Faculty of Medicine, School of Pharmacy, Institute of Drug Research, The Hebrew University of Jerusalem, Jerusalem, Israel.
David R. Bloom Center for Pharmacy, The Hebrew University of Jerusalem, Jerusalem, Israel.
Epilepsia. 2020 Jun;61(6):1082-1089. doi: 10.1111/epi.16542. Epub 2020 May 26.
Four pivotal randomized placebo-controlled trials have demonstrated that adjunctive therapy with cannabidiol (CBD) improves seizure control in patients with Dravet syndrome (DS) and Lennox-Gastaut syndrome (LGS). Between 47% and 68% of patients allocated to CBD treatment in these trials were receiving clobazam (CLB), which shows complex interactions with CBD resulting, in particular, in a 3.4- to 5-fold increase in plasma concentration of the active metabolite norclobazam. This raises concern as to the role played by these interactions in determining the reduction in seizure frequency in CBD-treated patients, and the question of whether CBD per se has clinically evident antiseizure effects. We appraised available evidence on the clinical consequences of the CBD-CLB interaction, focusing on subgroup analyses of seizure outcomes in patients on and off CLB comedication in the pivotal CBD trials, as provided by the European Medicines Agency Public Assessment Report. Evaluation of the results of individual trials clearly showed that improvement in seizure control over placebo was greater when CBD was added on to CLB than when it was added on to other medications. However, seizure control was also improved in patients off CLB, and despite the small sample size the difference vs placebo was statistically significant for the 10 mg/kg/d dose in one of the two LGS trials. Stronger evidence for an antiseizure effect of CBD independent of an interaction with CLB emerges from meta-analyses of seizure outcomes in the pooled population of LGS and DS patients not receiving CLB comedication. Although these results need to be interpreted taking into account methodological limitations, they provide the best clinical evidence to date that CBD exerts therapeutic effects in patients with epilepsy that are independent of its interaction with CLB. Greater antiseizure effects, and a greater burden of adverse effects, are observed when CBD is combined with CLB.
四项关键性的随机安慰剂对照试验表明,辅助使用大麻二酚(CBD)可改善德拉维氏综合征(DS)和 Lennox-Gastaut 综合征(LGS)患者的癫痫发作控制情况。在这些试验中,接受 CBD 治疗的患者中有 47%至 68%正在接受氯巴占(CLB)治疗,这表明 CBD 与 CLB 之间存在复杂的相互作用,特别是导致活性代谢物去甲氯巴占的血浆浓度增加 3.4 至 5 倍。这引发了人们对这些相互作用在确定 CBD 治疗患者癫痫发作频率降低中所起作用的关注,以及 CBD 本身是否具有明显的抗癫痫作用的问题。我们评估了关于 CBD-CLB 相互作用的临床后果的现有证据,重点分析了欧洲药品管理局公共评估报告中提供的关键 CBD 试验中接受和不接受 CLB 共用药的患者的癫痫发作结局亚组分析。对各个试验结果的评估清楚地表明,当 CBD 与 CLB 联合使用时,与安慰剂相比,对癫痫发作的控制改善程度大于当 CBD 与其他药物联合使用时。然而,在停用 CLB 的患者中,癫痫发作控制也得到了改善,尽管样本量较小,但在两项 LGS 试验中的一项中,对于 10mg/kg/d 剂量,与安慰剂相比差异具有统计学意义。从未接受 CLB 共用药的 LGS 和 DS 患者的汇总人群中进行的关于癫痫发作结局的荟萃分析为 CBD 具有独立于与 CLB 相互作用的抗癫痫作用提供了更强的证据。当 CBD 与 CLB 联合使用时,观察到更强的抗癫痫作用和更大的不良反应负担。