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• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/658—Medicinal preparations containing organic active ingredients o-phenolic cannabinoids, e.g. cannabidiol, cannabigerolic acid, cannabichromene or tetrahydrocannabinol
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K36/00—Medicinal preparations of undetermined constitution containing material from algae, lichens, fungi or plants, or derivatives thereof, e.g. traditional herbal medicines
  • A61K36/18—Magnoliophyta (angiosperms)
  • A61K36/185—Magnoliopsida (dicotyledons)
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/0012—Galenical forms characterised by the site of application
  • A61K9/0019—Injectable compositions; Intramuscular, intravenous, arterial, subcutaneous administration; Compositions to be administered through the skin in an invasive manner
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
  • A61P25/08—Antiepileptics; Anticonvulsants
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
  • A61P25/08—Antiepileptics; Anticonvulsants
  • A61P25/10—Antiepileptics; Anticonvulsants for petit-mal
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
  • A61P25/08—Antiepileptics; Anticonvulsants
  • A61P25/12—Antiepileptics; Anticonvulsants for grand-mal
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P43/00—Drugs for specific purposes, not provided for in groups A61P1/00-A61P41/00
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K2121/00—Preparations for use in therapy

Definitions

• This invention relates to the use of one or a combination of phyto-cannabinoids in the treatment of epilepsy and more particularly to the use of tetrahydrocannabivarin (THCV) in the treatment of generalized seizure and / or cannabidiol (CBD) in
• Epilepsy is a chronic neurological disorder presenting a wide spectrum of diseases that affects approximately 50 million people worldwide (Sander, 2003).
• WO 2006/054057 makes reference to the potential use of THCV to treat epilepsy amongst a range of diseases.
• WO2009/007697 discloses formulations containing THCV and CBD.
• Cunha et al (1980) reported a study on 16 grand mal patients who were not doing well on conventional medication. They received their regular medication and either 200-300mg of cannabidiol or a placebo. Of the patients who received CBD, 3 showed complete improvement, 2 partial, 2 minor, while 1 remained unchanged. The only unwanted effect was mild sedation. Of the patients who received the placebo, 1 improved and 7 remained unchanged.
• Trembly et al (1990) reports an open trial with a single patient who was given 900-1200mg of cannabidiol a day for 10 months. This trial showed seizure frequency was markedly reduced in the patient.
• CBD tetrahydrocanibinol
• Neuronal activity is a prerequisite for proper brain function.
• disturbing the excitatory - inhibitory equilibrium of neuronal activity may induce epileptic seizures.
• epileptic seizures can be grouped into two basic categories: partial and generalised seizures. Partial seizures originate in specific brain regions and remain localised - most commonly the temporal lobes (containing the hippocampus), whereas generalised seizures appear in the entire forebrain as a secondary generalisation of a partial seizure (McCormick and Contreras, 2001 , Lutz, 2004).
• the league also categorized generalised seizures into numerous clinical seizure types, some examples of which are outlined below:
• Tonic-clonic seizures often known as "grand mal", are the most frequently encountered of the generalised seizures (Dreifuss et al., 1981 ).
• This generalised seizure type has two stages: tonic muscle contractions which then give way to a clonic stage of convulsive movements. The patient remains unconscious throughout the seizure and for a variable period of time afterwards.
• Atonic seizures are the result of sudden loss of muscle tone to either a specific muscle, muscle group or all muscles in the body (Dreifuss et al., 1981 ).
• cognitive deficits e.g. diminishing ability of neuronal circuits in the hippocampus to learn and store memories
• epilepsy also greatly affects the lifestyle of the sufferer - potentially living in fear of consequential injury (e.g. head injury) resulting from a grand ma/ seizure or the inability to perform daily tasks or the inability to drive a car unless having had a lengthy seizure-free period (Fisher et al., 2000).
• consequential injury e.g. head injury
• THCV tetrahydrocannabivarin
• CBD cannabidiol
• the medicament is to treat clonic and / or tonic seizures.
• the preferred daily dose of THCV is at least 1.5mg, more preferably at least 5mg through 10mg to15mg or more.
• the THCV is used in combination with at least a second
• CBD cannabinoid
• the CBD is preferably present in an amount which will provide a daily dose of at least 400mg, more preferably at least 600mg and as much as 800mg or more, but preferably less than 1200mg.
• the cannabinoids may be present as pure or isolated cannabinoids or in the form of plant extracts. Where a plant extract is used it is preferable that the THC content is less than 5% by weight of the total cannabinoids, more preferably less than 4% through 3%, 2% and 1 %. THC can be selectively removed from extracts using techniques such as chromatography.
• the invention also extends to using a phyto-cannabinoid in the manufacture of a medicament to treat a specific form of epilepsy.
• composition for use in treating generalised seizures and / or partial seizure comprising THCV and or CBD
• composition preferably takes the form of a plant extract containing one or more phytocannabinoids and one or more excipients.
• THCV and / or CBD for use in the manufacture of a medicament for use in the treatment of generalised seizures and / or partial seizure.
• Figure 1 shows latencies to initial and later seizure severities.
• the mean latencies to first myoclonic jerk (FMJ) and scores of 3.5 are shown ⁇ S. E. M. for vehicle or for low, medium or high doses of THCV BDS and 70mg/kg PTZ.
• n 8 - 10;
• Figure 2 shows seizure duration and time to death.
• n 3 - 10 dependent on proportions of animals that died within experimental groups.
• J vehicle group had no deaths and so no value is shown here;
• Figure 4 shows mortality rates. Mortality rates expressed as percentages for animals treated with vehicle or with low, medium or high doses of THCV BDS and
• Figure 5 shows latencies to initial and later seizure severities.
• the mean latencies to first myoclonic jerk (FMJ) and scores of 3.5 are shown ⁇ S. E. M. for vehicle or for low, medium or high doses of THCV BDS and 80mg/kg PTZ.
• n 7 - 10;
• Figure 7 shows median severity scores. Median severity scores for groups of animals treated with vehicle or with low, medium or high doses of THCV BDS prior to
• Figure 9 A-D show PTZ-induced seizure development and duration with pure THCV.
• D shows the mean duration of seizures (s) in animals that survived post-seizure. All values ⁇ S.E.M., * indicates significant difference from vehicle group (P ⁇ 0.05; Mann-Whitney U test);
• Figure 10 A-B show the effect of CBD on PTZ-induced seizures
• B % of vehicle- and CBD-dosed (1 , 10,100mg/kg CBD) animals that experienced tonic-clonic seizures as a result of IP injection of 80mg/kg PTZ. * indicates significant result (p ⁇ 0.01 );
• Figure 1 1 shows the lack of effect of THCV on the percentage mortality.
• Figure 12 shows the lack of effect of THCV on the mean maximum seizure severity. Significance was assessed by 1 -way ANOVA with Tukey's post-hoc test;
• Figure 13 A-D shows the percentage of animals in each group that reached specified seizure states when treated with THCV. Significant differences vs control were assessed using a binomial test. P ⁇ 0.05.
• Figure 14 shows the effect of CBD on the percentage mortality. Significance assessed by binomial test; * shows a significant increase in mortality (P ⁇ 0.05). Note that this effect only appeared at 10 mg/kg and was lost at 100 mg/kg, suggestive of a biphasic effect;
• Figure 15 shows the mean maximum seizure severity. Significance was assessed by 1 -way ANOVA with Tukey's post-hoc test; P>0.5 for all comparisons vs control;
• Figure 16 A-D describes the percentage of animals in each group that reached specified seizure states. Significant differences vs control were assessed using a binomial test. P ⁇ 0.05 ( * ); P ⁇ 0.001 ( *** );
• Figure 17 shows the effects of CBD upon mean tonic-clonic frequency.
• Figure 18 describes the percentage duration of time spent in a tonic-clonic state compared to the total duration of the seizure period. Significance was assessed using a one way ANOVA with Tukey's post-hoc test. P ⁇ 0.05 ( * );
• Figure 19 A-B describes the effects of CBD upon tonic-clonic seizures without postural control.
• A % of animals that experienced tonic-clonic seizures without postural control.
• B frequency with which animals displayed tonic-clonic seizures without postural control in the two hour recording period (or until death).
• A binomial statistical test;
• B one-way ANOVA followed by Tukey test. ** , *** and # indicate p ⁇ 0.01 , 0.001 and 0.1 respectively; and
• Figure 20 A-C describes the effect of CBD on penicillin-induced seizure severity and mortality.
• A Median severity of seizures (grey line), also shown is the 25th and 75th percentiles (black horizontal lines) and the maximum and minimum values (upward and downward error bars respectively).
• B Percentage of animals that remained seizure free throughout.
• C Percentage mortality.
• A one-way ANOVA followed by Tukey test.
• B&C binomial statistical test; * , *** and # indicate p ⁇ 0.05, 0.001 and 0.1.
• mice Male Wistar rats (P24-29; 75-1 10g) were used to assess the effects of the cannabinoids: THCV (BDS and pure) and CBD on the PTZ model of generalised seizures. Animals were habituated to the test environment, cages, injection protocol and handling prior to experimentation. Animals were housed in a room at 21 Q C on a 12 hour light: dark cycle (lights on 0900) in 50% humidity, with free access to food and water.
• THCV BDS and pure
• CBD cannabinoids
• a range of doses of PTZ (50-100mg/kg body weight) were used to determine the best dose for induction of seizures (see below). As a result, doses of 70 and
• IP intra-peritoneally
• cannabinoids low, medium or high dose
• cannabinoids vehicle 1 :1 :18 ethanol:Cremophor: 0.9%w/v NaCI solution
• Animals were then observed for 30 mins, after which time they received an IP injection of 70 or 80mg/kg PTZ.
• Negative vehicle controls were
• FMJ myoclonic jerk
• the THCV BDS comprised a whole extract of a chemovar in which THCV was the predominant cannabinoid. (i.e. it was the major cannabinoid present in the extract, 80% by weight of the total cannabinoid content).
• THC was the second most prevalent cannabinoid, and was present in significant amounts, (i.e. it comprised greater than 10% by weight of the total cannabinoid content, being present at about 16%), and there were a number of minor cannabinoids identified, each comprising less than 2% by weight of the total cannabinoid content as measured by HPLC analysis.
• the ratio of THCV to THC in this extract is about 5:1.
• the THCV content was 67.5% by weight of the extract and the THC content was 13.6% by weight of the extract, with the other identified cannabinoids in total comprising about 3% by weight of the extract, the remaining 16% comprising non- cannabinoids.
• THCV BDS The effect of THCV BDS on PTZ-induced seizures was first assessed against a PTZ dose of 70 mg/kg. As described below, this yielded a vehicle control group that did not typically experience severe seizure scores. Therefore THCV BDS was also screened against an 80mg/kg dose of PTZ. It was felt that the increased seizure severity experienced by vehicle control animals exposed to 80mg/kg PTZ was a more appropriate test of potential anti-convulsant activity.
• THCV BDS Three doses of THCV BDS were assessed against a concentration of PTZ known to induce moderate seizures in rats (70mg/kg; see pilot, above).
• the low, medium and high doses of THCV BDS used were 0.37, 3.70 and 37.04mg/kg, and yielded actual THCV doses of 0.25, 2.5 and 25mg/kg respectively. These doses were matched by THCV content to those being used for screening pure THCV against PTZ- induced seizures.
• THCV BDS did not have any significant effects on latency to first myoclonic jerk or on latency to attaining a severity score of 3.5 on the seizure severity scale (Fig 1 ). It should be noted that although values for both these variables were higher for animals treated with medium and high dose THCV BDS compared to control, this failed to reach significance (P>0.05). Similarly, no significant impact on duration of seizure was seen (Fig 2).
• THCV BDS did not have a significant effect on latencies to FMJ or a severity score of 3.5 (Fig 5). Similarly, no effect was observed on seizure durations (Fig 6).
• Low dose THCV BDS decreased both seizure severity (Fig 7) and mortality (Fig 8) in animals that received doses of 80mg/kg PTZ. Animals that received low THCV BDS had a lower median severity score (3.5 compared to 6) than vehicle controls. However, this difference was not significant (P>0.5). The low THCV BDS dose group also had a mortality rate half that of the vehicle control group (30% vs 60%).
• Groups treated with medium and high doses of THCV BDS had a lower seizure severity score of 4.75 (P>0.5 vs control), and a lower mortality rate of 50%, compared to 6 and 60% respectively.
• Table 3 below displays the values for median seizure severity in each experimental group.
• CBD was also screened in the PTZ model.
• IP intra-peritoneally
• IP intra-peritoneally
• THCV caused no significant changes in the percentage of animals showing unilateral forelimb clonus, bilateral forelimb clonus or tonic-clonic seizures at any dose. Interestingly, 0.25 mg/kg THCV caused a significant increase in the percentage of animals showing bilateral forelimb clonus with rearing and falling although this effect was not seen at any other dose.
• Figure 15 details that CBD had no effect upon the mean maximum severity of seizure reached per animal group.
• Figures ' ! 6 A-D detail the percentage of animals in each group that reached particular seizure states (unilateral forelimb clonus, bilateral forelimb clonus, bilateral forelimb clonus with rearing and falling and tonic-clonic).
• CBD caused significant decreases in the percentage of animals showing unilateral forelimb clonus at CBD doses >1 mg/kg, Interestingly, although no significant differences in the percentage of animals exhibiting bilateral forelimb clonus were found, the percentage of animals manifesting with bilateral forelimb clonus with rearing and falling were significantly reduces at all CBD doses >1 mg/kg. The percentage of animals exhibiting tonic-clonic seizures was significantly reduced at CBD doses of 1 mg/kg and 100 mg/kg but not 10 mg/kg (c.f. Figure 14).
• CBD effects of CBD upon tonic-clonic seizure events by examining the mean frequency of tonic-clonic events as is shown in Figure 17.
• CBD caused a significant reduction in mean tonic-clonic frequency at all doses tested.
• CBD effects upon the mean frequency of all other seizure scores were also assessed in the same way but no significant differences vs control were found (P>0.5 for all).
• CBD (1 , 10 and 100mg/kg) or CBD vehicle (1 :1 :18 ethanokCremophor: 0.9% W w // NaCI) was administered i.p. to adult male Wistar rats (>250g).
• animals had been surgically implanted with a cannula into the right lateral ventricle under anaesthesia.
• 150IU penicillin was infused into the right lateral ventricle in 1.5 ⁇ l saline solution over one minute and seizure behaviour video recorded for two hours.
• THCV pure
• CBD pure
• Such an extract may contain other cannabinoids and the non-cannabinoid components which result from extraction, by for example, carbon dioxide as disclosed in WO04/016277, which components may support an "entourage" effect in the endocannabinoid system.
• a rat / human conversion factor suggests a CBD daily dose of at least 600mg (and optionally between 400mg and 800mg) and for THCV at least 1.5mg (medium) to preferably at least 15mg (high).
• a phytocannabinoid extract is to be used, an extract with low or negligible levels of THC and therapeutically effective levels of THCV and / or CBD is desired.
• CONSROE P.F., WOOD, G.C. & BUCHSBAUM, H. (1975) Anticonvulsant Nature of Marihuana Smoking. J.American Medical Association 234 306-307
• Cannabis-psychosis pathway independent of other types of psychopathology HUIZINK, A. & VERHULST, F. C. (2005) Cannabis-psychosis pathway independent of other types of psychopathology. Schizophr Res, 79, 289-95.
• FISHER FISHER, R. S., VICKREY, B. G., GIBSON, P., HERMANN, B., PENOVICH, P., SCHERER, A. & WALKER, S. (2000) The impact of epilepsy from the patient's perspective I. Descriptions and subjective perceptions. Epilepsy Res, 41 , 39-51.
• Epilepsies Epilepsies. Epilepsia, 1 1 , 1 14-1 19.

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