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      Dose-Ranging Effect of Adjunctive Oral Cannabidiol vs Placebo on Convulsive Seizure Frequency in Dravet Syndrome : A Randomized Clinical Trial

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          Abstract

          This randomized clinical trial evaluates the efficacy and safety of 2 doses of a pharmaceutical formulation of cannabidiol vs placebo for adjunctive treatment of convulsive seizures in patients with Darvet syndrome.

          Key Points

          Question

          Is adjunctive cannabidiol at doses of 10 and 20 mg/kg/d superior to placebo in reducing convulsive seizure frequency in patients with Dravet syndrome?

          Findings

          This double-blind clinical trial randomized 199 children with Dravet syndrome to cannabidiol (10 or 20 mg/kg/d) or matched placebo for 14 weeks. Convulsive seizure frequency compared with baseline was reduced by 48.7% in the 10-mg/kg/d cannabidiol group and 45.7% in the 20-mg/kg/d cannabidiol group vs 26.9% in the placebo group.

          Meaning

          Both doses of adjunctive cannabidiol were similarly efficacious in reducing convulsive seizures associated with Dravet syndrome.

          Abstract

          Importance

          Clinical evidence supports effectiveness of cannabidiol for treatment-resistant seizures in Dravet syndrome, but this trial is the first to evaluate the 10-mg/kg/d dose.

          Objective

          To evaluate the efficacy and safety of a pharmaceutical formulation of cannabidiol, 10 and 20 mg/kg/d, vs placebo for adjunctive treatment of convulsive seizures in patients with Dravet syndrome.

          Design, Setting, and Participants

          This double-blind, placebo-controlled, randomized clinical trial (GWPCARE2) recruited patients from April 13, 2015, to November 10, 2017, with follow-up completed on April 9, 2018. Of 285 patients screened from 38 centers in the United States, Spain, Poland, the Netherlands, Australia, and Israel, 86 were excluded, and 199 were randomized. Patients were aged 2 to 18 years with a confirmed diagnosis of Dravet syndrome and at least 4 convulsive seizures during the 4-week baseline period while receiving at least 1 antiepileptic drug. Data were analyzed from November 16 (date of unblinding) to December 13 (date of final outputs), 2018, based on intention to treat and per protocol.

          Interventions

          Patients received cannabidiol oral solution at a dose of 10 or 20 mg/kg per day (CBD10 and CBD20 groups, respectively) or matched placebo in 2 equally divided doses for 14 weeks. All patients, caregivers, investigators, and individuals assessing data were blinded to group assignment.

          Main Outcomes and Measures

          The primary outcome was change from baseline in convulsive seizure frequency during the treatment period. Secondary outcomes included change in all seizure frequency, proportion with at least a 50% reduction in convulsive seizure activity, and change in Caregiver Global Impression of Change score.

          Results

          Of 198 eligible patients (mean [SD] age, 9.3 [4.4] years; 104 female [52.5%]), 66 were randomized to the CBD10 group, 67 to the CBD20 group, and 65 to the placebo group, and 190 completed treatment. The percentage reduction from baseline in convulsive seizure frequency was 48.7% for CBD10 group and 45.7% for the CBD20 group vs 26.9% for the placebo group; the percentage reduction from placebo was 29.8% (95% CI, 8.4%-46.2%; P = .01) for CBD10 group and 25.7% (95% CI, 2.9%-43.2%; P = .03) for the CBD20 group. The most common adverse events were decreased appetite, diarrhea, somnolence, pyrexia, and fatigue. Five patients in the CBD20 group discontinued owing to adverse events. Elevated liver transaminase levels occurred more frequently in the CBD20 (n = 13) than the CBD10 (n = 3) group, with all affected patients given concomitant valproate sodium.

          Conclusions and Relevance

          Adjunctive cannabidiol at doses of 10 and 20 mg/kg/d led to similar clinically relevant reductions in convulsive seizure frequency with a better safety and tolerability profile for the 10-mg/kg/d dose in children with treatment-resistant Dravet syndrome. Dose increases of cannabidiol to greater than 10 mg/kg/d should be tailored to individual efficacy and safety.

          Trial Registration

          ClinicalTrials.gov Identifier: NCT02224703

          Related collections

          Most cited references26

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          World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects.

          (2013)
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            A new method for measuring daytime sleepiness: the Epworth sleepiness scale.

            The development and use of a new scale, the Epworth sleepiness scale (ESS), is described. This is a simple, self-administered questionnaire which is shown to provide a measurement of the subject's general level of daytime sleepiness. One hundred and eighty adults answered the ESS, including 30 normal men and women as controls and 150 patients with a range of sleep disorders. They rated the chances that they would doze off or fall asleep when in eight different situations commonly encountered in daily life. Total ESS scores significantly distinguished normal subjects from patients in various diagnostic groups including obstructive sleep apnea syndrome, narcolepsy and idiopathic hypersomnia. ESS scores were significantly correlated with sleep latency measured during the multiple sleep latency test and during overnight polysomnography. In patients with obstructive sleep apnea syndrome ESS scores were significantly correlated with the respiratory disturbance index and the minimum SaO2 recorded overnight. ESS scores of patients who simply snored did not differ from controls.
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              ILAE classification of the epilepsies: Position paper of the ILAE Commission for Classification and Terminology

              The International League Against Epilepsy (ILAE) Classification of the Epilepsies has been updated to reflect our gain in understanding of the epilepsies and their underlying mechanisms following the major scientific advances that have taken place since the last ratified classification in 1989. As a critical tool for the practicing clinician, epilepsy classification must be relevant and dynamic to changes in thinking, yet robust and translatable to all areas of the globe. Its primary purpose is for diagnosis of patients, but it is also critical for epilepsy research, development of antiepileptic therapies, and communication around the world. The new classification originates from a draft document submitted for public comments in 2013, which was revised to incorporate extensive feedback from the international epilepsy community over several rounds of consultation. It presents three levels, starting with seizure type, where it assumes that the patient is having epileptic seizures as defined by the new 2017 ILAE Seizure Classification. After diagnosis of the seizure type, the next step is diagnosis of epilepsy type, including focal epilepsy, generalized epilepsy, combined generalized, and focal epilepsy, and also an unknown epilepsy group. The third level is that of epilepsy syndrome, where a specific syndromic diagnosis can be made. The new classification incorporates etiology along each stage, emphasizing the need to consider etiology at each step of diagnosis, as it often carries significant treatment implications. Etiology is broken into six subgroups, selected because of their potential therapeutic consequences. New terminology is introduced such as developmental and epileptic encephalopathy. The term benign is replaced by the terms self-limited and pharmacoresponsive, to be used where appropriate. It is hoped that this new framework will assist in improving epilepsy care and research in the 21st century.

                Author and article information

                Journal
                JAMA Neurol
                JAMA Neurol
                JAMA Neurology
                American Medical Association
                2168-6149
                2168-6157
                May 2020
                2 March 2020
                11 May 2020
                2 March 2020
                : 77
                : 5
                : 1-10
                Affiliations
                [1 ]Department of Neurology, Nicklaus Children’s Hospital, Miami, Florida
                [2 ]Epilepsy Research Centre, The University of Melbourne at Austin Health and the Royal Children’s Hospital, Melbourne, Victoria, Australia.
                [3 ]Florey Institute, Melbourne, Victoria, Australia.
                [4 ]Murdoch Children’s Research Institute, Melbourne, Victoria, Australia.
                [5 ]Stichting Epilepsie Instellingen Nederland, Zwolle, the Netherlands
                [6 ]Pediatric Neurology Unit, Clínica Universidad de Navarra, Navarra Institute for Health Research, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
                [7 ]Department of Neurology, Hospital Ruber Internacional, Madrid, Spain
                [8 ]Jane and John Justin Neurosciences Center, Cook Children’s Medical Center, Ft Worth, Texas
                [9 ]Neuroscience Institute, Division of Pediatric Neurology, Department of Neurology, Seattle Children’s Hospital and University of Washington, Seattle
                [10 ]GW Research, Ltd, Cambridge, United Kingdom
                [11 ]Greenwich Biosciences, Inc, Carlsbad, California
                Author notes
                Article Information
                Group Information: A list of the GWPCARE2 Study Group members appear at the end of the article.
                Accepted for Publication: January 9, 2020.
                Published Online: March 2, 2020. doi:10.1001/jamaneurol.2020.0073
                Correction: This article was corrected on May 11, 2020, to fix the spelling of collaborator Katherine Moretz, MD’s name, which had been incorrectly given as Katherine Mortez in the Group Members section.
                Open Access: This is an open access article distributed under the terms of the CC-BY-NC-ND License. © 2020 Miller I et al. JAMA Neurology.
                Corresponding Authors: Ian Miller, MD, Department of Neurology, Nicklaus Children’s Hospital, 3200 SW 60th Ct, Ste 302, Miami, FL 33155 ( ian.miller@ 123456mchdocs.com ); Ingrid E. Scheffer, MBBS, PhD, FRS, Epilepsy Research Centre, 245 Burgundy St, Heidelberg, Victoria 3084, Australia ( i.scheffer@ 123456unimelb.edu.au ).
                Author Contributions: Mr Checketts had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
                Concept and design: Miller, Gil-Nagel.
                Acquisition, analysis, or interpretation of data: All authors.
                Drafting of the manuscript: Miller, Saneto, Dunayevich, Knappertz.
                Critical revision of the manuscript for important intellectual content: All authors.
                Statistical analysis: Checketts.
                Administrative, technical, or material support: Scheffer, Perry, Dunayevich.
                Supervision: Miller, Scheffer, Gunning, Sanchez-Carpintero, Gil-Nagel, Perry, Dunayevich, Knappertz.
                Conflict of Interest Disclosures: Dr Miller reported receiving grants and other compensation from Greenwich Biosciences during the conduct of the study and grants, personal fees, and other compensation from Greenwich Biosciences, nonfinancial support and other compensation from Dravet Syndrome Foundation, grants and nonfinancial support from Insys Pharmaceuticals, personal fees and nonfinancial support from BioMarin Pharmaceutical, Inc, and Upshire-Smith Laboratories, LLC, and grants, personal fees, and nonfinancial support from Zogenix, Inc, outside the submitted work. Dr Scheffer reported receiving other compensation from GW Pharmaceuticals during the conduct of the study; other from Zynerba Pharmaceuticals, Inc, Zogenix, Inc, Ovid Therapeutics, Inc, Marinus, and Ultragenyx Pharmaceutical, Inc, personal fees and other compensation from UCB, personal fees from GlaxoSmithKline, Eisai Co, Ltd, BioMarin Pharmaceutical, Inc, Nutricia, and Xenon Pharmaceuticals, outside the submitted work; a patent to WO06/133508 issued; and research funding from the National Health and Medical Research Council, Health Research Council of New Zealand, and National Institutes of Health. Dr Gunning reported serving on scientific advisory boards of GW Pharmaceuticals, Zogenix, Inc, and Ovid Therapeutics, Inc/Takeda Pharmaceutical Company Limited; serving on the speaker’s bureau for LivaNova plc; and serving as the principal investigator for trials sponsored by GW Research, Ltd, and Zogenix, Inc. Dr Sanchez-Carpintero reported receiving research support from GW Pharmaceuticals and Zogenix for clinical trials; serving on advisory boards for Novartis International AG, GW Pharmaceuticals, and Zogenix, Inc; and serving as a trial investigator for GW Research, Ltd and Ovid Therapeutics, Inc/Takeda Pharmaceutical Company Limited. Dr Gil-Nagel reported serving as an investigator, speaker, and advisory board member for Bial, Eisai Co, Ltd, Esteve, UCB, GW Pharmaceuticals, GW Research, Ltd, Zogenix, Inc, Stoke Therapeutics, Sanofi, and Arvelle Therapeutics. Dr Perry reported participating on advisory boards for Upsher-Smith Laboratories, LLC, and Zogenix, Inc, as a consultant for Encoded Therapeutics, Inc, and as a trial investigator for GW Research, Ltd, and Zogenix, Inc. Dr Saneto reported serving as a principal investigator on the GW Research, Ltd, trials for Dravet Syndrome Foundation and TSC; on the data safety monitoring board for a clinical study sponsored by Reata Pharmaceuticals for Friedreich ataxia; as principal investigator on a study sponsored by Stealth Pharmaceutical for primary mitochondrial myopathy; as principal investigator on a study sponsored by Zogenix, Inc, in patients with Dravet syndrome; and on the speaker’s bureau for GW Pharmaceuticals. No other disclosures were reported.
                Funding/Support: This study was supported by GW Research, Ltd.
                Role of the Funder/Sponsor: The sponsor was responsible for the design and conduct of the study. The sponsor was involved with the collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
                Group Members: The following investigators are members of the GWPCARE2 Study Group: Gregory Barnes, MD, University of Louisville Autism Center, Louisville, Kentucky; Hari Bhathal, MD, Neurocenter Barcelona, Centro Médico Teknon, Barcelona, Spain; Verónica Cantarín-Extremera, MD, Neuropediatrics, Hospital Universitario Niño Jesús, Madrid, Spain; Michael G. Chez, MD, Sutter Medical Group, Neuroscience, Roseville, California; Dave F. Clarke, MD, Dell Medical School at University of Texas, Austin; Aviva Fattal-Valevski, MD, Department of Pediatric Neurology, Dana-Dwek Children’s Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Michael Frost, MD, Minnesota Epilepsy Group, St Paul; Antonio Gil-Nagel, MD, PhD, Hospital Ruber Internacional, Madrid, Spain; Monisha Goyal, MD, Department of Pediatrics, University of Alabama, Birmingham; Robert S. Greenwood, MD, Department of Neurology, University of North Carolina School of Medicine, Chapel Hill; Boudewijn Gunning, MD, Stichting Epilepsie Instellingen Nederland, Zwolle, the Netherlands; Jonathan J. Halford, MD, Medical University of South Carolina, Charleston; Julián Lara Herguedas, MD, Neuropediatrics Unit, Pediatrics Unit, Puerta de Hierro, Majadahonda Hospital, Madrid, Spain; Gregory L. Holmes, MD, Department of Neurological Sciences, University of Vermont College of Medicine, Burlington; Siddharth Kapoor, MD, University of Kentucky College of Medicine, Lexington; Katarzyna Kotulska, MD, The Children’s Memorial Health Institute, Warsaw, Poland; Linda Laux, MD, Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern Feinberg School of Medicine, Chicago, Illinois; Annick Laridon, MD, Epilepsy Centre for Children and Youth Pulderbos, Zanhoven, Belgium; John A. Lawson, MBBS, Sydney Childrens Hospital, Randwick, Syndney, Australia; Paul D. Lyons, MD, Virginia Comprehensive Epilepsy Program at Winchester Medical School, Winchester; Jennifer Madan Cohen, MD, Connecticut Children’s Medical Center and University of Connecticut School of Medicine, Hartford; Deepak Madhavan, MD, Boys Town National Research Hospital, Boys Town, Nebraska; Eric D. Marsh, MD, Departments of Neurology and Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia; Maria Mazurkiewicz-Beldzinska, MD, Medical University of Gdańsk, Gdańsk, Poland; Ian Miller, MD, Nicklaus Children’s Hospital, Miami, Florida; Wendy G. Mitchell, MD, Children’s Hospital of Los Angeles, Los Angeles, California; Krystyna Mitosek-Szewczyk, MD, Department of Pediatric Neurology, Medical University of Lublin, Lublin, Poland; David B. Moore, MD, McFarland Clinic, Ames, Iowa; Richard P. Morse, MD, Department of Neurology and Pediatrics, Children’s Hospital at Dartmouth-Hitchcock, Lebanon, New Hampshire; Katherine Moretz, MD, Memorial Health University Medical Center, Savannah, Georgia; Lawrence Morton, MD, Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia; M. Scott Perry, MD, Cook Children’s Medical Center, Fort Worth, Texas; Lukasz Przyslo, MD, PhD, Department of Neurology, Research Institute of Polish Mother’s Memorial Hospital, Lodz, Poland; Colin Roberts, MD, Doernbecher Childhood Epilepsy Program, Oregon Health and Science University, Portland; William E. Rosenfeld, MD, The Comprehensive Epilepsy Care Center for Children and Adults, St Louis, Missouri; Russell P. Saneto, DO, PhD, Seattle Children’s Hospital/University of Washington and the Neuroscience Institute, Seattle; Rocio Sanchez-Carpintero, MD, Clínica Universidad de Navarra, Pediatric Neurology Unit and IdiSNA, Navarra Institute for Health Research, Pamplona, Spain; Ingrid E. Scheffer, MBBS, PhD, FRS, University of Melbourne, Austin Health, The Royal Children’s Hospital, Florey Institute and Murdoch Children’s Research Institute, Melbourne, Australia; Eric Segal, MD, Hackensack University Medical Center, Hackensack Meridian School of Medicine, Hackensack, New Jersey; Gregory B. Sharp, MD, Arkansas Children’s Hospital/University of Arkansas for Medical Sciences, Little Rock; Juan R. Uranga, MD, Clínica Plaza de las Monjas, Huelva, Spain; Vicente Villanueva, MD, Refractory Epilepsy Unit, Neurology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain; Arie Weinstock, MD, Jacobs School of Medicine and Biomedical Sciences, Oishei Children’s Outpatient Center, Buffalo, New York; Bruria Ben Zeev, MD, Department of Pediatric Neurology, Dana-Dwek Children’s Hospital Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; and Marta Żołnowska, MD, Centrum Medyczne Plejady, Kraków, Poland.
                Meeting Presentations: Data from this study were previously presented at the American Academy of Neurology annual meeting; May 7, 2019; Philadelphia, Pennsylvania; the 33rd International Epilepsy Congress; June 24, 2019; Bankok, Thailand; and the Child Neurology Society annual meeting; October 24 and 25, 2019; Charlotte, North Carolina.
                Data Sharing Statement: See Supplement 3.
                Additional Contributions: We thank the patients, their families, and the study sites that participated in this trial. Scott Polen, BA, Greenwich Biosciences, Inc, contributed as the clinical study manager; Kevan VanLandingham, MD, PhD, Greenwich Biosciences, Inc, contributed to the study design and interpretation of the data; Kenneth Sommerville, MD, PhD, Greenwich Biosciences, Inc, contributed to the study design; and Stephen Wright, MA, MD, FRCP, GW Research, Ltd, contributed to the study design. Medical writing support was provided to the authors by Keira Kim, BS, Greenwich Biosciences, Inc, and Lauren Whyte, PhD, GW Research, Ltd, at the time the work was completed. None of these contributors received any compensation other than salary as employees.
                Article
                noi200003
                10.1001/jamaneurol.2020.0073
                7052786
                32119035
                2925839c-4023-4436-89e0-bc0a51a6fb73
                Copyright 2020 Miller I et al. JAMA Neurology.

                This is an open access article distributed under the terms of the CC-BY-NC-ND License.

                History
                : 17 September 2019
                : 9 January 2020
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