Sunday, December 14, 2014

CANNABIS DOSING AND TITRATION RECOMMENDATIONS Children, Elders, and Cannabis, CBD and other cannabinoids

Children, Elders, and Cannabis, CBD and other cannabinoids
Primer for parents and other caregivers

NOTE: this is a work-in-progress.  While written with my series of over 40 children with seizure disorder and/or autism in mind, children are part of a larger group of patients: the cannabis-naïve, those new to using cannabis, and the medically-naive, (those who have used cannabis in the past, but now want to see whether cannabis can help some illness or symptom that they have since developed. 
            In that vein, I will be editing these guidelines based on more experience, feedback from patients, caregivers, and other practitioners, and further advances in research and medicine

CBD dosing guidelines

DrFrank's CBD dosing guidelines:
I recommend starting at 0.5 mg/pound of body weight/day into 2 or 3 doses each day, and gradually increasing up to 5 mg/pound/day.
NOTE: 5 mg/pound would be a very large dose for THC, in my opinion.
But these numbers assume mostly CBD, with very low THC levels.
The main side effects to monitor, while increasing dose, are intoxication, sedation, tachycardia, and dysphoria (opposite of euphoria). Fortunately, cannabis has an extremely good safety profile, with no recorded deaths from overdose.
So when assessing the benefits versus risks, we might exceed the “theoretical maximum” of 5 mg/pound/day, and go higher as needed, and as tolerated.

Background info:
I have based my guidelines above on the following 2 sources:
--Dr. Bonni Goldstein, pediatric emergency physician and cannabis expert, who shared her experience at our quarterly meeting of the Society of Cannabis Clinicians in September 2014, and
--GW Pharmaceuticals, who is supplying the CBD-only tincture, Epidiolex, for it’s study on children with certain seizure disorders.

Dr. Bonni Goldstein’s dosing::
0.5 mg/pound/day in 3 doses
increase 0.5 mg/pound/day at weekly intervals, up to 2-6 mg/pound/day.

GW Pharmaceutical's Epidiolex:
5 mg/kilogram body weight/day divided in 2 doses (NOTE that this dosing is in KILOGRAMS (kg) of body weight, rather than POUNDS.

When titrating, it’s Important to know:
Child’s weight
Actual MILLIGRAMS/dose of CBD, THC, and any other cannabinoids (not just ratios), so we can evaluate what we might want to increase or decrease, per volume of tincture or per piece of edible.

Some “CBD” sources are steering parents and patients to other products containing significant amounts of other cannabinoids, which may or may not be as useful, but add to the total “cannabinoid load”, and can make it harder to titrate doses of CBD and THC, the two cannabinoids we know the most about.

I feel it is important to see how optimal dosing of CBD affects the patient’s symptoms or illness.  I have concerns about adding too many variables too soon, such as THC-A or CBG.  THC-A is “THC acid” which is the precursor of THC found in raw cannabis.  Apparently it is not psychoactive, which may or may not be a good quality, but I am not sure how pharmacologically active it is for seizure control

I believe that THC, and possibly also THC-A also have their places, especially with some of the behavioral issues of autism, which is a common co-factor in many of the seizure disorders I have seen.  But I recommend that until you have titrated up to near the “theoretical maximum”* dose of CBD and evaluated the effects, that you try to avoid adding other variables, such as other cannabinoids.

DrFrank’s CBD info rap:
CBD vs. THC-Russo GW Tale of Two Cannabinoids article 

I'll try to simplify what I know.
THC is the more psychoactive of the many cannabinoids in cannabis.  There are over 70 identified, most in minuscule amounts.
CBD is of low psycho-activity. I'm not sure I'd say NO psycho-activity though, but much less than THC.  I also think that CBD-rich cannabis would cause less of the anxiety and/or paranoia that some people experience with cannabis.

GW Pharmaceuticals is a company in the U.K. that has extracted THC and CBD from the whole plant, and has been able to market it in Europe and Canada as a 50:50 sublingual spray called Sativex.  It is NOT available in the U.S. at this time

Here is the url for the article by Ethan Russo MD, and Geoffrey Guy MD of GW Pharmaceuticals:
A Tale of Two Cannabinoids
The therapeutic rationale for combining tetrahydrocannabinol and cannabidiol
The salient sentence in the abstract is:
"CBD is demonstrated to antagonise some undesirable effects of THC including intoxication, sedation and tachycardia, while 
contributing analgesic, anti-emetic, and anti-carcinogenic properties in its own right."

More info at:

a website by Fred Gardner and Martin Lee, our editors at O'Shaughnessy's, the Journal of the Society of Cannabis Clinicians.