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Cannabidiol (CBD)

Table of Contents

What is Cannabidiol

Cannabidiol (CBD) is a phytocannabinoid discovered in 1940. It is one of 113 identified cannabinoids in cannabis plants and accounts for up to 40% of the plant’s extract.[7] In 2018, clinical research on cannabidiol included preliminary studies of anxiety, cognition, movement disorders, and pain.[8]

Cannabidiol can be taken into the body in multiple ways, including by inhalation of cannabis smoke or vapor, as an aerosol spray into the cheek, and by mouth. It may be supplied as CBD oil containing only CBD as the active ingredient (no included tetrahydrocannabinol [THC] or terpenes), a full-plant CBD-dominant hemp extract oil, capsules, dried cannabis, or as a prescription liquid solution.[2] CBD does not have the same psychoactivity as THC,[9][10] and may change the effects of THC on the body if both are present.[7][8][9][11] As of 2018, the mechanism of action for its biological effects has not been determined.[8][9]

In the United States, the cannabidiol drug Epidiolex was approved by the Food and Drug Administration in 2018 for the treatment of two epilepsy disorders.[12] Since cannabis is a Schedule I controlled substance in the United States,[13] other CBD formulations remain illegal to prescribe for medical use or to use as an ingredient in foods or dietary supplements.[14]

Medical uses

Epilepsy

See also: Charlotte’s web (cannabis)

There has been little high-quality research into the use of cannabidiol for epilepsy. The limited available evidence primarily focuses on refractory epilepsy in children.[15] Using medical-grade cannabidiol in combination with conventional medication has shown some promise for reducing seizure frequency and improving quality of life.[15] While cannabidiol treatment is generally well tolerated, it is also associated with some minor adverse effects.[15]

In the United States, the cannabidiol drug Epidiolex was approved by the Food and Drug Administration (FDA) in 2018 for treatment of epilepsy associated with Lennox–Gastaut syndrome or Dravet syndrome in patients 2 years of age and older.[2][12]

Other uses

Preliminary research on other possible therapeutic uses for cannabidiol include several neurological disorders, but the findings have not been confirmed by sufficient high-quality clinical research to establish such uses in clinical practice.[6][9][16][17][18] In October 2019, the FDA issued an advisory warning that the effects of CBD during pregnancy or breastfeeding are unknown, indicating that the safety, doses, interactions with other drugs or foods, and side effects of CBD are not clinically defined, and may pose a risk to the mother and infant.[19]

Side effects

Preliminary research indicates that cannabidiol may reduce adverse effects of THC, particularly those causing intoxication and sedation, but only at high doses.[20] Safety studies of cannabidiol showed it is well tolerated, but may cause tiredness, diarrhea, or changes in appetite as common adverse effects.[21] Epidiolex documentation lists sleepiness, insomnia and poor quality sleep, decreased appetite, diarrhea, and fatigue.[2]

Potential interactions

Laboratory evidence indicated that cannabidiol may reduce THC clearance, increasing plasma concentrations which may raise THC availability to receptors and enhance its effect in a dose-dependent manner.[22][23] In vitro, cannabidiol inhibited receptors affecting the activity of voltage-dependent sodium and potassium channels, which may affect neural activity.[24] A small clinical trial reported that CBD partially inhibited the CYP2C-catalyzed hydroxylation of THC to 11-OH-THC.[25] Little is known about potential drug interactions, but CBD-mediates a decrease in clobazam metabolism.[26]

Pharmacology

Pharmacodynamics

Cannabidiol has low affinity for the cannabinoid CB1 and CB2 receptors,[27][28] although it can act as an antagonist of CB1/CB2 agonists despite this low affinity.[28] Cannabidiol may be an antagonist of GPR55, a G protein-coupled receptor and putative cannabinoid receptor that is expressed in the caudate nucleus and putamen in the brain.[29] It also may act as an inverse agonist of GPR3, GPR6, and GPR12.[30] CBD has been shown to act as a serotonin 5-HT1A receptor partial agonist.[31] It is an allosteric modulator of the μ- and δ-opioid receptors as well.[32] The pharmacological effects of CBD may involve PPARγ agonism and intracellular calcium release.[7]

Pharmacokinetics

The oral bioavailability of CBD is approximately 6% in humans, while its bioavailability via inhalation is 11 to 45% (mean 31%).[4][5] The elimination half-life of CBD is 18–32 hours.[6] Cannabidiol is metabolized in the liver as well as in the intestines by CYP2C19 and CYP3A4 enzymes, and UGT1A7, UGT1A9, and UGT2B7 isoforms.[2] CBD may have a wide margin in dosing.[17]

Pharmaceutical preparations

Nabiximols (brand name Sativex), a patented medicine containing CBD and THC in equal proportions, was approved by Health Canada in 2005 to treat central neuropathic pain in multiple sclerosis, and in 2007 for cancer-related pain.[33] In New Zealand, Sativex is “approved for use as an add-on treatment for symptom improvement in people with moderate to severe spasticity due to multiple sclerosis who have not responded adequately to other anti-spasticity medication.”[34]

Epidiolex is an orally administered cannabidiol solution. It was approved in 2018 by the US Food and Drug Administration for treatment of two rare forms of childhood epilepsy, Lennox-Gastaut syndrome and Dravet syndrome.[12][14]

Chemistry

Cannabidiol is insoluble in water but soluble in organic solvents such as pentane. At room temperature, it is a colorless crystalline solid.[35] In strongly basic media and the presence of air, it is oxidized to a quinone.[36] Under acidic conditions it cyclizes to THC,[37] which also occurs during pyrolysis (smoking).[38] The synthesis of cannabidiol has been accomplished by several research groups.[39][40][41]

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