Therapeutic potential of cannabinoids in combination cancer therapy

 Advances in Biological Regulation“Derivatives of the plant Cannabis sativa have been used for centuries for both medical and recreational purposes, as well as industrial. The first proof of its medicinal use comes from ancient China, although there is evidence of its earlier utilization in Europe and Asia. In the 19th century, European practitioners started to employ cannabis extracts to treat tetanus, convulsions, and mental diseases and, in 1851, cannabis made its appearance in the Pharmacopoeia of the United States as an analgesic, hypnotic and anticonvulsant. It was only in 1937 that the Marijuana Tax Act prohibited the use of this drug in the USA. The general term Cannabis is commonly used by the scientific and scholar community to indicate derivatives of the plant Cannabis sativa. The word cannabinoid is a term describing chemical compounds that are either derivate of Cannabis (phytocannabinoids) or artificial analogues (synthetic) or are produced endogenously by the body (endocannabinoids). A more casual term “marijuana” or “weed”, a compound derived from dried Cannabis flower tops and leaves, has progressively superseded the term cannabis when referred to its recreational use. The 2018 World health organisation (WHO) data suggest that nearly 2.5% of the global population (147 million) uses marijuana and some countries, such as Canada and Uruguay, have already legalised it. Due to its controversial history, the medicinal use of cannabinoids has always been a centre of debate. The isolation and characterisation of Δ9 tetrahydrocannabinol (THC), the major psychoactive component of cannabis and the detection of two human cannabinoid receptor (CBRs) molecules renewed interest in the medical use of cannabinoids, boosting research and commercial heed in this sector. Some cannabinoid-based drugs have been approved as medications, mainly as antiemetic, antianorexic, anti-seizure remedies and in cancer and multiple sclerosis patients’ palliative care. Nevertheless, due to the stigma commonly associated with these compounds, cannabinoids’ potential in the treatment of conditions such as cancer is still largely unknown and therefore underestimated.”

https://pubmed.ncbi.nlm.nih.gov/33422460/

https://www.sciencedirect.com/science/article/abs/pii/S2212492620300853?via%3Dihub

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L-Theanine Prevents Long-Term Affective and Cognitive Side-Effects of Adolescent Δ-9-Tetrahydrocannabinol Exposure and Blocks Associated Molecular and Neuronal Abnormalities in the Mesocorticolimbic Circuitry

Journal of Neuroscience“Chronic adolescent exposure to Δ-9-Tetrahydrocannabinol (THC) is linked to elevated neuropsychiatric risk and induces neuronal, molecular and behavioural abnormalities resembling neuropsychiatric endophenotypes. Previous evidence has revealed that the mesocorticolimbic circuitry, including the prefrontal cortex (PFC) and mesolimbic dopamine (DA) pathway are particularly susceptible to THC-induced pathological alterations, including dysregulation of DAergic activity states, loss of PFC GABAergic inhibitory control and affective and cognitive abnormalities. There are currently limited pharmacological intervention strategies capable of preventing THC-induced neuropathological adaptations.

L-theanine is an amino acid analogue of L-glutamate and L-glutamine derived from various plant sources, including green tea leaves. L-theanine has previously been shown to modulate levels of GABA, DA and glutamate in various neural regions and to possess neuroprotective properties.

Using a pre-clinical model of adolescent THC exposure in male rats, we report that L-theanine pre-treatment prior to adolescent THC exposure is capable of preventing long-term, THC-induced dysregulation of both PFC and VTA DAergic activity states, a neuroprotective effect which persists into adulthood. In addition, pre-treatment with L-theanine blocked THC-induced downregulation of local GSK-3 and Akt signaling pathways directly in the PFC, two biomarkers previously associated with cannabis-related psychiatric risk and sub-cortical DAergic dysregulation.

Finally, L-theanine powerfully blocked the development of both affective and cognitive abnormalities commonly associated with adolescent THC exposure, further demonstrating functional and long-term neuroprotective effects of L-theanine in the mesocorticolimbic system.

SIGNIFICANCE STATEMENT With the increasing trend of cannabis legalization and consumption during adolescence, it is essential to expand knowledge on the potential effects of adolescent cannabis exposure on brain development and identify potential pharmacological strategies to minimize THC-induced neuropathology. Previous evidence demonstrates that adolescent THC exposure induces long-lasting affective and cognitive abnormalities, mesocorticolimbic dysregulation and schizophrenia-like molecular biomarkers that persist into adulthood.

We demonstrate for the first time that L-theanine, an amino acid analogue of L-glutamate and L-glutamine, is capable of preventing long-term THC side-effects. L-theanine prevented development of THC-induced behavioral aberrations, blocked cortical downregulation of local GSK-3 and Akt signaling pathways and normalized dysregulation of both PFC and VTA DAergic activity, demonstrating powerful and functional neuroprotective effects against THC-induced developmental neuropathology.”

https://pubmed.ncbi.nlm.nih.gov/33268546/

https://www.jneurosci.org/content/early/2020/11/24/JNEUROSCI.1050-20.2020

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Short-Term Medical Cannabis Treatment Regimens Produced Beneficial Effects among Palliative Cancer Patients

pharmaceuticals-logo“In the last decade the use of medical cannabis (MC) for palliative cancer treatment has risen. However, the choice between products is arbitrary and most patients are using Tetrahydrocannabinol (THC)-dominant cannabis products.

In this study, we aimed to assess the short-term outcomes of MC treatment prescribed by oncologists in relation to the type of cannabis they receive.

A comparative analysis was used to assess the differences in treatment effectiveness and safety between THC-dominant (n = 56, 52%), cannabidiol (CBD)-dominant (n = 19, 18%), and mixed (n = 33, 30%) MC treatments. Oncology patients (n = 108) reported on multiple symptoms in baseline questionnaires, initiated MC treatment, and completed a one-month follow-up.

Most parameters improved significantly from baseline, including pain intensity, affective and sensory pain, sleep quality and duration, cancer distress, and both physical and psychological symptom burden. There was no significant difference between the three MC treatments in the MC-related safety profile. Generally, there were no differences between the three MC treatments in pain intensity and in most secondary outcomes.

Unexpectedly, CBD-dominant oil treatments were similar to THC-dominant treatments in their beneficial effects for most secondary outcomes. THC-dominant treatments showed significant superiority in their beneficial effect only in sleep duration compared to CBD-dominant treatments.

This work provides evidence that, though patients usually consume THC-dominant products, caregivers should also consider CBD-dominant products as a useful treatment for cancer-related symptoms.”

https://pubmed.ncbi.nlm.nih.gov/33265945/

https://www.mdpi.com/1424-8247/13/12/435

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Use of Medical Cannabis to Treat Traumatic Brain Injury

View details for Journal of Neurotrauma cover image“There is not a single pharmacological agent with demonstrated therapeutic efficacy for traumatic brain injury (TBI). With recent legalization efforts and the growing popularity of medical cannabis, patients with TBI will inevitably consider medical cannabis as a treatment option.

Preclinical TBI research suggests cannabinoids have neuroprotective and psychotherapeutic properties.

Our review identified a paucity of high-quality studies examining the beneficial and adverse effects of medical cannabis on traumatic brain injury, with only a single Phase III randomized control trial. However, observational studies demonstrate that TBI patients are using medical and recreational cannabis to treat their symptoms, highlighting inconsistencies between public policy, perception of potential efficacy, and the dearth of empirical evidence.

We conclude that randomized controlled trials and prospective studies with appropriate control groups are necessary to fully understand the efficacy and potential adverse effects of medical cannabis for TBI.”

https://pubmed.ncbi.nlm.nih.gov/33256496/

https://www.liebertpub.com/doi/10.1089/neu.2020.7148

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Consensus-Based Recommendations for Titrating Cannabinoids and Tapering Opioids for Chronic Pain Control

International Journal of Clinical Practice“Opioid misuse and overuse has contributed to a widespread overdose crisis and many patients and physicians are considering medical cannabis to support opioid tapering and chronic pain control. Using a five-step modified Delphi process, we aimed to develop consensus-based recommendations on: 1) when and how to safely initiate and titrate cannabinoids in the presence of opioids, 2) when and how to safely taper opioids in the presence of cannabinoids, and 3) how to monitor patients and evaluate outcomes when treating with opioids and cannabinoids.

Results: In patients with chronic pain taking opioids not reaching treatment goals, there was consensus that cannabinoids may be considered for patients experiencing or displaying opioid-related complications, despite psychological or physical interventions. There was consensus observed to initiate with a cannabidiol (CBD)-predominant oral extract in the daytime and consider adding tetrahydrocannabinol (THC). When adding THC, start with 0.5-3 mg, and increase by 1-2 mg once or twice weekly up to 30-40 mg/day. Initiate opioid tapering when the patient reports a minor/major improvement in function, seeks less as-needed medication to control pain, and/or the cannabis dose has been optimized. The opioid tapering schedule may be 5%-10% of the morphine equivalent dose (MED) every 1 to 4 weeks. Clinical success could be defined by an improvement in function/quality of life, a ≥ 30% reduction in pain intensity, a ≥ 25% reduction in opioid dose, a reduction in opioid dose to < 90 mg MED, and/or reduction in opioid-related adverse events.

Conclusions: This five-stage modified Delphi process led to the development of consensus-based recommendations surrounding the safe introduction and titration of cannabinoids in concert with tapering opioids.”

https://pubmed.ncbi.nlm.nih.gov/33249713/

https://onlinelibrary.wiley.com/doi/10.1111/ijcp.13871

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Prescribed medical cannabis in women with gynecologic malignancies: A single-institution survey-based study

Gynecologic Oncology Reports “Research within a gynecologic oncology population has lagged behind the uptake in use of medical cannabis for symptom control. This study seeks to evaluate patient experience with prescribed medical cannabis obtained through licensed dispensaries in women with gynecologic malignancies.

A 43-item survey exploring patient experience with medical cannabis was administered to women with gynecologic malignancies who used medical cannabis prescribed by a gynecologic oncologist. Thirty-six eligible patients were approached for consent, and 31 patients returned completed surveys (86%). Ninety-three percent had advanced or recurrent disease; 74% were receiving chemotherapy or immunotherapy.

Eighty-three percent reported medical cannabis provided relief from cancer or treatment-related symptoms including decreased appetite (41%), insomnia (41%), neuropathy (41%), anxiety (35%), nausea (29%), joint pain (29%), bone pain (29%), abdominal pain (25%), and depression (19%). Eighty percent of patients reported medical cannabis worked the same or better than other traditional medications for management of their cancer or treatment-related symptoms, and 83% reported medical cannabis had an equivalent or better side effect profile.

Of the subset of patients using medical cannabis for pain, 63% reported a reduction in opioid use. Patients perceive that medical cannabis was useful for relief of cancer and treatment-related symptoms, suggesting medical cannabis may be a reasonable alternative or adjunct therapy. Medical cannabis was well tolerated and may have the potential to improve neuropathic pain and decrease opioid use.”

https://pubmed.ncbi.nlm.nih.gov/33204797/

“Patients with gynecologic malignancies perceive medical cannabis relieves multiple cancer-related symptoms. Medical cannabis is well-tolerated and perceived to have a favorable side effect profile. Patients using medical cannabis for pain control report an associated reduction in opioid use.”

https://www.sciencedirect.com/science/article/pii/S2352578920301338?via%3Dihub

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Preliminary assessment of medical cannabis consumption by cancer survivors

Complementary Therapies in Medicine “Objectives: To assess the motivation of cancer survivors to consume medical cannabis and to assess the patterns of use, perceived efficacy, as well as side and adverse effects.

Results: The mean monthly dosage of cannabis consumed was 42.4 grams; 95.8% of respondents reported not consuming cannabis regularly before being diagnosed with cancer; the most common way of administration was smoking, and most of the participants reported taking cannabis throughout the day. The most common symptoms for which participants took medical cannabis were pain (n = 169, 88.9%), sleeping disorder (n = 144, 75.8%) and anxiety (n = 79, 41.6%). Twenty patients (10.5%) reported on mild side (or adverse) effects.

Conclusions: This study indicates that cancer survivors may indeed consume cannabis for symptom relief, and not merely for recreational purposes. Although our findings point to perceived safety and efficacy of medical cannabis for cancer survivors, more research is needed to study the adequate role that cannabis may have for treating symptoms associated with cancer survivorship.”

https://pubmed.ncbi.nlm.nih.gov/33197667/

“In conclusion, despite the many challenges and uncertainties, cannabis is being slowly diffused into healthcare. Survivors who have ongoing symptoms as a result of their prior treatments should be carefully assessed as to whether there is a medical need for which cannabis may be helpful. Indeed, patients and physicians should establish and maintain a therapeutic alliance in which medical needs and potential treatments, including medical cannabis, are honestly discussed and mutually considered and agreed upon.”

https://www.sciencedirect.com/science/article/pii/S0965229920318598?via%3Dihub

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Cannabinoids in the management of frontotemporal dementia: a case series

 “Background: Frontotemporal dementia (FTD) is characterized by progressive deterioration in behaviors, executive function and/or language. The behavioral variant (Bv) is characterized by disinhibition and obsessive/compulsive behaviors. These symptoms are sometimes resistant to medications. This series examines patients suffering with treatment-resistant Bv-FTD who were prescribed cannabinoid and related compounds for other indications.

Case presentation: Three FTD cases from a dementia clinic were identified. These patients had disability due to behavior despite typical pharmacologic management. These patients were prescribed marijuana for comorbidities (anxiety, insomnia and pain). In all cases, use of cannabinoid products showed significant improvements in behavior and in the primary indication for prescription.

Conclusion: Review of these cases demonstrates potential for the use of cannabinoids in the management of treatment-resistant Bv-FTD.”

https://pubmed.ncbi.nlm.nih.gov/33190583/

“Frontotemporal dementia is a complicated and difficult disease that can be challenging to manage and often leads to significant burden on caregivers. Sometimes management of behavioral changes is difficult even with medications. In this case series, we report three cases of patients with behavior that was resistant to typical treatment who showed improvement in behavior when they were prescribed medical marijuana for other reason.”

https://www.futuremedicine.com/doi/10.2217/nmt-2020-0048

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THE PHARMACOLOGICAL CASE FOR CANNABIGEROL (CBG)

Journal of Pharmacology and Experimental Therapeutics: 375 (3) “Medical cannabis and individual cannabinoids, such as tetrahydrocannabinol (THC) and cannabidiol (CBD), are receiving growing attention in both the media and the scientific literature. The Cannabis plant, however, produces over 100 different cannabinoids, and cannabigerol (CBG) serves as the precursor molecule for the most abundant phytocannabinoids.

CBG exhibits affinity and activity characteristics between THC and CBD at the cannabinoid receptors, but appears to be unique in its interactions with alpha-2 adrenoceptors and 5-HT1A Studies indicate that CBG may have therapeutic potential in treating neurological disorders (e.g., Huntington’s Disease, Parkinson’s Disease, and multiple sclerosis), inflammatory bowel disease, as well as having antibacterial activity.

There is growing interest in the commercial use of this unregulated phytocannabinoid. This review focuses on the unique pharmacology of CBG, our current knowledge of its possible therapeutic utility, and its potential toxicological hazards.

Significance Statement Cannabigerol (CBG) is currently being marketed as a dietary supplement and, as with cannabidiol (CBD) before, many claims are being made about its benefits. Unlike CBD, however, little research has been performed on this unregulated molecule, and much of what is known warrants further investigation to identify potential areas of therapeutic uses and hazards.”

https://pubmed.ncbi.nlm.nih.gov/33168643/

https://jpet.aspetjournals.org/content/early/2020/11/09/jpet.120.000340

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Update on cannabis and cannabinoids for cancer pain

Current Issue Cover Image “The prevalence of cancer pain will continue to rise as pain is common among the survivorship and general cancer population. As interest in cannabis and cannabinoids for medicinal use including pain management continues to rise, there is growing need to update and review the current state of evidence for their use. The literature was searched for articles in English with key words cannabis, cannabinoids, and cancer pain. The sources of articles were PubMed, Embase, and open Google search.

Recent findings: In a double-blind randomized placebo-controlled trial including a 3-week treatment period of nabiximol for advanced cancer patients with pain refractory to optimized opiate therapy, improvements in average pain were seen in the intention to treat population (P = 0.0854) and per- protocol population (P = 0.0378).

Summary: To date, preclinical data has demonstrated evidence to suggest promising potential for cancer pain and the urgent need to translate this into clinical practice. Unfortunately, due to limited data, for adults with advanced cancer being treated with opiate therapy, the addition of cannabis or cannabinoids is not currently supported to address cancer pain effectively.”

https://pubmed.ncbi.nlm.nih.gov/33110020/

https://journals.lww.com/co-anesthesiology/Abstract/2020/12000/Update_on_cannabis_and_cannabinoids_for_cancer.19.aspx

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