
  13. falls
  14. gait
  15. tremor
  16. sensory symptoms

For each item the rating scale goes from 0 (no abnormalities) to 4 (presence of abnormalities) The mean total UPDRS score decreased from 45.9 at baseline to 36.4 at the last visit; the UPDRS motor score decreased from 27.3 to 20.3. Mean rigidity subscore significantly decreased from 9.14 to 6.29. Some patients stated that their pain and irritability have also decreased.

Dr. Laurie K. Mischley et al, from the Bastyr University Research Institute, studied the effects of inhaled cannabis (Epidiolex) on the tremors of PD patients by using motion sensors and interviewing the patients themselves. The participating patients wore a device to monitor their movements for two weeks and they logged their impressions in a daily journal. The sensors registered the frequency and amplitude of the parkinsonian tremor during the wakeful state; the patients pressed a button each time they took the drug.

In this study the duration and the magnitude of the tremor was compared one hour before and hour after the inhalation of Epidiolex; after the study ended the patients responded a few questions about their impressions of the effects. Four patients that took more than 10 doses and had a tremor more than 2% of the time in the hour before the use of Epidiolex, showed decreased tremor in the hour after they took the drug. The monitored data showed that the effect might have lasted up to three hours after the use of Epidiolex. In the follow-up, 9 out of the 10 participants said their symptoms had ameliorated. The side effects included: sleepiness, short-term memory loss and dry throat. An unexpected but useful collateral effect was the improvement of sleep.

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