USE OF CANNABIDIOL IN THE TREATMENT OF SEIZURES ASSOCIATED WITH RARE EPILEPSY SYNDROMES RELATED TO GENETIC ABNORMALITIES

Abstract

The present invention relates to the use of cannabidiol (CBD) for the treatment of seizures associated with rare epilepsy syndromes. In particular the seizures associated with rare epilepsy syndromes that are treated are those which are experienced in patients with gross chromosomal mutations including 15q11.2 deletion; 1p36 deletion; 22Q11 duplication; 9p21.1 deletion with autistic spectrum disorder; monosomy 16p13.3 and trisomy 2p25.3; chromosome 3q duplication; and trisomy 13. In a further embodiment the types of seizures include tonic, tonic-clonic, atonic, absence, focal seizures without impairment, focal seizures with impairment and focal seizures with secondary generalisation. Preferably the dose of CBD is between 5 mg/kg/day to 50 mg/kg/day.

Claims

1. A cannabidiol (CBD) preparation for use in the treatment of seizures associated with gross chromosomal mutation, wherein the gross chromosomal mutation is one of: 15q11.2 deletion; 1p36 deletion; 22Q11 duplication; 9p21.1 deletion with autistic spectrum disorder; monosomy 16p13.3 and trisomy 2p25.3; chromosome 3q duplication; or trisomy 13.

2. A CBD preparation for use according to claim 1, wherein the seizures associated with gross chromosomal mutations are tonic, tonic-clonic, atonic, absence, focal seizures without impairment, focal seizures with impairment and focal seizures with secondary generalisation.

3. A CBD preparation for use according to any of the preceding claims, wherein the CBD preparation comprises greater than 95% (w/w) CBD and not more than 0.15% (w/w) tetrahydrocannabinol (THC).

4. A CBD preparation for use according to any of the preceding claims, wherein the CBD preparation comprises greater than or equal to 98% (w/w) CBD and less than or equal to 2% (w/w) other cannabinoids, wherein the less than or equal to 2% (w/w) other cannabinoids comprise the cannabinoids tetrahydrocannabinol (THC); cannabidiol-C1 (CBD-C1); cannabidivarin (CBDV); and cannabidiol-C4 (CBD-C4), and wherein the THC is present as a mixture of trans-THC and cis-THC.

5. A CBD preparation to any of the preceding claims, wherein the CBD preparation is used in combination with one or more concomitant anti-epileptic drugs (AED).

6. A CBD preparation for use according to claim 5, wherein the one or more AED is selected from the group consisting of: valproic acid, levetiracetam, clobazam, zonisamide, rufinamide, lacosamide, topiramate, clonazepam, perampanel, brivaracetam, gabapentin and phenobarbital.

7. A CBD preparation for use according to any of the preceding claims, wherein the CBD is present is isolated from cannabis plant material.

8. A CBD preparation for use according to any of the preceding claims, wherein at least a portion of at least one of the cannabinoids present in the CBD preparation is isolated from cannabis plant material.

9. A CBD preparation for use according to claims 1 to 6, wherein the CBD is present as a synthetic preparation.

10. A CBD preparation for use according to claim 9, wherein at least a portion of at least one of the cannabinoids present in the CBD preparation is prepared synthetically.

11. A CBD preparation for use according to any of the preceding claims, wherein the dose of CBD is greater than 5 mg/kg/day.

12. A CBD preparation for use according to any of the preceding claims, wherein the dose of CBD is 20 mg/kg/day.

13. A CBD preparation for use according to any of the preceding claims, wherein the dose of CBD is 25 mg/kg/day.

14. A CBD preparation for use according to any of the preceding claims, wherein the dose of CBD is 50 mg/kg/day.

15. A method of treating seizures associated with gross chromosomal mutation comprising administering a cannabidiol (CBD) preparation to the subject in need thereof.

Description

DETAILED DESCRIPTION

Preparation of Highly Purified CBD Extract

[0054] The following describes the production of the highly-purified (>95% w/w) cannabidiol extract which has a known and constant composition.

[0055] In summary the drug substance used is a liquid carbon dioxide extract of high-CBD containing chemotypes of Cannabis sativa L. which had been further purified by a solvent crystallization method to yield CBD. The crystallisation process specifically removes other cannabinoids and plant components to yield greater than 95% CBD. Although the CBD is highly purified because it is produced from a cannabis plant rather than synthetically there is a small number of other cannabinoids which are co-produced and co-extracted with the CBD. Details of these cannabinoids and the quantities in which they are present in the medication are as described in Table A below.

TABLE-US-00001 TABLE A Composition of highly purified CBD extract Cannabinoid Concentration CBD >95% w/w CBDA NMT 0.15% w/w CBDV NMT 1.0% w/w Δ.sup.9 THC NMT 0.15% w/w CBD-C4 NMT 0.5% w/w > - greater than NMT - not more than

Preparation of Botanically Derived Purified CBD

[0056] The following describes the production of the botanically derived purified CBD which comprises greater than or equal to 98% w/w CBD and less than or equal to other cannabinoids was used in the open label, expanded-access program described in Example 1 below.

[0057] In summary the drug substance used in the trials is a liquid carbon dioxide extract of high-CBD containing chemotypes of Cannabis sativa L. which had been further purified by a solvent crystallization method to yield CBD. The crystallisation process specifically removes other cannabinoids and plant components to yield greater than 95% CBD w/w, typically greater than 98% w/w.

[0058] The Cannabis sativa L. plants are grown, harvested, and processed to produce a botanical extract (intermediate) and then purified by crystallization to yield the CBD (botanically derived purified CBD).

[0059] The plant starting material is referred to as Botanical Raw Material (BRM); the botanical extract is the intermediate; and the active pharmaceutical ingredient (API) is CBD, the drug substance.

[0060] All parts of the process are controlled by specifications. The botanical raw material specification is described in Table B and the CBD API is described in Table C.

TABLE-US-00002 TABLE B CBD botanical raw material specification Test Method Specification Identification: Visual Complies A TLC Corresponds to standard (for CBD & CBDA) B HPLC/UV Positive for CBDA C Assay: In-house NLT 90% of assayed CBDA + CBD (HPLC/UV) cannabinoids by peak area Loss on Drying Ph. Eur. NMT 15% Aflatoxin UKAS method NMT 4 ppb Microbial: Ph. Eur. NMT 10.sup.7 cfu/g TVC NMT 10.sup.5 cfu/g Fungi NMT 10.sup.2 cfu/g E.coli Foreign Matter: Ph. Eur. NMT 2% Residual Herbicides and Ph .Eur. Complies Pesticides

TABLE-US-00003 TABLE C Specification of an exemplary botanically derived purified CBD preparation Test Test Method Limits Appearance Visual Off-white/pale yellow crystals Identification A HPLC-UV Retention time of major peak corresponds to certified CBD Reference Standard Identification B GC-FID/MS Retention time and mass spectrum of major peak corresponds to certified CBD Reference Standard Identification C FT-IR Conforms to reference spectrum for certified CBD Reference Standard Identification D Melting Point 65-67° C. Identification E Specific Optical Conforms with certified CBD Reference Rotation Standard; −110º to −140º (in 95% ethanol) Total Purity Calculation ≥98.0% Chromatographic Purity 1 HPLC-UV ≥98.0% Chromatographic Purity 2 GC-FID/MS ≥98.0% CBDA HPLC-UV NMT 0.15% w/w CBDV 0.2-1.0% w/w THC 0.01-0.1% w/w CBD-C4 0.3-0.5% w/w Residual Solvents: GC Alkane NMT 0.5% w/w Ethanol NMT 0.5% w/w Residual Water Karl Fischer NMT 1.0% w/w

[0061] The purity of the botanically derived purified CBD preparation was greater than or equal to 98%. The botanically derived purified CBD includes THC and other cannabinoids, e.g., CBDA, CBDV, CBD-C1, and CBD-C4.

[0062] In some embodiments, the CBD preparation comprises not more than 0.15% THC based on total amount of cannabinoid in the preparation. In some embodiments, the CBD preparation comprises about 0.01% to about 0.1% THC based on total amount of cannabinoid in the preparation. In some embodiments, the CBD preparation comprises about 0.02% to about 0.05% THC based on total amount of cannabinoid in the preparation.

[0063] In some embodiments, the CBD preparation comprises about 0.2% to about 1.0% CBDV based on total amount of cannabinoid in the preparation. In some embodiments, the CBD preparation comprises about 0.2% to about 0.8% CBDV based on total amount of cannabinoid in the preparation.

[0064] In some embodiments, the CBD preparation comprises about 0.3% to about 0.5% CBD-C4 based on total amount of cannabinoid in the preparation. In some embodiments, the CBD preparation comprises about 0.3% to about 0.4% CBD-C4 based on total amount of cannabinoid in the preparation.

[0065] In some embodiments, the CBD preparation comprises about 0.1% to about 0.15% CBD-C1 based on total amount of cannabinoid in the preparation.

[0066] Distinct chemotypes of the Cannabis sativa L. plant have been produced to maximize the output of the specific chemical constituents, the cannabinoids. Certain chemovars produce predominantly CBD. Only the (−)-trans isomer of CBD is believed to occur naturally. During purification, the stereochemistry of CBD is not affected.

Production of CBD Botanical Drug Substance

[0067] An overview of the steps to produce a botanical extract, the intermediate, are as follows: [0068] a) Growing [0069] b) Direct drying [0070] c) Decarboxylation [0071] d) Extraction—using liquid CO.sub.2 [0072] e) Winterization using ethanol [0073] f) Filtration [0074] g) Evaporation

[0075] High CBD chemovars were grown, harvested, dried, baled and stored in a dry room until required. The botanical raw material (BRM) was finely chopped using an Apex mill fitted with a 1 mm screen. The milled BRM was stored in a freezer prior to extraction.

[0076] Decarboxylation of CBDA to CBD was carried out using heat. BRM was decarboxylated at 115° C. for 60 minutes.

[0077] Extraction was performed using liquid CO.sub.2 to produce botanical drug substance (BDS), which was then crystalized to produce the test material. The crude CBD BDS was winterized to refine the extract under standard conditions (2 volumes of ethanol at −20° C. for approximately 50 hours). The precipitated waxes were removed by filtration and the solvent was removed to yield the BDS.

Production of Botanically Derived Purified CBD Preparation

[0078] The manufacturing steps to produce the botanically derived purified CBD preparation from BDS were as follows: [0079] a) Crystallization using C.sub.5-C.sub.12 straight chain or branched alkane [0080] b) Filtration [0081] c) Vacuum drying

[0082] The BDS produced using the methodology above was dispersed in C.sub.5-C.sub.12 straight chain or branched alkane. The mixture was manually agitated to break up any lumps and the sealed container then placed in a freezer for approximately 48 hours. The crystals were isolated via vacuum filtration, washed with aliquots of cold C.sub.5-C.sub.12 straight chain or branched alkane, and dried under a vacuum of <10 mb at a temperature of 60° C. until dry. The botanically derived purified CBD preparation was stored in a freezer at −20° C. in a pharmaceutical grade stainless steel container, with FDA food grade approved silicone seal and clamps.

Physicochemical Properties of the Botanically Derived Purified CBD

[0083] The botanically derived purified CBD used in the clinical trial described in the invention comprises greater than or equal to 98% (w/w) CBD and less than or equal to 2% (w/w) of other cannabinoids. The other cannabinoids present are THC at a concentration of less than or equal to 0.1% (w/w); CBD-C1 at a concentration of less than or equal to 0.15% (w/w); CBDV at a concentration of less than or equal to 0.8% (w/w); and CBD-C4 at a concentration of less than or equal to 0.4% (w/w).

[0084] The botanically derived purified CBD used additionally comprises a mixture of both trans-THC and cis-THC. It was found that the ratio of the trans-THC to cis-THC is altered and can be controlled by the processing and purification process, ranging from 3.3:1 (trans-THC:cis-THC) in its unrefined decarboxylated state to 0.8:1 (trans-THC:cis-THC) when highly purified.

[0085] Furthermore, the cis-THC found in botanically derived purified CBD is present as a mixture of both the (+)-cis-THC and the (−)-cis-THC isoforms.

[0086] Clearly a CBD preparation could be produced synthetically by producing a composition with duplicate components.

[0087] Example 1 below describes the use of a botanically derived purified CBD in an open label, expanded-access program to investigate the clinical efficacy and safety of purified pharmaceutical cannabidiol formulation (CBD) in the treatment of seizures associated with gross chromosomal mutations including 15q11.2 deletion; 1p36 deletion; 22Q11 duplication; 9p21.1 deletion with autistic spectrum disorder; monosomy 16p13.3 and trisomy 2p25.3; chromosome 3q duplication; and trisomy 13.

Example 1: Clinical Efficacy and Safety of Purified Pharmaceutical Cannabidiol (CBD) in the Treatment of Patients with Gross Chromosomal Mutations

Study Design

[0088] Subjects were required to be on one or more AEDs at stable doses for a minimum of two weeks prior to baseline and to have stable vagus nerve stimulation (VNS) settings and ketogenic diet ratios for a minimum of four weeks prior to baseline.

[0089] Patients were administered botanically derived purified CBD in a 100 mg/mL sesame oil-based solution at an initial dose of between 5 and 15 milligrams per kilogram per day (mg/kg/day) in two divided doses. Dose was then increased weekly by 5 mg/kg/day to a goal of to 25 mg/kg/day.

[0090] A maximum dose of 50 mg/kg/day could be utilised for patients who were tolerating the medication but had not achieved seizure control; these patients had further weekly titration by 5 mg/kg/day.

[0091] There were seven patients in this study, and each received CBD for various durations of time. Modifications were made to concomitant AEDs as per clinical indication.

[0092] Seizure frequency, intensity, and duration were recorded by caregivers in a diary during a baseline period of at least 28 days. Changes in seizure frequency relative to baseline were calculated after at least 2 weeks and at defined timepoints of treatment.

Statistical Methods:

[0093] Patients may be defined as responders if they had more than 50% reduction in seizure frequency compared to baseline. The percent change in seizure frequency was calculated as follows:

[00001]$\begin{array}{c}\%\mathrm{change}\\ \mathrm{seizure}\\ \mathrm{frequency}\end{array}=\frac{\left(\left(\mathrm{weekly}\mathrm{seizure}\mathrm{frequency}\mathrm{time}\mathrm{interval}\right)-\left(\mathrm{weekly}\mathrm{seizure}\mathrm{frequency}\mathrm{Baseline}\right)\right)}{\left(\mathrm{weekly}\mathrm{seizure}\mathrm{frequency}\mathrm{Baseline}\right)}\times 100$

[0094] The percent change of seizure frequency may be calculated for any time interval where seizure number has been recorded. For the purpose of this example the percent change of seizure frequency for the end of the treatment period was calculated as follows:

[00002]$\begin{array}{c}\%\mathrm{reduction}\\ \mathrm{seizure}\mathrm{frequency}\end{array}=\frac{\left(\left(\mathrm{weekly}\mathrm{seizure}\mathrm{frequency}\mathrm{Baseline}\right)-\left(\mathrm{weekly}\mathrm{seizure}\mathrm{frequency}\mathrm{End}\right)\right)}{\left(\mathrm{weekly}\mathrm{seizure}\mathrm{frequency}\mathrm{Baseline}\right)}\times 100$

Results

Patient Description

[0095] The seven patients enrolled in the open label, expanded-access program had gross chromosomal mutations including 15q11.2 deletion; 1p36 deletion; 22Q11 duplication; 9p21.1 deletion with autistic spectrum disorder; monosomy 16p13.3 and trisomy 2p25.3; chromosome 3q duplication; and trisomy 13. These patients experienced several different seizure types including tonic, tonic-clonic, atonic, absence, focal seizures without impairment, focal seizures with impairment and focal seizures with secondary generalisation, and were taking several concomitant AEDs.

[0096] The age of patients ranged from 3-16 years, four were male and three were female as detailed in Table 1 below.

TABLE-US-00004 TABLE 1 Patient demographics, seizure type and concomitant medication Patient Age Number (years) Sex Seizure types Concomitant AEDs 1  8.65 F Tonic-clonic CLB, LEV, ZNS 2  3.51 M Atonic CLN 3  6.33 F Tonic, tonic-clonic, absence CLB, LCS 4 13.68 M Focal without impairment, CLB, PMP focal with secondary generalisation 5 16.31 M Tonic, absence, focal without CLB, VPA, BRV impairment 6 10.87 F Atonic, focal without RFN, ZNS impairment, focal with impairment 7  6.75 M Tonic, tonic-clonic, absence CLB, GBP, PHB, TPM VPA = valproic acid, LEV = levetiracetam, CLB = clobazam, ZNS = zonisamide, RFN = rufinamide, LCS = lacosamide, TPM = topiramate, CLN = clonazepam, PMP = perampanel, BRV = brivaracetam, GBP = gabapentin, PHB = phenobarbital

Study Medication and Concomitant Medications

[0097] All seven patients were titrated up to at least 20 mg/kg/day of CBD and two patients were titrated up to at least 25 mg/kg/day (#1, 5). The average number of concomitant AEDs at the time of starting CBD was two per patient (range: 1-4).

Clinical Changes

[0098] Tables 2A-G illustrate the seizure frequency for each patient as well as the dose of CBD given.

TABLE-US-00005 TABLE 2A Seizure frequency data for Patient 1 Patient 1 Seizure Type Dose CBD Time Tonic-clonic (mg/kg/day) Baseline 102.0  — 4 weeks 6.0  5.0 8 weeks 14.0   5.0 12 weeks 6.0 10.0 24 weeks 3.0 15.0 36 weeks 1.3 20.0 48 weeks 1.3 20.0 60 weeks 1.0 20.0 72 weeks 1.6 20.0 84 weeks 4.6 20.0 96 weeks 6.3 20.0 108 weeks 2.1 20.0 120 weeks 3.4 20.0

[0099] Patient 1 was treated for 120 weeks and experienced a 96.7% reduction in tonic-clonic seizures over the treatment period.

TABLE-US-00006 TABLE 2B Seizure frequency data for Patient 2 Patient 2 Seizure Type Dose CBD Time Atonic (mg/kg/day) Baseline 156.0 — 2 weeks 120.0  5.0 4 weeks 120.0 10.0 8 weeks 120.0 15.0 12 weeks 180.0 25.0 24 weeks 104.0 22.5 36 weeks 160.0 25.0 48 weeks 320.0 25.0 60 weeks 180.0 25.0 72 weeks  20.0 25.0 84 weeks  72.0 25.0 96 weeks 148.0 25.0 108 weeks  60.0 25.0 120 weeks  88.0 25.0

[0100] Patient 2 was treated for 120 weeks and experienced a 43.6% reduction in atonic seizures over the treatment period.

TABLE-US-00007 TABLE 2C Seizure frequency data for Patient 3 Patient 3 Seizure Type Dose CBD Time Tonic Tonic-clonic Absence (mg/kg/day) Baseline 100.0 8.0 15.0 — 4 weeks 20.0 3.0 1.0 5.0 8 weeks 11.0 2.0 1.0 10.0 12 weeks 28.0 4.0 0.0 12.5 24 weeks 11.3 0.0 0.3 15.0 36 weeks 16.4 0.0 0.3 20.0 48 weeks 12.0 0.0 0.6 25.0 60 weeks 5.0 4.3 0.3 25.0 72 weeks 4.0 0.0 0.0 25.0 84 weeks 5.3 1.3 0.0 25.0 96 weeks 3.7 0.0 1.8 25.0 108 weeks 0.0 0.0 0.0 25.0 132 weeks 0.0 0.9 2.4 25.0

[0101] Patient 3 was treated for 132 weeks and experienced a 100% reduction in tonic seizures, a 88.8% reduction in tonic-clonic seizures and a 84% reduction in absence seizures over the treatment period.

TABLE-US-00008 TABLE 2D Seizure frequency data for Patient 4 Patient 4 Seizure Type Focal Focal with without secondary Dose CBD Time impairment generalisation (mg/kg/day) Baseline 16.0  13.0  — 2 weeks 0.0 0.0 15.0 4 weeks 0.0 0.0 20.0 8 weeks 18.0  0.0 25.0 12 weeks 0.0 0.0 25.0 16 weeks 1.0 0.0 25.0 24 weeks 2.0 0.8 25.0

[0102] Patient 4 was treated for 24 weeks and experienced a 83.3% reduction in focal seizures without impairment and a 93.8% reduction in focal seizures with secondary generalisation over the treatment period.

TABLE-US-00009 TABLE 2E Seizure frequency data for Patient 5 Patient 5 Seizure Type Focal without Dose CBD Time Tonic Absence impairment (mg/kg/day) Baseline 14.0  55.0 12.0  — 2 weeks 8.0 78.0 0.0 10.0 4 weeks 4.3 81.8 47.4  15.0 8 weeks 1.9 39.6 2.9 20.0 12 weeks 5.1 43.4 1.0 20.0 16 weeks 3.0  6.0 0.0 20.0 24 weeks 7.0  0.0 0.0 20.0

[0103] Patient 5 was treated for 24 weeks and experienced a 50% reduction in tonic seizures, a 100% reduction in absence seizures and a 100% reduction in focal seizures without impairment over the treatment period.

TABLE-US-00010 TABLE 2F Seizure frequency data for Patient 6 Patient 6 Seizure Type Focal without Focal with Dose CBD Time Atonic impairment impairment (mg/kg/day) Baseline 2.0 3.0 2.0 — 2 weeks 0.0 0.0 4.0 10.0 4 weeks 0.0 0.0 2.0 20.0 8 weeks 0.0 0.0 2.0 25.0 12 weeks 0.0 1.0 3.0 25.0 16 weeks 2.0 5.0 2.0 25.0 24 weeks 3.0 6.0 5.0 25.0

[0104] Patient 6 was treated for 24 weeks and did not experience a reduction in seizures over the treatment period.

TABLE-US-00011 TABLE 2G Seizure frequency data for Patient 7 Patient 7 Seizure Type Dose CBD Time Tonic Tonic-clonic Absence (mg/kg/day) Baseline 352.0 272.0 92.0 — 4 weeks 372.0 240.0 20.0 10.0 12 weeks 308.0 448.0 12.0 10.0 16 weeks 308.0 448.0 12.0 10.0 24 weeks 248.0 404.0 20.0 10.0 48 weeks 216.0 356.0 20.0 15.0 60 weeks 244.0 304.0 28.0 20.0 72 weeks 244.0 304.0 28.0 20.0 84 weeks 208.0 280.0 32.0 25.0 108 weeks 184.0 288.0 24.0 25.0 120 weeks  0.0  5.6  0.0 23.6 132 weeks  0.0  2.4  0.0 23.2 144 weeks  0.0  0.0  0.0 25.9

[0105] Patient 7 was treated for 144 weeks and experienced a 100% reduction in tonic seizures, a 100% reduction in tonic-clonic seizures and a 100% reduction in absence seizures over the treatment period.

[0106] Overall, patients reported reductions of 43.6-100% in seizures over period of treatment with CBD.

[0107] Significantly, one patient became completely seizure free after 144 weeks of treatment with CBD (patient 7), whilst one patient became seizure free in their tonic seizures after 108 weeks of treatment (patient 3) and one patient became seizure free in their absence seizures and focal seizures without impairment after 24 weeks and 16 weeks of treatment respectively (patient 5).

[0108] CBD was effective in reducing the frequency of the following seizure types: tonic, tonic-clonic, atonic, absence, focal seizures without impairment and focal seizures with secondary generalisation

CONCLUSIONS

[0109] These data indicate that CBD was able to significantly reduce the number of seizures associated with gross chromosomal mutations including 15q11.2 deletion; 1p36 deletion; 22Q11 duplication; 9p21.1 deletion with autistic spectrum disorder; monosomy 16p13.3 and trisomy 2p25.3; chromosome 3q duplication; and trisomy 13. Clearly the treatment is of significant benefit in this difficult to treat epilepsy syndrome given the high response rate experienced in most patients.

[0110] Of interest are patients with tonic-clonic seizures (patients 1, 3 and 7), and patients with absence seizures (patients 3, 5 and 7) who obtained significant benefit.

[0111] In conclusion, this study signifies the use of CBD for treatment of seizures associated with gross chromosomal mutations. Seizure types include tonic, tonic-clonic, atonic, absence, focal seizures without impairment and focal seizures with secondary generalisation for which seizure frequency rates decreased significantly, by 44-100%.

REFERENCES

[0112] 1. Gu et al. (2019) “Cannabidiol attenuates seizures and EEG abnormalities in Angelman syndrome model mice.” The Journal of Clinical Investigation, Vol 129, 2019; pp 5462-5467 [0113] 2. Ho and Wassman (2017) “A case for cannabidiol in Wolf-Hirschhorn syndrome seizure management.” American Journal of Medical Genetics, Vol 173A, 2017; pp 324-326.