Author Topic: (AAN) Beyond MS, cannabis unproven in neurology  (Read 104 times)

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Offline agate

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(AAN) Beyond MS, cannabis unproven in neurology
« on: April 29, 2014, 02:50:46 pm »
Selected abstracts from the AAN conference, currently ongoing, will be posted soon. The article below is from MedPage Today, April 29, 2014:

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AAN: Beyond MS, Cannabis Unproven in Neurology


By John Gever, Deputy Managing Editor, MedPage Today

Reviewed by F. Perry Wilson, MD, MSCE; Instructor of Medicine, Perelman School of Medicine at the University of Pennsylvania

...

PHILADELPHIA -- Marijuana has no proven benefit for any neurological disorder other than multiple sclerosis (MS) but does have significant adverse effects, an American Academy of Neurology evidence review found.

For the most part, the lack of documented efficacy is because cannabis has not yet been tested rigorously -- or at all -- as therapy for such conditions, according to the review by Barbara Koppel, MD, of New York Medical College in New York City, and other members of the AAN's guideline development panel.

The review was published in the AAN's flagship journal Neurology in conjunction with the group's annual meeting here. It was also endorsed by the American Epilepsy Society, the American Autonomic Society, and the International Rett Syndrome Foundation.

At an AAN press conference, Koppel observed that marijuana is seldom prescribed, "but it may be overused -- people are still using it on their own."

She also noted that patients obtaining cannabis products from dispensaries where medical uses are legal don't typically get specific advice from their physicians, and hence the AAN review did not address it specifically.

She said the physician's role in those states is to certify that patients have a condition listed by the state as a qualification for medical marijuana treatment; detailed consultations on what specific product to buy is left to dispensary staff.

As such, "that's totally out of the purview of this review," Koppel said.

Added fellow panel member Gary Gronseth, MD, of the University of Kansas Medical Center in Kansas City, "When we say that there's insufficient information or insufficient evidence that [something] is effective for a condition, that's not the same thing as saying that there's evidence that it's not effective for that condition."

In March, the committee's findings on marijuana and associated products as treatments for various aspects of MS were published as a separate guideline. As is clear from the new review, the evidence base for those applications is much more extensive than for use in other conditions.

For MS, the panel found strong evidence that some cannabis products improve subjective perceptions of spasticity and spasticity-associated pain and may also improve some bladder problems.

But in addition to applications in MS, the panel also examined several other conditions for which cannabis products have reportedly been used. Primarily these have been those marked by involuntary movements, including Huntington's disease, Tourette syndrome tics, cervical dystonia, and levodopa-triggered dyskinesias in Parkinson's disease. The committee also analyzed the evidence that cannabis products may reduce seizure frequency in epilepsy.

The potential use of cannabinoids for other conditions was not covered in the guideline because the panel found no evidence of any kind to review.

There was not much to analyze for any condition other than MS, it turned out.

Koppel and colleagues identified a single high-quality trial of the cannabis derivative nabilone for Huntington's disease, one study of cannabidiol for levodopa-related dyskinesia, and none for Tourette syndrome, cervical dystonia, or epilepsy. The panel did consider seven other studies of lesser quality.

The bottom line for each condition studied:

~Huntington's disease: insufficient evidence (with 52 patients total, the two available studies were underpowered to determine efficacy)

~Levodopa-related dyskinesia: moderate evidence that an oral cannabis extract is ineffective

~Tourette syndrome tics: insufficient evidence

~Cervical dystonia: insufficient evidence

~Epilepsy: insufficient evidence

On the other hand, Koppel and colleagues were persuaded that cannabis products have enough adverse effects to cause clinical concern, although this was not shown in rigorous studies.

Their meta-analysis of placebo-controlled studies involving a total of some 3,000 patients showed that three times as many treated with cannabinoids stopped because of adverse effects compared with controls. But those studies were mostly vague on the causes for discontinuations.

Nevertheless, Koppel and colleagues referred to other analyses "outside of treatment trials" that identified increases in cognitive impairment.

"Some patients who have neurological conditions may have preexisting cognitive dysfunction, which may increase their susceptibility to cannabinoids' toxicities," they wrote in the guideline.

Of particular concern was a report of four seizures in an MS trial conducted in Great Britain involving more than 600 patients, Koppel said at the press conference. Two were in patients with no previous seizure history, and the trial investigators indicated that they were at least possibly medication-related.

Suicidality has also been reported in trial data, the panel found. "It is especially concerning that a medication that may have an adverse effect of suicide may be prescribed in a population such as patients with MS who are already at increased suicide risk," they wrote.

Not surprisingly, the committee called for randomized trials to provide better evidence both for the possible utility of cannabis products for neurological conditions as well as for the risks.

"There's a place for it [medical marijuana in neurology] and more work is going to need to be done to figure out exactly where," said Koppel.

The work had no commercial funding. All guideline authors disclosed that they had no relevant relationships with industry.

______
Primary source: Neurology

Source reference: Koppel B, et al "Systematic review: Efficacy and safety ofmedical marijuana in selected neurologic disorders: Report of the Guideline Development Subcommittee of the American Academy of Neurology" Neurology 2014; 82: 1556-63.

The entire article can be seen here.
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SPMS, diagnosed 1980. Avonex 2001-2004. Copaxone 2007-2010. Glatopa (glatiramer acetate 40mg 3 times/week) since 12/16/20.

Offline agate

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From MS Discovery, May 14, 2014:

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AAN Review Supports Treating Symptoms of MS with Cannabis

A review of the literature conducted by the American Academy of Neurology supports the use of cannabis to treat some symptoms of MS, including spasticity, pain related to spasticity, overactive bladder, and painful burning and numbness

LISA J. BAIN

A review of available scientific research conducted by the American Academy of Neurology, published in Neurology and presented at the AAN Annual Meeting in Philadelphia, found that certain forms (oral and spray) of cannabis can help treat some symptoms of MS, particularly spasticity, pain related to spasticity, overactive bladder, and painful burning and numbness (Koppel et al., 2014).
 
Barbara S. Koppel, M.D., a neurologist at New York Medical College in New York, and Gary Gronseth, M.D., a neurologist at the University of Kansas Medical Center in Kansas City, discussed the findings at a press conference on April 28, 2014. 
 
Their review included studies of multiple formulations of cannabinoids, including oral forms and a mucosal spray. Two studies in MS patients of smoked marijuana, which the review called “the most familiar form of cannabis,” were also included, although the review concluded that there was insufficient evidence to determine efficacy. Dr. Gronseth noted, however, that “when we say there is insufficient information or evidence to indicate that it’s effective for a condition, that’s not the same thing as saying it’s not effective for that condition.”
 
While Cannabis sativa, Cannabis indica, and hybrid strains of the plant contain some 60 pharmacologically active compounds, the oral and spray forms included in the review contain only one or two: Δ9-tetrahydrocannabinol (THC), which is responsible for psychoactive effects, and/or cannabidiol (CBD), which is nonpsychoactive. Only two oral forms—dronabinol (Marinol) and nabilone (Cesamet), both synthetic forms of THC—have received FDA approval and only for the treatment of chemotherapy-related nausea and vomiting or loss of appetite and weight loss in people with AIDS. Nabiximols (Sativex), an oromucosal spray containing a 1:1 ratio of THC and CBD, has been approved in Canada and much of Europe for the treatment of MS-related spasticity.
 
Whether the AAN review will influence prescribing practices of physicians is unknown. Stanley Cohan, M.D., Ph.D., a neurologist and medical director of the Providence Multiple Sclerosis Center in Portland, Oregon, told MSDF that physicians face a conundrum with regard to prescribing cannabis since their narcotics licenses are issued by the federal government, which classifies marijuana and its cannabinoids in Schedule 1, a designation for drugs including heroin and LSD that have high abuse potential and no accepted medical uses. “Until the legal landscape is clarified, I think there will be a limit to its use,” he said. With regard to the FDA-approved forms, Cohan said they are very expensive and most insurance companies will not pay for them. Moreover, he said most patients prefer natural marijuana.
 
Koppel said the review “highlights the need for more high-quality research studies of the long-term efficacy and safety of the use of medical marijuana in neurologic illnesses.” For people who advocate increased use of medical marijuana, Dr. Koppel had this advice: “The best way to find answers in the future is to be a participant in these kinds of trials.”
 
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Disclosures and sources of funding

Dr. Koppel and Dr. Gronseth report no disclosures relevant to the review. The review was funded by the American Academy of Neurology. Dr. Cohan has received personal compensation for activities with Acorda Therapeutics, Biogen Idec, Novartis, and Sanofi-Aventis Pharmaceuticals Inc. Dr. Cohan has received research support from Biogen Idec, Novartis, Sanofi-Aventis Pharmaceuticals Inc., Roche Diagnostics Corporation, and Opexa.
MS Speaks--online for 17 years

SPMS, diagnosed 1980. Avonex 2001-2004. Copaxone 2007-2010. Glatopa (glatiramer acetate 40mg 3 times/week) since 12/16/20.