Patent Application
20230321121
The present disclosure relates generally to formulations for medicinal use as alternatives to opioid-based pain killers. More particularly, the present disclosure relates to cannabinoid formulations for use in pain management to spare opioid medications currently in use or to spare their introduction.
Individuals managing pain often turn to medicinal options that offer pain alleviation, but are accompanied by unintended side-effects such as stomach upset, constipation, and risk of addiction. Alternatives to opiate drugs are urgently needed. For individuals already prescribed an opioid-based pain medication, an opioid sparing effect is desired; permitting a patient to take a lower amount of opioids, and optionally taper off of opioid use entirely. An opioid sparing formulation would allow a patient to feel a similar or reduced level of pain relief while taking fewer opioids, or may allow a prescribing physician to forego prescription of opioid pain medication entirely.
Cannabinoids are a group of structurally similar compounds isolated from cannabis plants, which activate cannabinoid receptors and ion channels in cells. Cannabinoids may be synthesized or may be isolated from cannabis plants or plant extracts (herein: a cannabinoid-containing plant extract), Cannabinoids can be isolated from plants or extracts to the extent that they are obtained in nearly pure, or essentially pure form, free of significant amounts of other naturally occurring compounds, such as other cannabinoids or plant-derived molecules such as terpenes. Known cannabinoids include but are not limited to tetrahydrocannabinol (THC); cannabidiol (CBD), cannabichromene (CBC); tetrahydrocannabidivarin (THCV); tetrahydrocannabinolic acid (THCA); cannabigerol (CBG); cannabidivarin (CBDV), cannabinol (CBN), and cannabidiolic acid (CBDA). Cannabis plants may be bred to have different amounts of a certain cannabinoid, as may be desirable for different purposes. THC and CBD have, to date, been considered as the predominant cannabinoids of interest.
CBD has been widely studied medicinal effects. CBD is regarded as having an effect on 5HT1A receptor-mediated neurotransmission, as well as on anandamide metabolism and activation of TRPV1 receptor channels that facilitate CB1- and CB2-mediated responses (Crippa JS 2018).
Δ9-THC exerts partial agonistic activity on CB1 and CB2 receptors with high binding affinity with CB1 receptor leading to its psychoactive activity.
Cannabichromene (CBC) is a major non-psychotropic cannabinoid naturally found in the Cannabis sativa plant,
The proportion of each of these cannabinoids in the cannabis plant is, however, dependent on environmental growth conditions, geographical location, genetics, and chemotype (Lewis M A 2017).
CBC has moderate affinity (Ki˜100 nanomolar) only for CB2 receptors and binds to 081 receptors only at concentrations higher than 1 micromolar (Shinjyo & De Marxo, 2013). The major CBC activity in brain has been suggested to be partly dependent on indirect activation of CB1 receptor by inhibition of cellular uptake of anandamide (De Petrocellis et al., 2011) and activation of TRPA1 (Transient Receptor potential A1) channels (Izzo et al., 2012). In fact, CBC is found to be the most potent agonist of all the phytocannabinoids at TRPA1 channels (Maione et al., 2011). CBC has also shown anti-inflammatory effects (Izzo et al., 2012).
It has been demonstrated that CBD can act synergistically with Δ9-THC and contribute to the analgesic effect of medicinal-based cannabis extract (Russo 2011).
The agonistic activity of CBC with CB1 and CB2 receptors can offer a promising approach to potentiate the effect of other cannabinoids that exert their activities via binding and activation of CB1 an CB2 receptors.
Medicinal uses of cannabinoids are known, and formulations specifically to treat pain have been described. WO2007/083098 A1 (GW Pharma Ltd) describes cannabinoid-containing plant extracts for treatment of neural degeneration. U.S. Patent Publication No, US2016/0106705 (United Cannabis Corp.) describes cannabis extracts having at least four cannabinoids and a terpene or flavonoid for use in relieving anxiety, pain, and related disorders. WO2016/044370 A1 (India Globalization Capital Inc.) teaches a topical pain-relieving formulation containing a combination of THC, CBD and cobalamin. WO2013/165251 A1 (ECHO Pharmaceuticals BV) describes a thin film evaporation method for obtaining THC-containing isolates, which may have trace only amounts of CBN or CBD. In WO20121144892 A1 (Fytagoras BV), the use of acidic cannabinoids such as THC, CBD, and other cannabinoids for enhancing an animal's natural cellular resistance to disease is described. Further, in WO20121160358 A1 (GW Pharma Ltd.), the use of at least one of CBG, CBC, CBDV and THCV as a treatment of neuropathic pain is described.
The potential of cannabinoid combinations for medicinal uses has not been fully explored in regard to opioid sparing, and in particular opioid tapering or as an opioid alternative that negates initiation of use of opioid medications. It is desirable to provide a cannabinoid formulation with beneficial properties for use in an opioid sparing approach to the management of pain.
It is an object of the present disclosure to obviate or mitigate at least one disadvantage of previous formulations for the management and treatment of pain in a manner that spares opioid use.
There is described herein a method of opioid sparing in a subject in need of pain management, said method comprising administering to said subject an effective amount of a formulation consisting of tetrahydrocannabinol (THC), cannabichromene (CBC), cannabidiol (CBD) and one or more excipients, wherein the ratio of THC:CBC:CBD is 1:1:1 on a weight % basis.
The subject may be in need of pain management for treating pain due to cancer, injury, accident, surgery, inflammation, tissue damage, arthritis, joint pain, pain from infection, gastrointestinal pain, diabetes, diabetes neuropathy, post-shingles neuralgia, neuropathic pain, peripheral neuropathy, multiple sclerosis, musculoskeletal pain, osteoarthritis pain, pain associated with cancer chemotherapy, and/or joint pain.
The formulation may be administered in a dosage form selected from the group consisting of a pill, tablet, capsule, syrup, oil-based spray, gel capsule, and liquid oil form. The formulation may provide to the subject a total amount of from about 5 mg to about 30 mg of each of THC, CBC, and CBD per dose. For example, the formulation may provide the subject with THC:CBC:CBD in amounts in the range of from 5:5:5 to 10:10:10 mg per dose. The subject may be administered the formulation from 2 to 6 times per day, with each of THC, CBC, and CBD being provided in an amount ranging from 25 to 100 mg per day.
The method may have an opioid sparing effect in a subject that has previously been administered an opioid medication for pain management, and wherein administration of the formulation is concomitant with a reduction in the administration of the opioid medication. Further, the subject may be an individual who has not previously been administered an opioid medication for pain management, and the use of the present method and formulation negates use of opioids, sparing circulation of such opioid medication not only to the individual but to society. This sparing effect may ultimately reduce need from a manufacturing standpoint such that fewer opioid medications are in circulation and thus susceptible to use or misuse.
In another embodiment, a method of opioid sparing in a subject in need of pain management is described, wherein said method comprises administering to the subject a first formulation and a second formulation at different times of a multi-dose daily regime. In this embodiment, the first formulation may consist of cannabichromene (CBC), cannabidiol (CBD) and one or more excipients on a weight % basis: 17%-54% CBC; and 46%-83% CBD. In this embodiment, the second formulation consists of tetrahydrocannabinol (THC), cannabichromene (CBC), cannabidiol (CBD) and one or more excipients, wherein the ratio of THC:CBC:CBD in the second formulation is 1:1:1 on a weight % basis.
In this embodiment, the method of opioid sparing for subjects in need of pain management is for treating subjects having pain due to cancer, injury, accident, surgery, inflammation, tissue damage, arthritis, joint pain, pain from infection, gastrointestinal pain, diabetes, diabetes neuropathy, post-shingles neuralgia, neuropathic pain, peripheral neuropathy, multiple sclerosis, musculoskeletal pain, osteoarthritis pain, pain associated with cancer chemotherapy, and/or joint pain.
The first formulation may comprise CBC : CBD in amounts of from 5 mg: 5 mg to 10 mg:10 mg per dose; and the second formulation may comprises THC:CBC:CBD in amounts of from 5 mg: 5 mg: 5 mg to 10 mg: 10 mg: 10 mg per dose. For example, the cannabinoids CBC and CBD may be present in the first formulation in amounts according to a ratio of CBC:CBD ranging from 1:5 to 5:5.
Both he first and second formulations may be prepared in a dosage form independently selected from the group consisting of a pill, tablet, capsule, syrup, oil-based spray, gel capsule, and liquid oil form. The second formulation may provide a total amount of from about 5 mg to about 30 mg of THC, CBC and CBD per dose. Optionally, the first and second formulations may provide a total amount of from about 10 mg to about 30 mg of CBC and CBD per dose, such that the subject is administered 2 to 6 doses per day, and/or the total amount of CBC and CBD administered per day may be from 25 to 100 mg,
In this embodiment of the method of opioid sparing, the subject may be an individual who has previously been administered an opioid medication for pain management, and wherein administration of the first and second formulation is concomitant with a reduction in the administration of the opioid medication. Further, the subject may be one who has not previously been administered an opioid medication for pain management.
Other aspects and features of the present disclosure will become apparent to those ordinarily skilled in the art upon review of the following description of specific embodiments.
Embodiments of the present disclosure will now be described, by way of example only, with reference to the attached Figures.
SNL model and learning effects. Data are presented as mean±SEM. Statistical significances: *p<0.05 (two-way mixed ANOVA followed by Dunnetts test). BL: Baseline; D8 5 h: Day 8, 5 hours post-treatment; D8 9 h: Day 8, 9 hours post-treatment; D9: Day 9; PD: Post-dosing.
Generally, the present disclosure provides a method for opioid sparing in subjects in need of pain management. A wide variety of types of pain can be managed in this way, including but not limited to pain due to cancer, injury, accident, surgery, inflammation, tissue damage, arthritis, joint pain, pain from infection, gastrointestinal pain, diabetes, diabetes neuropathy, post-shingles neuralgia, neuropathic pain, peripheral neuropathy, multiple sclerosis, musculoskeletal pain, osteoarthritis pain, pain associated with cancer chemotherapy, and/or joint pain..
The formulation contains three primary cannabinoid ingredients, although other cannabinoids may be present as well. For the three primary cannabinoid ingredients, the ratios of the three to one another has been optimized relative to one another. The following primary cannabinoid ingredients are present in the formulation: (−)-trans-delta-9-tetrahydrocannabinol (Δ9-THC), which is herein referred to as “THC”, cannabichromene (CBC), and cannabidiol (CBD). The amount (percent wt/wt basis) of THC:CBC:CBD present in the formulation, expressed relative to each other as a percentage of these primary cannabinoid ingredients can be from 30% -45% THC; 9% -35% CBC, and 30% -45% CBD,
According to an embodiment described, the THC:CBC:CBD ratio is 1:1:1 on a weight % basis.
Dosages within these ratios, in mg amount, may be, for example: 5 mg THC, 1-5 mg CBC, and 5 mg CBD per dose. A higher amount per dose, but in similar ratios may be amount 8 mg THC, 1.6-8 mg CBC, and 8 mg CBD per dose. A smaller amount per dose, but in similar ratios may be 3 mg THC, 2 mg CBC, and 3 mg CBD. A wide variety of other ratios are possible, for example 1:1:1.
It is the cannabichromene (CBC) content that primarily varies in this formulation, while the THC and CBD content is provided in similar amounts that are generally equal to or greater than the amount of CBC. Thus, for example, CBC could be present in an amount that is less than (as low as about one fifth of) the THC and CBD amounts, alternatively, all three primary cannabinoid ingredients could be present in roughly similar quantities.
Accordingly, there is provided herein a formulation for use in a method of pain management by a subject in need thereof, said formulation comprising tetrahydrocannabinol (THC), cannabichromene (CBC), and cannabidiol (CBD) as primary cannabinoids, and an excipient; wherein the primary cannabinoids comprise or consist of, on a weight % basis:
The formulation so used may be employed for management of pain due to musculoskeletal pain, osteoarthritis pain, and/or joint pain as well as other types of pain attributable to inflammation. Neuropathic pain and nociceptive pain can be addressed with the formulation as described herein. Pain due to cancer, injury, accident, surgery, inflammation, tissue damage, arthritis (including osteoarthritis and rheumatoid arthritis), joint pain, pain from infection, gastrointestinal pain, diabetes, diabetes neuropathy, post-shingles neuralgia, neuropathic pain, peripheral neuropathy, multiple sclerosis, musculoskeletal pain, osteoarthritis pain, pain associated with cancer chemotherapy, and/or joint pain may also be treated as described herein.
Advantageously, a subject that has previously been administered an opioid medication for pain management, when administered of the formulation described herein, can be spared opioid use, as the administration of the present formulation of THC:CBC:CBD 1:1:1 permits a concomitant reduction in the administration of the opioid medication, such as tapering and/or eliminating use.
When the subject has not previously been administered an opioid medication for pain management, the present method of opioid sparing permits the pain to be managed adequately such that initiation of opioid administration can be avoided.
The primary cannabinoids may be present in the formulation in amounts according to a ratio of THC:CBC:CBD ranging from 5:5:5 to 5:1:5.
The formulation may be prepared in a dosage form selected from the group consisting of a pill, tablet, gel capsule, syrup, oil-based spray, and liquid oil form.
The formulation may provide a total amount of from about 1 mg to about 25 mg of primary cannabinoid per dose, or from 5 to 30 mg per dose, preferably from about 5 to 30 mg, such as from about 5 mg to about 20 mg. For example, the formulation can provide the subject with THC:CBC:CBD in amounts of up to 20:20:20 mg per dose, preferably in the range of from 5:5:5 to 10:10:10 mg per dose.
A method for pain management in a subject in need thereof is provided, comprising administering to the subject an effective amount of a formulation comprising tetrahydrocannabinol (THC), cannabichromene (CBC), and cannabidiol (CBD) as primary cannabinoids, and an excipient; wherein the primary cannabinoids comprise or consist of, on a weight % basis:
According to the method, the pain to be managed is musculoskeletal pain, osteoarthritis pain, and/or joint pain, as well as other pain types which may be attributable to inflammation. Additionally, the pain to be managed may include pain due to cancer, injury, accident, surgery, inflammation, tissue damage, arthritis, joint pain, pain from infection, gastrointestinal pain, diabetes, diabetes neuropathy, post-shingles neuralgia, neuropathic pain, peripheral neuropathy or multiple sclerosis.
The formulation used in the methods may be one in which the primary cannabinoids are present in amounts according to a ratio of THC:CBC:CBD ranging from 5:5:5 to 5:1:5 In the method, the formulation may be administered in a dosage form selected from the group consisting of a pill, tablet, gel capsule, syrup, oil-based spray, or liquid oil form. The method may involve administration of a total amount of from about 1 mg to about 25 mg of primary cannabinoid per dose, preferably from about 5 mg to about 20 mg per dose. The formulation may be administered in amounts to provide the subject with THC:CBC:CBD in amounts of up to 20:20:20 mg per dose, preferably in the range of from 5:5:5 to 10:10:10 mg per dose.
A method of pain management in a subject in need thereof is described, which comprises, administering to the subject a first formulation and a second formulation at different times of a multi-dose daily regime. The first formulation comprises cannabichromene (CBC) and cannabidiol (CBD) as primary cannabinoids, and an excipient. The primary cannabinoids in the first formulation comprise or consist of, on a weight % basis: 17%-54% CBC; and 46%-83% CBD. The second formulation comprises tetrahydrocannabinol (THC), cannabichromene (CBC), and cannabidiol (CBD) as primary cannabinoids, and an excipient. The primary cannabinoids in the second formulation comprise or consist of, on a weight % basis: 30%-45% THC; 9%-35% CBC; and 30%-45% CBD.
The method is used for treating or managing musculoskeletal pain, osteoarthritis pain, and/or joint pain. Additionally, the method may be used for treatment of pain due to cancer, injury, accident, surgery, inflammation, tissue damage, arthritis, joint pain, pain from infection, gastrointestinal pain, diabetes, diabetes neuropathy, post-shingles neuralgia, neuropathic pain, peripheral neuropathy or multiple sclerosis.
Exemplary ratios of the primary cannabinoids may be present in the first formulation in amounts of CBC:CBD ranging from 1:5 to 5:5, Exemplary ratios of primary cannabinoids in the second formulation may range from THC:CBC:CBD from 5:5:5 to 5:1:5.
In the described method, the first and second formulations may be prepared in a dosage form independently selected from the group consisting of a pill, tablet, gel capsule, syrup, oil-based spray, and liquid oil form.
The method may provide from about 1 mg to about 25 mg of primary cannabinoid per dose or from 5 to 30 mg per dose, for example from about 5 mg to about 20 mg, or from 5 to 30 mg of primary cannabinoid per dose, such as from 15 to 30 mg per dose.
In an exemplary multi-dose daily regime, the subject is administered (for example, self-administers) the formulation from 2 to 6 times per day, with total primary cannabinoids being provided in an amount ranging from 25 to 100 mg per day. An exemplary dose of the formulation comprises THC:CBC:CBD in amounts in the range of from 5:5:5 to 10:10:10 mg per dose. In an exemplary regimen, one or two gel capsules containing 5 mg:5 mg:5 mg of THC:CBC:CBD are taken every 4-6 hours.
A formulation pairing is described for use in a method of pain management by a subject in need thereof. The formulation pairing comprises a first formulation and a second formulation for use at different times of a multi-dose daily regime. The first formulation comprises CBC and CBD as primary cannabinoids on a weight % basis of: 17%-54% CBC; and 46%-83% CBD, together with an excipient. The second formulation comprises THC, CBC, CBD as primary cannabinoids, on a weight % basis of: 30%-45% THC; 9%-35% CBC; and 30%-45% CBD, together with an excipient.
The formulation pairing may be used by individuals who may wish to defer psychoactive effects of THC to certain times of day, when managing pain due to musculoskeletal pain, osteoarthritis pain, and/or joint pain, as well as types of pain attributable to inflammation. Individuals experiencing pain due to cancer, injury, accident, surgery, inflammation, tissue damage, arthritis, joint pain, pain from infection, gastrointestinal pain, diabetes, diabetes neuropathy, post-shingles neuralgia, neuropathic pain, peripheral neuropathy or multiple sclerosis will also benefit from the formulation pairing for pain management.
The formulation pairing may comprise primary cannabinoids present in the first formulation in amounts according to a ratio of CBC:CBD ranging from 1:5 to 5:5, and primary cannabinoids in the second formulation in amounts of THC:CBC:CBD ranging from 5:5:5 to 5:1:5. The ratio of CBC:CBD within the first and second formulations may be the same or different within the formulation pairing. For example, when the same, the CBC:CBD ratio may be consistently 5:5 in both the first and the second formulation. When different between the first and second formulations, the ratio may be from 1:5 to 5:5, such as 1:5 in the first formulation and 3:5 in the second formulation (which also contains THC), for a three-component ratio of 5:3:5 of THC:CBC:CBD.
The first and second formulations of the pairing need not be in the same dosage form, and may differ depending on a subject's preference. The first and second formulations can be in a form independently selected from the group consisting of a pill, tablet, capsule such as a gel capsule, syrup, oil-based spray, and liquid oil form,
The formulation pairing may provide a total amount of from about 1 mg to about 25 mg of primary cannabinoid per dose, for example from about 5 mg to about 20 mg of primary cannabinoid per dose. With regard to the amount of CBC in the first and second formulations, these may provide the subject with CBC in amounts of up to 20 mg per dose, such from 5 to 10 mg per dose.
The formulation pairing may be packaged together, for example provided a kit together with instructions for use in a multi-dose daily regime.
Exemplary multi-dose daily regimes may include a periodic or timed multi-dose regime of every 4 to 6 hours, or may be associated with daily events such as waking, meal time, and bed time. The first formulation from which THC is absent may be administered in the earlier part of the day when an individual may wish to avoid any psychoactive effect of THC for typical daytime activities and interaction, whereas the second formulation containing THC may be administered in the later part of the day, when the same individual may find the effect of THC desirable. For example, the second formulation may be utilized in the evening or at bed time. The desired time of day may depend on when an individual sleeps or naps, which may be influenced by a working schedule, such as for individuals who may work night shifts.
The term “primary” is meant to indicate the cannabinoids that are primarily responsible for the intended effect of pain management, as described herein, THC, CBC, and CBD are primary cannabinoids in this context. If another cannabinoid is present in the formulation in a lower, an approximately similar, or even a higher amount, the quantity present would not mean that the cannabinoid is a “primary” component of the formulation, although such additional cannabinoids may be present.
The primary cannabinoids THC, CBC, and CBD may be present in the formulation from natural sources, such as from one or more cannabis plants, an in particular extracts thereof. Or the cannabinoids may be obtained from one or more isolated sources, or from a synthetic source where one or more of the desired cannabinoids is synthesized. A blend of natural and synthetic cannabinoids may be used so that a natural source with a variable content (due to growing conditions or other reasons), may be standardized to pre-determined amounts using adjustment with synthetic or isolated sources.
An extract may be obtained from a plant that is specially modified or grown under conditions conducive to production of a cannabinoid ratio particularly suited to the desired primary cannabinoid ratio, without needing to dramatically alter or supplement the amount of any of the primary cannabinoids present.
If purification of cannabinoids is desired extraction methods such as an ethanolic extraction, or a CO2 based extraction may be used.
Plants may be bred or cultured, or growth conditions can be optimized to reflect the requisite ratio of THC:CBC:CBD. Further, two or more plants or extracts bearing ratios differing from the intended ratio may be combined in amounts that result in the desired pre-determined ratio.
Other cannabinoids may be incidentally present in the formulation, and if present, the quantities of such additional cannabinoid ingredients would not reduce the pain management features of the formulation.
Intended uses of this formulation for pain management include musculoskeletal pain, osteoarthritis pain, and/or joint pain. Other types of pain such as cancer-related pain as well as non-cancer-related pain, such as acute pain from injury, accident, surgery, inflammation, or from tissue-damaging conditions such as arthritis and joint pain, pain from infection, gastrointestinal pain, diabetes, diabetes neuropathy, post-shingles neuralgia, nociceptive pain, neuropathic pain, peripheral neuropathy, multiple sclerosis, or from other sources of pain. Inflammatory pain, neuropathic pain, or pain in which inflammation is a contributing underlying cause, that may be attributed to increased excitability of peripheral nociceptive sensory fibres can be addressed by the present formulation. Other types of pain, such as described herein may also be encompassed. The altered activity of ion channels in sensory neurons, causing pain, can be lessened. This can address a number of conditions associated with chronic inflammation.
The formulation may be used by humans or by pets (companion animals such as dogs or cats), as well as for working animals such as horses.
Subjects in need of a therapeutic effect for pain management in the intended indications may use the formulation prior to, during, or after the medical event or need arises. Management of musculoskeletal pain, osteoarthritis pain, and/or joint pain is described herein. Cancer pain can be debilitating for a number of reasons, and cancer treatments can also lead to painful episodes. Management with the formulation described herein can avoid problems inherent with opiate use, such as constipation and addiction. Addition can lead to overuse, and eventually illegal sourcing of formulations that are unpredictable in composition, which may lead to overdose.
Regarding non-cancer pain, for example, prior to undergoing surgery where the pain can generally be anticipated, the formulation may be used prophylactically to lessen the pain that is anticipated. For the pain of an injury or unexpected damage from an accident, the formulation may be used acutely or on an ongoing basis in place or harsher or more damaging analgesic drugs such as opioids or NSAID pain killers.
The opioid sparing effect of the described methods can result in either concomitant reduced use of opioids by an individual already taking opioid medication, who can this reduce, eliminate or taper opioid use (all of which is considered “opioid sparing”, or may be used by an individual who is not yet taking an opioid medication, and who will be able to manage pain without opioids that may have otherwise been sought out or prescribed. In this way, opiate sparing also results, not only on an individual level, but also on a societal level that could reduce quantities of opioids manufactured and sold, in the long term.
The formulation is amenable to oral delivery, such as in a pill, tablet, gel capsules, syrup, oil-based spray, or liquid oil form. The oral form may be provided in a food or as a food supplement, which may be added to a food to be more palatable or readily consumed by a subject. Topical or nasal absorption is possible. A fat-soluble carrier, or nano- or micro-particles or emulsions may be used so that the highly fat-soluble cannabinoids can be more readily absorbed. The formulation may be prepared as an injectable, for intravenous, intramuscular, or intraocular delivery. The formulation may be delivered in a vapor, such as by vaping, in a vaporizer or puffer, or may be heated to cause volatilization and inhalation which could be considered as “smoking”.
Administration. It is understood that administration encompasses self- administration, as well as all other forms of provision. Administration by a medical practitioner such as by recommendation and/or by prescription is encompassed.
Dosages. The formulation can be delivered in relative amounts ranging from about 5:1:5 to 5:5:5 (i.e.—1:1:1) on a weight basis of THC, CBC, to CBD. Other cannabinoids may be present in these formulations. On a per dosage basis, the total amount of primary cannabinoids may range from 0.1 mg-50 mg, for example 1 mg-25 mg, 5 mg-30 mg, or 5 mg-20 mg per dose. If delivered in a liquid such as an oil, amounts may be expressed on a mg/mL basis, such as from 0.1 mg/mL-50 mg/mL per dose, for example 1 mg/mL-25 mg/mL, or 5 mg/mL-20 mg/mL per dose. Dosages may be used as needed depending on the severity of the pain experienced, but an individual may wish to use the formulation on an as-needed basis, ranging from once per day (or less, if not needed) to more frequently such as taking 6 doses per day, with a frequency of every 4 hours. A daily dose of from 25-100 mg per day may be used. Dosage may be increased or decreased over a period of time, as individuals may require.
An exemplary formulation may be a solid dosage form such as a pill, tablet, or granule-containing capsule. Alternatively, the formulation may be liquid-based, and may contain isolated or synthetic primary cannabinoids, or may be an oil-based extract of cannabis with about 5 mg/mL Δ9-THC, about 1-5 mg/mL CBC and about 5 mg/mL of CBD in liquid forms such as oil, and oil-based spray, or a liquid-containing gel capsule (soft-gel capsule). If liquid-containing or gel-containing capsules are used, these may be limited in volume, for example an approximate volume of 200 μL. The milligram quantity stated above as a dosage range may be included in each such capsule, or the capsules may be formulated so as to be less concentrated in units of mg/mL. When less concentrated capsules are used, then the appropriate dosage is delivered by increasing the number of capsules consumed per dose.
Excipients and Formulation Ingredients. The formulation may incorporate any acceptable excipients known in formulating drugs or cannabinoids. Such ingredients may include starch, cellulose, alginates, colloidal silicon, lubricants such as stearates, salts, aqueous and non-aqueous (fat soluble) ingredients. The usual formulation considerations would be brought to bear, as one of skill in the art would understand.
The pain that accompanies cancer is highly variable depending on the type of cancer, the treatment involved, and whether tumors themselves are causing the subject discomfort,
An individual experiencing the pain of a stage 4 carcinoma may use the formulation to manage this pain. Then individual may consume orally, on a regular basis such as every 6-hours, a dose of the following oil-based cannabinoid formulation.
The formulation comprises 5 mg/mL THC, 1 mg/mL CBC, and 5 mg/mL CBD, in an oil-based liquid. At the appropriate interval, the individual may take 1 mL orally.
Initially, the individual may begin by consuming 1 mL of the formulation at a frequency of twice per day. The dose may be titrated to a higher amount over time as the individual becomes accustomed to the formulation, until a dose of 1 to 2 mL, taken from 4 to 6 times per day is reached.
The pain of recovering from surgery can, at times, be anticipated in advance of the surgical procedure.
Prior to a surgery, and individual may wish to mitigate stress or worry by knowing effective pain relief is available. Following a surgery, or when a surgery does not require general anesthetic or extensive fasting, such as an oral surgery (fillings or root canal procedures), the individual may consume orally, in advance if possible, or following the surgery, a dose of the following pill-based cannabinoid formulation.
The formulation comprises 5 mg THC, 3 mg CBC and 5 mg CBD, in an pill; tablet, or soft-gel capsule form. The individual may take 1 or 2 of such a pill, tablet, or capsule orally. Optionally, a high-fat food may be simultaneously consumed to assist in efficiency of intestinal absorption, but only at a time when food consumption is permitted according to the surgical regime.
Formulation for Use in Pain Management following Injury
The pain that accompanies an acute and unexpected accident or injury can be debilitating to the individual as their recovery and healing proceeds.
An individual experiencing the acute pain brought on by such an unexpected event may use the formulation to manage this pain. Then individual may consume orally, on a regular or as-needed basis, a dose of the following encapsulated oil-based cannabinoid formulation until the pain subsides to a tolerable level.
The formulation is present in soft-gel capsules having an approximate volume of 200 μL per capsule. Each capsule comprises 5 mg THC, 2 mg CBC, and 5 mg CBD, in an oil-based liquid. The soft-gel capsule encapsulates the oil-based liquid with a gelatin-based shell that may incorporate other commonly known gel capsule ingredients, such as glycerin or sorbitol, so as to permit ease of swallowing. At the appropriate interval, the individual may take 1 capsule orally.
Initially, the individual may begin by consuming 1 capsule at a frequency of twice per day. The dose may be increased to a higher amount if the initial dose is well tolerated, and as the individual becomes accustomed to the formulation. A dose of 1 to 2 capsules, taken from 4 to 6 times per day may be used when the pain is most acute. Over time, as the individual recovers and heals, the frequency of use may be titrated down to a dose of 1 capsule twice per day, or even less frequently is used on an as-needed basis.
Globally, up to 10% of the population are affected by neuropathic pain (Bouhassira D, 2008; Colloca L, 2017) as a comorbidity with chemotherapy, diabetes, inflammatory and infectious disorders (Colloca L, 2017). Yet, an effective and safe treatment remains unfound. Several cannabinoids have been shown to possess efficacy as antinociceptives. In this example, a unique formulation is described for treatment of chronic pain. Neuropathic pain is characterized with burning and electrical-life sensations, pain causing by non-painful stimulants, and upon having persist symptoms, leads to sleep disturbance, anxiety and depression and impairment in quality of life (Colloca L, 2017). The study was designed to focus on the phenotypic profile of neuropathic pain and address challenges for clinical translation.
This study provides a comprehensive behavioral phenotypic assessment of the impact of cannabinoid treatments on chronic neuropathic pain. Using two different measures of mechanical threshold testing, electronic von Frey and kinematic assay by Gait analysis, significant reduction of mechanical hyperalgesia and allodynia ipsilateral to the ligated nerve were observed upon treatment with cannabidiol (CBD), delta 9-tetrahydrocannabinol (Δ9-THC), Cannabichrornene (CBC) at 1:1:1 ratio. CBD:THC:CBC at ratio of 5:5:5 mg/kg or 10:10:10 mg/Kg displayed a robust reduction in mechanical hypersensitivity and a strong reversion of tactile allodynia and effectively improved kinematic performance of SNL-induced neuropathic pain. Strikingly, this formulation was attributed to superior analgesic effect when compared to Pregabalin, a GABA analogue (Gamma aminobutyric acid) that is among the first-line treatment choices for neuropathic pain. This analgesic effect seems to be largely mediated by cannabichromene present in the formulation.
These results illustrate that the current formulation (CBD:THC:CBC at 1:1:1 ratio) potently reduces neuropathic pain and offers a new replacement for opioids as painkiller. Furthermore, addition of cannabichromene robustly mitigates the analgesic effect of CBD and A9-THC. This finding shows that adding CBC enables the possibility of a significant reduction in the daily dose and total intake of CBD and A9-THC in patients with chronic pain. Importantly, CBD:THC:CBC at 1:1:1 ratio offers a new solution where patients' quality of life is impaired because of poor outcome of opioids, risk of opioid dependency, increased drug intake and several visits to healthcare providers.
Purpose Of The Study. The objective of this study is to evaluate the effect of distinct doses of 3 cannabinoids on the intensity of SNL-induced mechanical hypersensitivity and altered kinematic performance as a validated model of chronic neuropathic pain. The studied cannabinoids are cannabidiol (CBD), cannabichromene (CBC), and delta 9-tetrahydrocannabinol (Δ9-THC). Spinal nerve ligation surgery causes partial denervation within the peripheral (sciatic) nerve, thereby evoking tactile hypersensitivity (allodynia) within the sciatic nerve innervation area. The SNL rat model was originally described in 1992 (Kim S H, 1992). Cannabinoids possess several functions according to their reactions with the endocannabinoid system. They are among the most promising candidates for studying different pain types,
The study in-life was conducted via the following steps:
All animal experiments were performed as specified in the license authorized by the national Animal Experiment Board of Finland and according to the National Institutes of Health (Bethesda, MD, USA) guidelines for the care and use of laboratory animals.
In total, 180 male Sprague-Dawley male rats were purchased from Charles River Germany and subjected to the study procedures. The body weight of the rats was 200-300 g on the day of SNL surgery, Prior to SNL surgery, upon the handlings and baseline tests—the number of animals were approximately 5-10% larger, in purpose of anticipating the rare but possible situations which require animal replacements (e.g. innately oversensitive animals). Animals were housed at a standard temperature (22±1° C.) and in a light-controlled environment (lights on from 7 am to 8 pm) with ad libitum access to food and water.
All animals were operated by spinal nerve ligation; all groups comprised n=15. The treatment groups received the following test article administrations:
All rats followed the same study design until completion of the D9 behavioral tests.
Table 1 shows the treatment details.
These results are presented for a 5 mg/kg treatment subset. The 10 mg/kg treatment subset results are presented below.
The Test Articles were handled and stored under standard operative procedures. The dose formulations were prepared according to detailed instructions provided by the vendor.
Test articles, their vehicle, or Pregabalin (positive control drug) were administered according to table 1 on study day 8 to all study animals. The route of administration of Cannabinoids or vehicle was intragastric (p.o.), while Pregabalin was administered intraperitoneally (i.p.). In addition to D8, pregabalin was administered on D9, at 2 h prior to the evF test.
The animals were enrolled to SNL surgery in daily cohorts of n=6. The rats first received an intraperitoneal dose of 0.03 mg/kg buprenorphine (Temgesic), minimum of 30 minutes prior to the surgery, to alleviate the operative and postoperative pain unrelated to neuropathy. Prior to spinal nerve ligation (SNL) procedure, the rats were anesthetized with isoflurane in 70% N2O and 30% O2; with a flow rate of 300 ml/min. Anesthesia was inducted in a chamber with 5% isoflurane for 2-3 min, and maintained through a snout mask with 1-2% isoflurane thereafter. A homeothermic blanket system was used for the rectal temperature to be monitored and maintained at 37.0° C.±1.5° C. during the operation.
A dorsal incision extending from L3 to S2 was performed to the medial dorsal area of the rat using aseptic technique. The L6/S1 posterior interarticular process was exposed using a combination of blunt and sharp dissection. The L6 transverse process in the spinal column was visualized and partially removed without manipulating the nerves, followed by exposing the L4 and L5 spinal nerves distal to their emergence from the intervertebral foramina.
The L5 nerve was ligated tightly with 6-0 silk suture. The L6 nerve was then located caudal and medial to the sacroiliac junction and tightly ligated with 6-0 silk suture, similarly to L5. Both ligatures were performed as double knots.
After performing the ligatures, the muscle layers, connective tissue and skin were dosed and animals allowed recovery from anesthesia in a homeothermic cage. Rats were monitored until fully awake and moving in the cage.
Postoperative care period occurred twice-daily for ad 7 days following surgery, and included the following procedures Careful observation of the general condition and welfare along with monitoring the operated paw and gait of the animal. The surgical wound and sutures were checked—and disinfected properly when required—twice a day, until the wound was properly closed. 0.03 mg/kg buprenorphine s.c. was administered upon first two postoperative days, at approximately every 12 hours. Rehydration with 4 ml of sterile saline i.p. directly after the surgery, continuing twice a day ad 7 days, or until no further weight loss occur. Any clear signs of pain, motor deficits or health issues beyond model and surgery related were recorded and animals with any paralysis or other model-unrelated motor deficit were excluded from further testing.
Tactile Allodynia Test (evF) and Pre-Handling and Baseline evF.
In this study, mechanical sensitivity to touch stimuli was defined at four timepoints by using electronic von Frey (evF) device along with the attached analysis software (Somedice®, Sweden).
Before subjecting the rats to the baseline evF, they were pre-handled for 2-3 min on two consecutive days, in purpose of decreasing oversensitivity in the test. Pre-handling was performed at a maximum of 3 days prior to baseline tests. Baseline evF took place at a minimum of 5 days after their arrival to CR animal facility, and at maximum of 5 days preceding the surgery day (d0).
Rats displaying inborn oversensitivity were disqualified from the study. Oversensitivity was defined as baseline paw withdrawal threshold (PWT) of <20 g with 1 mm probe. Following the baseline evF test, the rats were weighed, numbered, and distributed into treatment groups evenly regarding the baseline PWT and body weight.
Prior to any procedures (handling or tests), the animals were allowed for a 60-min habituation in the room where procedures performed.
To perform the evF test, the rats were placed in individual von Frey test chambers standing on an elevated steel mesh, The rats were then allowed to adapt in the chambers, and the test per se was emerged after they have settled down followed by investigating the chamber and grooming (approximately 15 min). Test was be performed while an animals were grooming, urinating, defecating or sleeping. Further description of test procedure is provided hereinbelow.
Conducting evF Test. Mechanical allodynia were assessed by evF test prior to SNL surgery (baseline), to define the individual sensitivity levels of the study animals. Next, the evF was performed on D7 post-SNL, to assess the hypersensitivity evoked by the SNL surgery, and to provide pre-dosing sensitivity values for comparing. On D8, the animals were subjected to the test at 2 h post-dosing (PD), at 4 h PD and at 8 h PD. Subsequently, the test was performed at 24 h PD, i.e. on D9. On D9, Group 2 received Pregabalin (i.p) at 2 h prior to testing.
On any test day, the rats were allowed to adapt in the test room for approximately 1 h prior to testing. Part of this time was used to test chamber adaptation, in order to reduce the stress and facilitate testing. The test may be commenced as the animals have explored the surroundings, groomed and calmed down. A rat is not tested in case it's urinating, defecating or sleeping.
The evF apparatus was used according to the manufacturer's instructions. Briefly, upon each measurement, the force is applied to mid-plantar surface of the hind paw in a linearly increasing rate.
The used evF probe diameter was 1 mm, and the chosen ascent rate of the force 10 g/s. The linearity of force application was monitored in real time. The applied force (in grams) causing paw withdrawal was recorded by the apparatus as the result for the trial.
Notes were taken during the test so, that possible sedative effects of the test articles was distinguished from the sensory effects.
Altogether, 5 repeated measurements were applied to each hind paw at each time-point leaving a minimum of 3-min interval between the repeats. Medians of the 5 measurement repeats were determined from each paw at any given time point. Both ipsi- and contralateral paws were also tested on each test day.
The rats were subjected to gait analysis at the baseline and on study days 8, 9, 11, 14 and 17, at a minimum of 30 min after the evF test. The assay were carried out by MotoRater (TSE Systems, Homburg, Germany), with the walking mode. Prior to commencing the test, the essential body points (e.g. joints, limbs, nose, tad) were marked for tracking. The information of the gait performance was captured using a high speed camera (300 frames/ second) from below and both sides. Next, the captured videos were converted to SimiMotion™ software. The raw data were obtained by tracking the marked points of the body from the videos recorded from all 3 dimensions. The raw data thus comprised correlation of the movements of different body points in coordinates related to the ground and each three dimensions.
Different gait patterns and movements were analyzed using a custom-made automated analysis system. Information about altogether over a hundred kinematic parameters were attained. These comprised e.g.:
All Motorater data were analyzed for the distinct parameters, as well as for all combined parameters, using principal component analysis (PCA). The obtained results were produced the model phenotype in gait analysis, i.e., the difference between vehicle and cannabinoid-treated animals regarding both individual parameters and PCA.
In addition to the baseline test, the motorater tests were performed altogether four times over the course of behavioral study phase:
The kinematic assay was not performed to the animals before a minimum of 30 min after evF test.
The motor phenotype of SNL model can be characterized and interpreted as the following combination of changes in the gait features:
The overall gait scores presented on the following three slides reflect all these changes together (using the discriminant direction vector as a “yardstick”), and are presented in a way that the average score at baseline is equal to zero. The average score of all study groups at D7 is equal to 3.107 (z-score). The decrease of the overall score means that the gait performance has changed towards to the pre-SNL status (BL).
The body weight of the animals was recorded at baseline evF testing, on the day of surgery (D0), and daily thereafter.
On D9, after the last motorater test, the behavioural study phase were completed by choosing 6 rats per group to continue into the PK-phase. The rest of animals were euthanized by an overdose of CO2, and decapitation.
Upon the endpoint day of the PK-phase, on D11, the rats were terminally anesthetized with pentobarbital (60 mg/kg Mebunat). Blood samples were collected via cardiac punctures, and plasma isolated by centrifugation with 2000×g for 10 min. Separated plasma samples were transferred into clean tubes and stored in −80° C. until shipment.
Next, the animals were transcardially perfused first with PBS. Brains were detached from the skull and snap-frozen in liquid N2. Thereafter, the brain samples were stored in −80° C. until shipment.
Lumbar DRGs were prepared to sight, and harvested from both sides, Lumbar DRGs L4-L6 from each side were pooled in a pre-labelled 2-ml tube (ipsilateral DRGs into one tube; contralateral DRGs to another), and post-fixation performed in 10% commercial formalin for 24 h (+4c″C), Finally, the DRG samples were briefly flushed with 0.1 M PBS, and stored in the buffer in +4° C. until and during the shipment.
General Health Status and Humane Endpoints. Animals were monitored daily by laboratory personnel. In the case that general health status of an animal has significantly worsened, it was sacrificed by an overdose of CO2, and decapitated. Definitions of acceptable endpoints include: no spontaneous movements and inability to drink or eat in a 24-h observation period, massive bleeding, spontaneous inflammation, missing anatomy, swelling or tumors larger than 20 mm, and inability to right itself for a 30-s period.
In addition, model specific end-point criteria apply:
The following materials and substances were used in the study:
All values are presented as the mean±standard error of the mean. All statistical analyses were conducted with a significance level of α=0.05, using GraphPad Prism (Version 8, GraphPad Software, Inc., San Diego, CA). Depending on the features of the data, the statistical tests were selected from the following parameters.
Simple comparisons between two groups was performed by either unpaired Student's t-test or, where the assumption of normality was rejected by the D'Agostino-Pearson or Shapiro-Wilk test, by the Mann-Whitney U-test. Welch's t-test was used for pairwise comparisons if data was assumed to be normally distributed, otherwise with unequal variances. For comparisons between two measurements done on the same set of subjects, either paired Student's t-test or Wilcoxon signed-rank test was used as appropriate.
Comparisons involving more than three independent groups was carried out by one-way analysis of variance (ANOVA), or, if data are not normally distributed, by the Kruskal-Wallis test. If group/treatment factor was significant, post hoc multiple comparisons was performed. For comparing all means with all other means, either Tukey or Holm-Šidák test was used. Comparisons to control group mean was done by the Dunnett's test. In case of the Kruskal-Wallis test, post hoc multiple comparisons were done by using the Dunn's test.
For repeated observations on the same group, matched values were analyzed by repeated-measures ANOVA (for normally distributed data) or the Friedman test (for groups where the assumption of normality was rejected).Comparisons between two and more groups done at different points was analyzed by two-way repeated measures ANOVA with group/treatment as “between” factor and time as “within” factor. Main effects of group and time was initially determined and in case of their significant interaction, relevant post hoc multiple comparisons were performed.
No Significant Difference In Body Weight Of Various Groups of Snl-Rats Throughout the Study.
There was no statistical significance observed when comparing different treatment groups to vehicle treated animals.
CBD:THC:CBC at 5:5:5mg/kg was found to reduce mechanical hypersensitivity due to chronic pain. This was an important finding.
To evaluate mechanical hypersensitivity; this study employed electronic von Frey (evF) 8 days post-surgery, as well as paw withdrawal threshold determined within 24 hours post-dosing in each treatment group. The results were graphed and compared with baseline (time 0).
Treatment of rats with CBD+THC+CBC at 5:5:5 mg/kg significantly reduced SNL-induced mechanical hypersensitivity when compared vehicle group in evF test (p<0.01). Interestingly; treatment with CBD+THC+CBC at 5:5:5 mg/kg caused a significantly higher reduction of mechanical hypersensitivity when compared to Pregabalin positive control (p=0.0186), as evidenced in
Analysis of Area under the Curve (AUC) illustrated a marked increase of AUC in rats treated with CBD+THC+CBC at 5:5:5 mg/kg compared to rats treated CBD:THC:CBC at 5:5:1 mg/kg (
Table 2A and Table 2B shows multiple/pairwise comparison of treatment groups in electronic von Frey Area Under the Curve (AUC), Light Grey background: p<0.05 by Tukey's multiple comparisons; Dark Grey background: p<0.05 by Fisher's LSD for pairwise comparisons. Diff: Difference. CI: Confidence Interval. SE: Standard Error.
Although, treatment of rats with CBD:THC at 5:5 mg/kg ratio was indicated to be effective in reducing the intensity of mechanical hypersensitivity in evF test compared to vehicle (p <0.05), addition of 5mg/kg Cannabichromene to the compound, seemed to enhance the effect of CBD and THC (p <0.01). To support this notion, CBD+THC+CBC at 5:5:5 mg/kg also showed markedly greater efficacy than pregabalin (p =0.0186), while CBD+THC at 5:5 mg/kg (without CBC) was comparable to pregabalin in reducing mechanical hypersensitivity (p =0.6414) (Tables 2A & 2B). Additional group comparisons at each behavioral test timepoint would shed light on the impact of adding cannabichromene.
Group-wise differences were tested to narrow down pairwise post hoc comparison. In order to evaluate the effect of CBD+THC+CBC at 5:5:5 mg/Kg, between- group comparisons (
Between-group-comparisons revealed a significant difference when CBD+THC+CBC 5:5:5 mg/kg treatment was compared to vehicle at 2 hours post-dosing (p=0.0494, two-way ANOVA, Dunnett's post hoc) (
In addition, SNL rats treated with CBD+THC+CBC 5:5:5 mg/kg showed 33% increase in Paw Wthdrawal Threshold (% PWT) from baseline at 2 hours post-doing (p<0.05). At 4 hours post-dosing, the significance level was not quite reached (p=0.086; two-way ANOVA, Dunnett's post hoc) (
Within-group-comparisons conducted by two-way ANOVA, showed a highly significant time-bound effect present, as characterized by a dynamic response to administration, peaking at 2 hours post-dosing and gradually reverting to pre-dosing level,
Significant change from pre-dosing to 2 hours post-dosing was found in all cannabinoid groups in this subset, as well as in Pregabalin group (p <0.05, two-way ANOVA, Dunnett's post hoc) (
Based upon eVF assay results, increasing CBC from 1 mg/kg to 5 mg/kg, seem to prolong the effect of CBD+THC. It is noteworthy that at 24 hours post-dosing, the result value of the group with highest CBC concentration was still above the pre-dosing level. The difference from pre-dosing level at this timepoint however remains non-significant. Furthermore, what is worth noticing here, is the shape of the dynamic response to administration peaking at 2 hours post dosing and gradually reverting back, close to SNL injury level. The response intensity change with time is clearly different in high CBC dose group, compared to low CBC dose groups.
The effect of adding cannabichromene to CBD and THC was also evaluated SNL rats treated with CBD:THC 10:10 mg/Kg subset and the results are reported in below.
Overall, results from electronic von Frey test confirm the efficacy of CBD:THC:CBC at 5:5:5 mg/kg ratio in reducing SNL-induced mechanical hypersensitivity and indicate the efficacy of this formulation for chronic pain management. Further evaluation of chronic pain and motor control via kinematic gait analysis below explains the enhanced efficacy of CBD+THC when combined with CBC.
Comprehensive kinematic analysis was performed by high sensitivity MotoRater that allows detection of any subtle to severe gait changes in SNL model. Three-dimensional observation and analyses were performed from ventral, lateral left and right to assess movements based on trajectories of join positions and angles with respective properties, such as velocity and acceleration. An overall score was reported based on distance from baseline for each treatment group compared to vehicle or within each treatment group. The fine motor capabilities and the gait of the animals were evaluated at the baseline and four times after the SNL surgery, 2 h, 5 h, 9 h and 24 hours post-dosing using the kinematic movement analysis of altogether 97 separate parameters that were recorded.
Statistical significances of the adjusted p-values: *p<0.05; **p<0.01, ***p<0.001, ****p<0.0001.
Principal component analysis (PCA) was performed for the parameter data to reduce the number of variables, and to reveal correlations between separate parameters. PCA combines all the parameter data, reveals correlations between them, and provides an overall view of the fine motor and gait characteristics of the SNL-operated rats. Baseline BL and D7 differences in all study groups was presented in the bar graph (
This study reports SNL-induced motor phenotype based on PCA and present overall gait score based on between groups and within group comparisons for rats treated with CBD:THC 5:5 mg/kg with 0-5 mg cannabichromene, The groups were compared to vehicle (negative control) and pregabalin (positive control). Further motor phenotype assessment of SNL rats treated with CBD:THC 10:10 mg/kg subset are reported below.
One striking difference between CBD:THC:CBC at 5:5:5 mg/kg ratio treatment and other cannabinoid or Pregabalin treatment groups was a highly improved gait overall score at 5 hours and 9 hours post-dosing (p<0.05 and p<0.0001, respectively, two-way ANOVA, Dunnett's post hoc) (
As displayed in
Another major finding of fine motor kinematic analysis was a markedly significant time-bound effect displayed in the overall gait score of rats treated with CBD:THC:CBC at 5:5:5 mg/kg. These data showed a response to administration in all cannabinoid groups; the score either was decreased close to the baseline, or showed a ceased increase, in contrast to vehicle and pregabalin groups, which continued displaying growing overall score, referring here to moving away from the baseline score (
Thus, herein is provided evidence that treatment with CBD:THC:CBC 5:5:5 mg/kg proved to be the most potent compound in reversing tactile over the period of 24 h post-dosing. This formulation effectively reduced mobility impairment in rats up to 9 hours post-dosing (p<0.0001). This long-term effect was not observed in SNL-rats treated with Pregabalin or other cannabinoid groups.
Altogether, this study provides a comprehensive behavioral phenotypic assessment of the impact of cannabinoid treatments on chronic neuropathic pain.
CBD:THC:CBC at ratio of 5:5:5 mg/kg or 1:1:1 ratio displayed a robust reduction in mechanical hypersensitivity, as well as, a strong reversion of allodynia and a highly improved kinematic performance of SNL-induced neuropathic pain model over 9 hours after a single treatment.
This finding indicate that that adding proper dosage of Cannabichromene to cannabidiol and Δ9-THC may markedly reduce the daily dose in pain patients and also decrease the total intake of CBD and Δ9-THC as painkillers by patients.
An overall gait score is determined, which combines kinematic parameters into one single score. The score is based on those kinematic parameters which best characterize the disease model against healthy control. This approach is highly sensitive to determine disease model specific treatment effects.
Results of CBD:THC at 10:10 mg/kg. CBD:THC 10:10 mg/kg—Subset Comparisons.
In this subset, the most potent compound in reversing tactile over the period of 24 h post-dosing, was [CBD+THC 10:10 mg/kg]. However, both [CBD+THC+CBC 10:10:10 mg/kg] and [CBD+THC 10 mg/kg +CBC 2 mg/kg or 10:2:10 mg/kg] also displayed highly significant increase of the AUC, compared to the vehicle. Curve points: Pre-dosing 2 h, 4 h, 8 h, and 24 h post-dosing (
To compare different cannabinoid combinations sharing the dosage of 10 mg/kg THC, a subset of groups were formed and comparisons performed and presented accordingly (
In this subset, a similar effect was seen as with the formerly presented 5 mg/kg THC -subset. However, with these dose-mixtures, the conducted two-way ANOVA produced highly significant treatment-time interaction effect, based on the pre-selected groups. To further examine these differences, appropriate pairwise post hoc comparisons between Vehicle and both [CBD+THC 10:10 mg/kg] and [CBD+THC 10:10 mg/kg +CBC 2 mg/kg] were performed. Both these groups displayed a significant difference to the Vehicle group at 2 h post-dosing. While the result of [CBD+THC 10:10 mg/kg +CBC 2 mg/kg] at 4 h post-dosing was still significantly higher than Vehicle result, the [CBD+THC 10:10 mg/kg] at this timepoint remained lower, showing a slight trend (p<0.1) towards significantly reversed hypersensitivity compared to Vehicle two-way ANOVA, Dunnett's post hoc (
Within group comparison, displayed a highly significant time-bound effect of the sensitivity level with the 10 mg/kg of THC Subset, showing a similar dynamic response to administration, earlier seen in the 5 mg/kg THC Subset, peaking at 2 hours post-dosing, gradually reverting back to pre-dosing level thereafter. Perceivable statistical significance from pre-dosing to 2 h post-dosing was found in all cannabinoid groups in this subset, as well as in Pregabalin group (p<0.05, two-way ANOVA, Dunnett's post hoc) (
The slight rising trend, found near-significant in the 5 mg/kg THC Subset comparisons, was found non-significant with the 10 mg/kg THC Subset (p=0.1588, two-way ANOVA, Dunnett's post hoc) (
It is noteworthy that the difference between these analyses is merely presenting the nature of statistical modelling, where the confidence intervals and p-values accordingly are based on the overall variance found in all groups included in the analysis, resulting in slight changes in the final p-values, depending on the combination of groups included in the analysis.
The Effect of Increasing CBC Dose. To examine the effect of increasing CBC dosage, the following subset of groups were formed. CBD+THC 5 mg/kg, CBD+THC 5:5 mg/kg +CBC 1 mg/kg and CBD+THC+CBC 5:5:5 mg/kg (
In the first subset (5 mg/kg THC-groups), increased CBC dose appears to show marginally improved reversion of hypersensitivity, when compared to the groups with 0 or 1 mg/kg CBC. Still, no significant treatment effect, or treatment-time interaction effect was present in this subset of groups (p>0.05, two-way ANOVA) (
Further, highly significant time-bound effect was found in this subset as well.
Statistically significant difference between the pre-dosing and 2 h post-dosing value was found in all groups in this subset (p<0.05, two-way ANOVA, Dunnett's post hoc) (
It is worth noting that at 24 h PD, the result value of the group with highest CBC concentration still is above the Pre-dosing level. The difference from Pre-dosing level at this timepoint however remains non-significant.
The comparisons between the second subset of groups: [CBD+THC 10:10 mg/kg], [CBD+THC+CBC 10:10:2 mg/kg], [CBD+THC+CBC 10:10:10 mg/kg] show differences in
With 10 mg/kg THC, increasing CBC dose appeared to cause marginal reduction of the reversing effectivity of THC+CBD. However, no significant treatment effect or treatment-time interaction was displayed between this subset of groups (p>0.05, two-way ANOVA) (
Again, highly significant time-bound effect was shown within this subset of groups. A statistical significance was found in all groups. In this subset displayed significant or near statistical significant allodynia reversion (higher value) at 2 h post-dosing, (p<0.05, two-way ANOVA, Dunnett's post hoc) (
As with the previous subsets, so with this subset, it is worth noting that at 24 hours post-dosing, the result value of the group with highest CBC concentration still is above the pre-dosing level. The difference from pre-dosing level at this timepoint however remains non-significant.
What is worth noticing here, is the shape of that dynamic response to administration peaking at 2 hours post dosing and gradually reverting back, close to SNL injury level. The response intensity change with time is clearly different in high CBC dose group, compared to low CBC dose groups. Although a similar 2 hours post-dosing peak as seen with the other groups is lacking from [CBD+THC+CBC 10:10:10 mg/kg], a gradual increase (less hypersensitive) is shown through the timepoints of 4 h and 8 h. At 24 hours post-dosing, the level still remains above the pre-dosing value (non-significant difference).
The overall gait scores reflect all of those changes, that were found on PCA analysis, together (using the discriminant direction vector as a “yardstick”), and are presented in a way that the average score at baseline is equal to zero. The average score of all study groups at D7 is equal to 3.107 (z-scores. The decrease of the overall score means that the gait performance has changed towards to the pre-SNL status (BL).
Below, the overall gait scores are presented in subsets as previously described,
CBC Strongly Prolongs the Effect of CBD and THC and Markedly Improved SNL-Induced Mobility impairment: THC 10 mg/kg Subset Comparisons.
To compare different cannabinoid combinations that share the dosage of THC as 10 mg/kg, the following subset of groups were formed and comparisons performed and presented according to
Significant and highly significant treatment effect (towards baseline) were produced within the groups of this subset, when compared to Vehicle group. Further pairwise post hoc comparisons revealed, that at both 5h and 9h PD timepoints, both [CBD+THC 10:10 mg/kg] and [CBD+THC+CBC 10:10:10 mg/kg] were competent to yield significant difference to the Vehicle group (p<0.05, two-way ANOVA, Dunnett's post hoc) (
Moreover, highly significant time-bound effect was presented, when comparing the overall gait scores between the timepoints, within each group. Similar to the 5 mg/kg THC subset, in all cannabinoid groups, the score either was decreased close to the baseline, or exhibited a ceased increase. A profoundly different score pattern was displayed by the Vehicle and Pregabalin groups, with increasing score until 9 h PD timepoint, followed by a slight decrease to the 24 h PD timepoint (
Table 3 provides multiple pairwise comparison of treatment groups in electronic von Frey Area Under the Curve (AUC). Lighter shaded background: p<0.05 by Tukey's multiple comparisons; Darker shaded background: p<0.05 by Fisher's LSD for pairwise comparisons. Diff: Difference. Cl: Confidence Interval. SE: Standard Error.
These data show an improvement in pain management/pain relief parameters for formulations in which CBD, CBC and THC are all present versus formulations without CBC.
Formulations containing CBD, CBC, and THC in equal quantities were tested against formulations with only CBD and THC, or against vehicle to evaluate kinematic parameters. These data underscores the benefit of having CBC as the third primary cannabinoid in the formulation.
Baseline, D7, D8-5 h, D8-9 h and D9 Post-Dosing. Statistical significances: p≤0.01 was considered significant based on adjusted p-values.
Panel A—Ankle Range of Motion (ROM)—D9 PD: CBD+THC+CBC (5:5:5 mg/kg) vs. CBD+THC (5:5 mg/Kg): **p=0.009. Panel B—Percentage Paw Trajectory Shape (Forelimb)—D9: CBD+THC+CBC (5:5:5 mg/kg) vs. CBD+THC (5:5 mg/Kg): ** p=0.003. Panel C—Overall % Duty Cycle—D8-5 h AND D8-9 h: CBD+THC+CBC (5:5:5 mg/kg) vs. Vehicle: ** p=0.003 and ** p=0.004. Panel D—% Hindlimb Duty Cycle—D8-5 h AND D8-9 h: CBD+THC+CBC (5:5:5 mg/kg) vs. Vehicle: ** p=0.005 and ** p=0.003, respectively. Panel E—Toe Liftoff Angle Hindlimb [degree]—D9 PD: CBD+THC+CBC (5:5:5 mg/kg) vs. Vehicle: **p=0.000598. Panel F—Support Single: D8-5 h AND D8-9 h: CBD+THC+CBC (5:5:5 mg/kg) vs. Vehicle: ** p=0.003 and *p=0.014, respectively. N1/N2: Group sizes.
Table 4A and Table 4B show multiple/pairwise comparisons of particular kinematic gait parameters compared pre- and post-dosing. Only significant effects (p≤0.01) are shown, and Adj. sig (Adjusted Significance)=*p<0.05; **p<0.01; *** p<0.001.
The data presented in
Formulations for pain management were tested for effects on the human TRPA1 channel, expressed in mammalian cells using the ScreenPatch® assay (IonWorks™ Barracuda Based Assay): agonist mode. The data presented confirming a synergistic effect of cannabinoids (CBD:THC:CBC) at the ion channel level.
The test articles, also referenced herein as test formulations, were evaluated in an 8-point concentration-response format (4 replicate wells/concentration, Table 4A & Table 4B). The test articles were dissolved and initially serially diluted in dimethyl sulfoxide (DMSO). The final dilution was made in extracellular solution. The final DMSO concentration was 0.6% (v/v).
Stock solutions of positive control articles were prepared in batches, aliquoted for individual use. The positive control test solutions were prepared fresh on the day of experiment. The final DMSO concentration was 0.6% (v/v). In this study, the TRPA1 agonist mustard oil (MO) was used a positive control agonist. Reference antagonist, ruthenium red (0-10 μM), was used for both TRPA1.
TRPA1 ionotropic receptors expressed in CHO cells.
Ionworks Barracuda™
Intracellular solution (mM): 50 mM CsCl, 90 mM CsF, 2 mM MgCl2, 5 mM EGTA, 10 mM HEPES. Adjusted to pH 7.2 with CsOH, This solution was prepared in batches and stored at room temperature. In preparation for a recording session, the intracellular solution was loaded into the intracellular compartment of the PPC planar electrode.
Extracellular solution, HB-PS (composition in mM): NaCl, 137; KCl, 1.0; MgCl2, 2; CaCl2, 2; HEPES, 10; Glucose, 10; pH adjusted to 7.4 with NaOH (refrigerated until use). Holding potential: −70 mV, potential during agonist/antagonist application: −70 mV.
Extracellular buffer was loaded into the PPC plate wells (11 μL per well). Cell suspension was pipetted into the wells (9 μL per well) of the PPC planar electrode.
Whole-cell recording configuration was established via patch perforation with membrane currents recorded by on-board patch clamp amplifiers.
Single application (scan) protocol was used.
The application consisted of the addition of 20 μL of 2× concentrated test article solution at 10 μL/s (2 second total application time).
0-3000 μM mustard Oil (8 concentration dose-response, 4 replicates, half log scale).
0-10μM Ruthenium Red (8 concentrations, 4 replicates, half log scale).
An exemplary plates load map as used in the study is illustrated in the schematic shown in
Agonist and antagonist reference control: TRPA1 0-3000 μM mustard oil and Ruthenum Red 0-10 μM, respectively, performed with 1× concentrations.
Agonist properties of cannabichromene (CBC) and mixture of cannabidiol (CBD) and Δ9-THC were examined using an HTS electrophysiology-based approach, Ion Work Barracuda (IWB). A single-application protocol was employed.
Reference agonist, mustard oil, produced activation of TRPA1 receptors with EC50=479 μM. Non-selective inhibitor, ruthenium red, inhibited TRPA1 receptors with IC50=1.79 μM. Both E050 and IC50 values were consistent with historical data.
As shown in
CBC showed a weak partial agonist activity at TRPA1 receptors with EC50˜40 μM and EMAX˜10%, CBD+THC mixture showed more potent, and more pronounced partial agonist activity with EC50 ranged from 2.94 μM to 5.4 μM (at different concentrations of CBC) and EMAX equal 50% -60% relative to maximum current produced by 3000 μM mustard oil.
Data analysis were performed in two ways: First way: Table 5 and
Table 5 shows numeric information of agonist activity of CBD+THC mixture (0-300 μM each) in the presence of increasing concentrations of CBC (0-300 μM). Note that CBC produced concentration response as a weak partial agonist which did not have significant effect on concentration response to CBD+THC mixture, but showed a trend towards agonist effect of all three cannabinoids together.
Table 6 shows numeric information of agonist activity of CBC in control (0-300 μM) and in the presence of increasing concentrations of CBD+THC mixture (0.1-300 μM). Note that CBD+THC mixture, in concentrations ≥3 μM, produced concentration own response, which occluded concentration response to CBC. Note that at threshold activation of TRPA1 receptors by CBD+THC mixture (1 μM), concentration response of TRPA1 receptors increased in potency and efficacy (shown as bold text).
3
1
2.40
17.09
26.01
−1.00
CBC CRC control
0.86
10.31
44.14
−0.96
CBC CRC has been occluded by increasing concentrations of CBD+THC mixture and starting with 3 μM CBD+THC mixture CBC CRC was masked.
CBC has no effect on CBD+THC mixture CRC EC50 and EMAX. At highest concentrations CBC tested, initial portion of CBD+THC mixture CRC was increased, which resulted in marginal rightward shift of EC50 for CBD+THC mixture CRC. It can be concluded that CBC and CBD+THC mixture produce receptors activation with different degree of partial agonism by acting at the same binding site of TRPA1 receptors.
Positive modulation of concentration response to CBC (synergy) was observed at the near threshold concentration of CBD+THC mixture (1 μM, Table 6 and
Observed synergy of these two partial agonists can be attributable to the existence of two identical binding sites on TRPA1 receptor and positive cooperativity in binding of two ligand moieties to the receptors (orthosteric modulation). For example, binding of one ligand moiety to first binding site prime receptor or increase affinity of binding to the second binding site. An alternative explanation is an existence of positive allosteric modulation site. Without being limited to the mechanism of action, these synergistic effects were observed.
These data confirm direct activation of CBC on TRPA1 (Transient receptor potential Ankyrin 1) ion channel, as an important sensor of nociception in human,
The partial agonistic activity of CBC with CBD+THC mixture at the TRPA1 receptors was also confirmed.
The agonist activity of CBC with CBD+THC was presumably mediated via the same binding site.
At the near threshold activation of TRPA1 receptors with CBD+THC mixture (1 μM each), CBC activated TRPA1 receptors with greater efficacy and potency. Cannabichromene EMAX (efficacy) increased from 10±2% up to 16±1% and its potency from EC50=44 μM to EC50=26 μM (
This study also confirms the synergistic effect between CBC and CBD+THC.
Observed synergy of these two partial agonists could be theoretically explained by existing of two identical binding sites on TRPA1 receptor and positive cooperativity in binding of two ligand moieties to the receptors (orthosteric modulation). For example, binding of one ligand moiety to first binding site would prime receptor or increase affinity of the second binding site. Alternative explanation is an existence of specific positive allosteric modulation site. Additional experiments must be designed to address an exact mechanism of these synergistic effects.
Altogether, direct effect of cannabichromene on activation of TRPA1 ion channels and the increase in potency of cannabichromene with CBD+THC further confirm that CBC has pain management properties. Therefore, addition of CBC to CBD and Δ9-THC can lower the intake of CBD and THC in patients for pain management.
In this Example, data mining was performed to extend the multivariate kinematic data analysis and capture (a) Parameters indicative of analgesia vs. sedation phenotypes (analgesic or sedation ‘fingerprint’) (b) Quantitative measurement of parameters attributed to the temporal aspects of motion to evaluate temporal aspects of motion, such as positions, angles, velocities, and accelerations of body segments and joints during motion. Briefly, Contrastive Principal Component Analysis (cPCA) was utilized to identify different combinations of original variables which were linked to model effect, learning effect, and sedative effects. An orthogonalization procedure was used to make the obtained effects independent. cPC scores corresponding to identified cPCs were computed. In order to evaluate the analgesic and sedative effects of CBD:CBC:THC 5:5:5 mg/kg group, separate comparisons were performed with vehicle and pregabalin as controls, CBD+THC 10:10 mg/kg as positive control for sedation and CBC 10 mg/kg as negative control for sedation. The results of these comparisons were obtained by using all the previously identified components: model effect, learning effect and model orthogonal to learning, sedation orthogonal to model, and finally, the sedation orthogonal to both model and learning. The final sedative effect was also orthogonalized against both model and learning (speed effects), restricting to combination of gait changes which was associated with sedation. The sedative effect was carefully identified by using CBD:THC 10:10 mg/kg group at D8 9 h and was not linked to SNL model or learning effects. The parameters indicative of sedation were mostly associated with decreased overall speed, including increased stance and swing time, increased double support and decreased swing speed, as well as, decreased tail base height.
Regarding statistics, reference is made to a statistical method of Contrastive Principal Component Analysis (cPCA) (see Abid et al,, 2018); a cPCA based analysis framework implemented by R environment (R version 3.6.3); and statistical analysis with Ime4 (Bates et al., 2015) and emmeans (R version 1.4.5), R Foundation for Statistical Computing, Vienna, Austria.
SNL model score indicated a significant analgesic effect of CBD:CBC:THC 5:5:5 mg/kg that was comparable with that of CBD:THC combination when given at double the dose.
The SNL model score indicated a significant analgesic effect of CBD:CBC:THC at a level of 5:5:5 mg/kg and also showed reversal of SNL-induced pain at Day 8 5 h post-dosing compared to vehicle group (
These findings are suggestive of a potential synergistic effect of CBC with CBD and THC. This analgesic effect of CBD:CBC:THC at 1:1:1 ratio was not significant 9 hours post-dosing, which could be due to short half-life of cannabinoids (
Data mining successfully determined the analgesic effect and sedative effect of multiple treatments by comparing 97 different gait parameters in each animal.
The final SNL mod& effect was most distinctively associated with the following parameters: increased vertical hip movement, gait asymmetries, and increased hind limb toe clearance,
The parameters indicative of sedation were mostly linked to decreased overall speed (increased stance and swing times, increased double support and decreased swing speeds) or decreased tail base height.
The data mining indicated that Pregabalin treatment at 50 mg/kg exhibited no analgesic or sedative effect in the kinematic data. This lack of efficacy of Pregabalin in pain management was consistent with the results of the evF test when the time points were analyzed separately. The only significant effect of Pregabalin was found in the area under curve (AUC) analysis of evF. However, evF analyses revealed a marked analgesic effect of CBD:CBC:THC at a level of 5:5:5 mg/kg has superior analgesic effect when compared to Pregabalin (50 mg/kg), a GABA analogue that is among the first-line treatment choices for neuropathic pain (p=0.0186). Analysis of fine motor kinematic parameters further confirmed that Pregabalin treatment exhibited no analgesic or sedative effect on the kinematic gait performance
Significant recovery in SNL model effect score were found in CBD:THC 10:10 mg/kg and CBD:CBC:THC 5:5:5 mg/kg treatment groups at D8 5 h post-dosing, while no analgesic effect was indicated at 9 h post-dosing. This finding indicates that recovery in the SNL model score is associated with the analgesic treatment effect.
The CBD:CBC:THC formulation at a level of 5:5:5 mg/kg demonstrated a significant analgesic effect at D8 5 h post-dosing. This analgesic effect was comparable with that of a CBD:THC combination when given at double the dose, suggesting a potential synergy in the analgesic effect of CBC when used in combination with CBD:THC.
Final independent sedative effect was found only in the CBD+THC 10 mg/kg group at both D8 5h and D8 9h post-dosing.
Utilizing CBD:CBC:THC at a level of 5:5:5 mg/kg demonstrated a marked reversal of SNL-induced pain as indicated by improvement in interlimb coordination, enhanced body posture, and rectified knee and ankle angles.
Overall; CBD:CBC:THC at a level of 5:5:5 mg/kg exhibited a marked reversal of motor impairments indicated by changes in motor skill parameters associated with improvement in interlimb coordination, enhanced body posture, and rectified knee and ankle angles. This finding might offer a practical guide to study motors skill changes in clinical setting in patients with chronic pain. This study also identified that parameters associated with sedation are attributed to decreased overall speed, such as increased stance and swing time, increased double support and decreased swing speed, and decreased tail base height. These finding may offer clinically translatable solutions in human clinical trials.
These results affirm that a formulation comprising CBD:CBC:THC 5:5:5 can effectively achieve pain management in the Spinal Nerve Ligation (SNL) model.
The Effects of Single- and Repeated-Dose Treatment with CBD:CBC:THC at 1:1:1 ratio on Management of Chemotherapy-induced Polyneuropathv
In this Example, a pain model was used to compare efficacy of a multi- cannabinoid formulation and a known pain relieving medication, Duloxetine. Duloxetine is medicine within a class of drugs referred to as serotonin-norepinephrine reuptake inhibitors (SNRIs) for use in treatment of pain.
Mouse Oxaliplatin-induced polyneuropathy (OIPN) model was induced over a three-week period. The day of first Oxaliplatin (OXP) injection is referred to as day 0 (D0). OXP was administered as six separate intraperitoneal injections at 4.5-mg/kg (10 mL/kg, i.p.) to Groups 2, 3, and 4 on D0, D4, D8, D12, D16, and D20. The cumulative OXP dose was thus 27 mg/kg. The in-life procedures, such as observations, tests, and/or measurements were performed by Charles River Discovery Services with blinded methods. The mice were distributed into 4 groups (n=8 for Vehicle Control; n=10 OXP Control; n=20 CBD:CBC:THC; n=15 Duloxetine).
Table 8 shows planned and accomplished group sizes (N) as used here.
A significant percentage of C57BL/6J mice have a portosystemic liver shunt, which results in major alteration of brain morphometry, brain metabolites, physiological readouts (such as body weight and liver enzymes), and cognitive deficits. Prior to study initiation, plasma bile acid measurement was performed to exclude animals with abnormally high bile acid concentration (>15 μmol/L), which is a surrogate marker of the portosystemic liver shunt (Cudalbu et al. 2013). The bile acid concentrations were analyzed by an outsourced third-party, using Thermofisher Konelab Xti 20™, according to manufacturers instructions.
Animal body weights were measured before assigning the treatment groups and then on each day of the study. The last body weight measurement was performed upon endpoint sampling. Terminal body weights were not collected from animals found dead or euthanized moribund.
Following exposure to OXP for 20 days, Groups 3 and 4 were treated with CBD:CBC:THC (5:5:5 mg/kg, p.o.) and Duloxetine (25 mg/kg, i.p.), respectively, for 10 consecutive days. In a similar regimen Groups 1 and 2 (Vehicle Control and OXP-Vehicle Control, respectively) received a corresponding volume of 5% glucose solution at an administration volume of 10 mL/kg.
Acetone Cooling Test (ACT)
To produce a measurable cooling sensation, 10-15 μL of acetone was applied onto the medial area of the plantar hind paw with a 0.5 ml insulin syringe. Responses of a mouse to acetone were monitored for 20 s, and a score given based on a four-point scale (0-3 points), according to the response intensity, continuation, and briskness. The higher the score, the greater the cool allodynia sensed by the mouse.
Within one test timepoint, a total of 3 trials were performed per paw with a minimum gap of 5 min between testing. The three individual scores were added up to obtain a single score over a cumulative period of 60 s. Thus, for one test, the minimum score of one paw is 0 (no cool allodynia), while the maximum possible score is 9 (intensive cool allodynia). The total scores for the left and right paws were averaged to accomplish a single result value per mouse at each timepoint.
The Acetone Cooling Test was performed prior to OXP administration (Baseline), following the last OXP injection (D21), one day after the first CBD:CBC:THC, Duloxetine, or Vehicle treatment (D22), and after a 10-day daily dosing of CBD:CBC:THC, Duloxetine, or Vehicle treatment (D31). Taken together, the ACT was used to assess chemotherapy-Induce cool allodynia as stated in the schedule:
Prior to the ACT, mice underwent 30-60 min habituation in the test room and approximately 30-60 min habituation in the test chambers, Before baseline ACT, mice were pre-handled for 2 min on two consecutive days in their maintenance room for the purpose of decreasing false oversensitivity.
These data illustrate that the formulation CBD:CBC:THC is effective in pain management.
Out of a total of 90 mice, 76 were accepted for the baseline tests as they displayed normal plasma bile acid contents—i.e. 24 mice were disqualified from the study due to very high BA concentration in plasma, indicating the portosystemic shunt. Seven mice were disqualified from further study due to showing too mild cool allodynia. Furthermore, the welfare observations made upon testing found that Duloxetine caused the most adverse effects, as 30 ° k of the group displayed enlarged staring eyes and clearly decreased activity,
Oxaliplatin chemotherapy does not dramatically affect the body weight (BW) development. The raw BW values were normalized by the baseline weight, to obtain % BW Change from Baseline. The group means of this value are shown in
During the OXP exposure period, a slight weight gain of a few percentages is seen (compared to approximately 10% on Veh.-Veh. group). From D22 onwards, all groups display a slight decrease in body weight that starts increasing—depending on the group. A slower increase in body weight observed in CBD:CBC:THC and dulaxetine—treated groups may be due to the loss of appetite that can potentially be due to the treatment.
Moreover, 10-day repeated dosing with CBD:CBC:THC at 5:5:5 mg/kg showed significant reversion of chemotherapy-induced cool allodynia (D31 vs. D21), Similarly, repeated dosing with Duloxetine showed a significant reduction of cool allodynia (D31 vs. D21) (
In addition,
The CBD:CBC:THC (5:5:5 mg/kg) formulation was shown to be as effective at managing pain as a known pain relieving medication.
After the Oxaliplatin (OXP) exposure period, all OXP-treated groups displayed highly robust OIPN mod& induction as confirmed by the acetone cooling test (ACT).
CBD:CBC:THC (5:5:5 mg/kg) or Duloxetine (25 mg/kg) showed a comparable and significant reversion in polyneuropathy (chemotherapy-induced pain) upon single-dose treatment as measured by the ACT.
Upon chronic multiple-dose treatment for 10 days, CBD:CBC:THC (at 5:5:5 mg/kg) and Duloxetine caused a significant reduction in polyneuropathy (chemotherapy- induced pain) as measured in the ACT, as compared to the corresponding Vehicle control (Veh-OXP) group.
Of note, Duloxetine is the only recommended treatment for chemotherapy- induced peripheral neuropathy (CIPN) by the American Society of Clinical Oncology and the systematic review of treatments for CIPN show evidence for a moderate benefit of duloxetine (Hou et al, 2018). However, Duloxetine therapy causes significant side-effects. In accordance, in this study pronounced adverse effects were observed in 30% of the Duloxetine group, which included enlarged staring eyes and obvious decreased overall activity. Similar manifestations were observed following CBD:CBC:THC treatment at 5:5:5 mg/kg, however, the effects were notably very mild by comparison.
These results affirm efficacy of a formulation comprising CBD:CBC:THC 5:5:5 in pain management.
In this Example, a regime involving a day and night pairing of formulations is described for use in pain management. Individuals wishing to achieve pain management, but who may nevertheless wish to avoid any psychoactive effect of Δ9-THC (tetrahydrocannabinol, herein THC) during daytime or waking hours may utilize a formulation pairing in which THC is only present in the evening or bed time doses of the regime. THC can exert psychoactive activity, which may or may not be desirable to an individual at certain times of day, while such effects in the evening or at bedtime may be desirable. Other primary cannabinoids, such as cannabichromene (CBC) and cannabidiol (CBD), can exert the pain managing effects but without psychoactive activity.
A regime comprising taking a CBC:CBD formulation by day or at desired times, combined with a THC:CBC:CBD formulation in the evening or at bedtime or at desired times can address the varied needs of individuals wishing to achieve pain management.
In a multi-dose daily regime, for which an individual takes a morning dose (or breakfast dose), a mid-day dose (lunch time dose), an evening dose (dinner/supper time dose), and/or a night time (bedtime) dose, a formulation pairing may involve a CBC:CBD 1:5 to 5:5 (weight ratio) formulation that is taken at 8:00 am and 1:00 pm, followed by a THC:CBC:CBD 5:5:5 to 5:1:5 (weight ratio) formulation at 6:00 pm and 11:00 pm. By reserving the effect of the THC for the evening and bedtime doses, the THC effect can be reserved for certain times of day when an individual has no reservation regarding possible psychoactive effects.
The formulation pairing permits flexibility for individuals who may wish to defer or delay the THC-containing formulation for the evening or sleeping hours, to promote maximum alertness and/or avoid psychoactive effects during certain times of day.
Pain Management with Cannabinoid Formulation for Musculoskeletal Pain: Assessment in Osteoarthritis Rat Model
In this Example, a regime involving the formulation containing equal weight ratios of THC:CBC:CBD (herein, “the formulation”) was tested in a rat model of osteoarthritis as an exemplary type of musculoskeletal pain, with tramadol as a positive control. Animals were assessed at 7, 14, and 21 days of treatment for weight-bearing ability, and an inflammatory cytokine profile was assessed in synovial fluid.
Musculoskeletal diseases are injuries and disorders that affect the muscles, ligaments, nerves, tendons, cartilages, and spinal discs. These conditions limit body movement, overall performance, and therefore quality of life of the patients, The most common musculoskeletal diseases are osteoarthritis, gout, rheumatoid arthritis, back pain, osteoporosis, myasthenia gravis, and systemic lupus erythematous. The relevant pain types for musculoskeletal disorders and injuries are nociceptive pain, nociceptive inflammatory pain, and neuropathic pain. The following cannabinoid formulations are rigorously formulated to manage all three types of pain.
The objective of this study is to evaluate the effect of cannabinoids on acute and chronic joint pain assessed by measuring dynamic weight bearing (DWB) deficit and the cytokine level in the synovial fluid.
The animal model of joint pain was chemically induced by an intra-articular injection of 3 mg of monosodium- iodoacetate (in 25 μL saline) into the right knee joint of the rat given under isoflurane anesthesia. Dose level for La. injection of MIA has been selected based on previous literature report in rodents and internal validation data (Bove et al., 2003)
Animals received cannabinoid formulation or vehicle (p.o. by Oral gavage) once daily from Day 3 to Day 21 after model induction. Tramadol was administered a positive control for pain management with dosing once daily on Day 3, Day 5 to 7, Day 10 to 12 and Day 18 to 21. Since regular administration of Tramadol can produce tolerance due to its opium-like effect, intermittent dosing schedule was selected to prevent drug tolerance in the animals.
Joint pain was measured as the deficit in weight bearing by the MIA-injected limb. Dynamic Weight Bearing was evaluated using the BioSeb® automated DWB system according to the manufacturer's manual. The system consists of an arena box made from pressure-sensitive sensor mat on the bottom and an attached high- resolution camera on the top. The rat can freely move inside the arena box. A two-minute recording was done for each individual rat. The system automatically calculates the weight borne by each limb and the tail. Body weight is then measured for each rat immediately before the DWB for each time of testing. DWB measurement was performed at different time points as per schedule in Study Design. Data analysis of dynamic weight bearing was conducted off-line using the BioSebe software.
An exact volume of 0.1 mL of sterile saline containing the enzyme, Hyaluronidase from testes, Cat. #H3506 (Sigma) at 10 μg/mL concentration was injected in the right knee joint as per standard procedures. The knee was flexed and waited for about 2 minutes after injection to collect the lavages. The maximum amount of obtainable synovial fluid was collected, and the exact collected volume recorded (record both ‘injected’ and ‘collected’ volume). Any blood contamination of synovial fluid samples was recorded and the collected synovial fluid was transferred into separate, uniquely labelled clear polypropylene tubes, placed on dry ice and then transferred to a freezer set to maintain −80° C. for cytokines analysis. Terminal synovial fluid collected from all animals were analyzed with Luminex multiplex assay for Interleukin 6 (IL-6), Tumor Necrosis Factor-alpha (TNF-a), and Keratinocyte chemoattractant (KC-GRO),
In
The formulation management of osteoarthritis pain in a validated animal model of osteoarthritis, as shown by the significant improvement in weight bearing ability in the affected limbs at day 7 and day 14 of this study. The improvements in the weight-bearing parameter is consistent with the finding of improved inflammatory cytokines in the synovial fluid of the treatment group. The formulation is effective in alleviating, reducing, and managing muscular skeletal pain, such as osteoarthritis or joint pain, and such pain as may be attributable to inflammation.
Both neuropathic and nociceptive pain can be addressed with the formulation. Neuropathic pain, typically caused by inflammation, irritation or neural tissue compression can be addressed by using the formulation. Nociceptive pain may occur as a result of the body's reaction to painful stimuli such as in the back, in muscle, or in bone, whether or not nerve damage occurs. Pain from osteoarthritis may be classified as nociceptive or inflammatory) pain. Animal models of osteoarthritis illustrate that sensory nerve fibers can be damaged with destruction of a subchondral bone junction, and thus can result in neuropathic pain (NP).
In this Example, a regime and a formulation is described for use in managing osteoarthritis pain, and which may be used for managing other types of muscular skeletal pain, such as joint pain or other types of pain due to inflammation. The formulation comprises three primary cannabinoids THC, cannabichromene (CBC) and cannabidiol (CBD), which are provided in equal weight amounts in a gel capsule. Within each individual capsule, the cannabinoids present are: 5 mg THC, 5 mg CBC and 5 mg CBD, for a total amount of primary cannabinoids of 15 mg per capsule. The individual experiencing pain can decide on the timing of the regime, taking from about 30 to about 90 mg per day of total primary cannabinoids, as desired and/or required.
The regime comprises taking the THC:CBC:CBD formulation at periodic times per day, such as a morning dose (or breakfast dose), a mid-day dose (lunch time dose), an evening dose (dinner/supper time dose), and/or a night time (bedtime) dose. The dose may be taken with or without food, for example, before a meal.
An exemplary pain management formulation may involve a single capsule of the formulation at 7:30 am, 12:00 noon, 5:00 pm and 10:00 pm, with sleep occurring between 11:00 pm and 7:00 am. With each capsule having 15 mg of primary cannabinoid, the total daily consumption would thus be 60 mg (15 mg×4).
The formulation may be taken 2 times per day with a dose of 2 capsules per dose, for a total daily consumption of 90 mg ([3 doses/day]×[2 capsules/dose]×[15 mg/25 capsule]).
An individual may begin the regime on 1 capsule, 2 times per day, for a total of 30 mg total cannabinoids, in order to observe their own preference for or tolerance of the formulation, As desired, a third dosage time can be introduced per day, or an increase to 2 capsules per dose can be considered so as to address the pain attributable to osteoarthritis and/or joint pain.
The formulation pairing permits flexibility for individuals who may wish to defer or delay the THC-containing formulation for the evening or sleeping hours, to promote maximum alertness and/or avoid psychoactive effects during certain times of day.
In this Example, a regime and a formulation pairing is described for use in managing osteoarthritis pain, and which may be used for managing other types of muscular skeletal pain, such as joint pain or other types of pain due to inflammation. The formulation pairing comprises a first formulation with two primary cannabinoids cannabichromene (CBC) and cannabidiol (CBD), in equal weight amounts. Within each individual capsule, the cannabinoids present are: 5 mg CBC and 5 mg CBD, for a total amount of primary cannabinoids of 10 mg per capsule. A second formulation with three primary cannabinoids: THC, cannabichromene (CBC) and cannabidiol (CBD), in equal weight amounts is utilized. Within each individual capsule, the cannabinoids present are: 5 mg THC, 5 mg CBC and 5 mg CBD, for a total amount of primary cannabinoids of 15 mg per capsule.
A regime comprising taking the first formulation (the CBC:CBD formulation) by day or at desired times, combined with the second formulation (THC:CBC:CBD formulation) in the evening or at bedtime or at desired times can address the varied needs of individuals wishing to achieve pain management.
A multi-formulation multi-dose daily regime, may involve an individual taking a morning dose (or breakfast dose), a mid-day dose (lunch time dose), an evening dose (dinner/supper time dose), and/or a night time (bedtime) dose, a formulation pairing may involve a CBC:CBD 5:5 (weight ratio) formulation that is taken at 8:00 am and 1:00 pm, followed by a THC:CBC:CBD 5:5:5 to 5:1:5 (weight ratio) formulation at 6:00 pm and 11:00 pm. By reserving the effect of the THC for the evening and bedtime doses, the THC effect can be reserved for certain times of day when an individual has no reservation regarding possible psychoactive effects.
In this Example the effect of single or repeated oral administration of THC:CBC:CBD formulation at 1:1:1 ratio is investigated for effect on management of chemotherapy-Induced cold allodynia and hyperalgesia as compared to Duloxetine and vehicle control.
A stable mouse model of Oxaliplatin (OXP)-induced polyneuropathy (OIPN) was generated by a 20-day OXP challenge with six intraperitoneal injections (cumulative dose of 27 mg/kg). After OXP exposure period, all OXP-treated groups displayed highly robust model induction in the acetone cooling test (ACT; Baseline vs. Pre-dose). The animals were then treated with oral administration of vehicle, THC:CBC:CBD (5:5:5 mg/kg), or Duloxetine (25 mg/kg) to investigate the antinociceptive effect of each treatment.
The THC:CBC:CBD formulation in a 1:1:1 ratio permits management of chemotherapy-induced pain. The 1:1:1 formulation alleviates chemotherapy-induced cold allodynia and hyperalgesia. Treatment of mice with Oxaliplatin (OXP) for 20 days induces cold allodynia that is scored by an Acetone Cooling Test (ACT).
Upon single and 10-day repeated doses of treatment, THC:CBC:CBD treatment at 5:5:5 mg/kg significantly reversed the chemotherapy-induced pain toward the pre-OXP baseline (
Acetone Score toward pre-OXP Baseline. Data are presented as mean +SEM. Baseline: prior to OXP; Predose: post-OXP (i.e., evoked cold allodynia level); Repeat Dose: 10-day repeated dose. Veh-Veh (Vehicle-Vehicle) is the negative control treatment in mice that did not receive OXP. Statistical significances: **** p <0,0001, *** p <0.001, ** p <0,01, * p <0.05, compared to Predose within the same treatment group by two-way ANOVA, Dunnett's multiple comparisons test.
Upon a single dose treatment, THC:CBC:CBD treatment (5:5:5 mg/kg) showed the highest significance of allodynia reversion compared to pre-dose timepoint (p<0.001), while Duloxetine treatment (25 mg/kg) did not reach the same level of significance (p<25 <0.01).
Upon 10-day repeated dosing, THC:CBC:CBD (5:5:5 mg/kg) showed the highest level of significance in reversion of cold allodynia compared to pre-dose timepoints (p<0.01) against Duloxetine treatment that did not reach the same level of significance (25 mg/kg; p<0.05).
The magnitude of effect by THC:CBC:CBD was then normalized and calculated as a percentage of maximum possible effect (% MPE). THC:CBC:CBD (5:5:5 mg/kg) showed a statistically significant % MPE (p<0.05) for reversion of cold allodynia of approximately 38% after either single or 10-day repeated doses when compared to the corresponding vehicle control (
Subjective clinical observations made during the testing period noted that the Duloxetine-treated group exhibited adverse effects, with approximately 30% of animals displaying enlarged starting eyes and clearly decreased activity. These same manifestations were indicated as very mild by comparison for THC:CBC:CBD 1:1:1 formulation.
Up to 20-40% of cancer patients who undergo neurotoxic chemotherapy develop painful chemotherapy-induced peripheral neuropathy and it continues to be a challenge due to inadequate pain relief offered by most available drugs. The Applicant's inventive cannabinoid formulation having THC:CBC:CBD present in a 1:1:1 ratio, markedly reduced pain indicated by significant reversal of chemotherapy-induced cold allodynia and hyperalgesia. The anti-nociceptive effect of this cannabinoid formulation was qualitatively superior to Duloxetine. Given the interaction of both cannabinoids and SNRT (serotonin and norepinephrine reuptake inhibitors), such as Duloxetine, with 5-HT receptors at CNS level, this finding suggests a potential therapeutic target for management of pain in cancer patients undergone chemotherapy.
Cold allodynia and hyperalgesia are common signs in various conditions, including peripheral neuropathies caused by chemotherapeutic agents (e.g., oxaliplatin and paclitaxel), posttraumatic injury (e.g., complex regional pain syndrome type 2, amputation), and also as a consequence of a stroke (e.g., central poststroke pain). Cold-evoked pain is also a common occurrence in diabetic neuropathy. The instant 1:1:1 cannabinoid formulation offers solutions for these areas of unmet need. Utilization of the instant formulation is opioid sparing when the individual would otherwise have addressed their pain management using an opioid-derived medication, and/or because the formulation permits the use of opioid medication to be tapered down or displaced by the formulation to achieve adequate pain management.
The formulation pairing permits flexibility for individuals who may wish to defer or delay the THC-containing formulation for the evening or sleeping hours; to promote maximum alertness and/or avoid psychoactive effects during certain times of day.
In the preceding description, for purposes of explanation, numerous details are set forth in order to provide a thorough understanding of the embodiments. However, it will be apparent to one skilled in the art that these specific details are not required. References cited herein are incorporated by reference.
The above-described embodiments are intended to be examples only. Alterations, modifications and variations can be effected to the particular embodiments by those of skill in the art. The scope of the claims should not be limited by the particular embodiments set forth herein; but should be construed in a manner consistent with the specification as a whole.
The following documents are herein incorporated by reference.
Reithmeier D, Tang-Wal R, Seifert B, Lyon A W, Alcorn J, Acton B, Corley S. Prosser-Loose E, Mousseau D D, Lim H J, Tellez-Zenteno J, Huh L, Leung E, Carmant L and Huntsman R J. 2018. “The protocol for the Cannabidiol in children with refractory epileptic encephalopathy (CARE-E) study: a phase 1 dosage escalation study.” BMC Pediatrics 18:221.
Russo, E B. 2011. “Taming THC: potential cannabis synergy and phytocannabinoid-terpenoid entourage effects.” Br J Pharmacal 163:1344.
Shinjyo N, Di Marxo V. 2013. “The effect of cannabichromene on adult neural stem/progenitor cells.” Neurochemistry international 63(5): 432-437.
Wolf S A, Bick-Sander A, Fabel K, Leal-Galicia P, Tauber S, Ramirez-Rodriguez G, et al, 2010. “Cannabinoid receptor CB1 mediates baseline and activity-induced survival of new neurons in adult hippocampal neurogenesis.” Cell Commun Signal. 8:12.
This application is a Continuation-in-Part of U.S. patent application Ser. No. 17/225,968, filed on Apr. 8, 2021; which is a Continuation-in-Part of U.S. patent application Ser. No. 17/218,329, filed on Mar. 31, 2021; which is a Continuation-in-Part of U.S. patent application Ser. No. U.S. patent application Ser. No. 17/162,903, filed on Jan. 29, 2021; which is the U.S. National Phase of International Patent Application PCT/CA2020/050588 filed May 1, 2020 and which is also a Continuation-in-Part thereof. This application claims the benefit of and priority to U.S. patent application Ser. No. 17/225,968, filed Apr. 8, 2021; U.S. patent application Ser. No. 17/218,329, filed Mar. 31, 2021; U.S. patent application Ser. No. 17/162,903, filed Jan. 29, 2021; International Patent Application PCT/CA20201050588 filed May 1, 2020; U.S. Provisional Patent Application No. 62/842,696; filed on May 3, 2019; and U.S. Provisional Patent Application No. 63/011,508 filed Apr. 17, 2020; the contents of which are hereby incorporated by reference.
| Number | Date | Country | |
|---|---|---|---|
| 62842696 | May 2019 | US | |
| 63011508 | Apr 2020 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 17225968 | Apr 2021 | US |
| Child | 18336432 | US | |
| Parent | 17218329 | Mar 2021 | US |
| Child | 17225968 | US | |
| Parent | 17162903 | Jan 2021 | US |
| Child | 17218329 | US | |
| Parent | PCT/CA2020/050588 | May 2020 | US |
| Child | 17162903 | US |
