The past few years have seen a huge surge in interest in using cannabis – in particular, the cannabinoid, cannabidiol (CBD) – for epilepsy. Furthermore, Epidiolex, a mostly CBD-based medication, has been approved by the FDA for the treatment of Dravet and Lennox-Gastaut Syndrome, both severe forms of epilepsy.
There also seem to be several pieces of hard-quality evidence suggesting that various cannabinoids have significant anti-seizure properties. While we will be looking mostly at using CBD for treating epilepsy, it is important to note that there are other cannabinoids that could be useful as well.
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Why is CBD Effective for Epilepsy?
If we want to think broadly about how many illnesses and diseases could be caused, then there is a simple answer: “inflammation”. Whether it is neuroinflammatory disorders (e.g. epilepsy, Parkinson’s disease, multiple sclerosis) or autoimmune conditions (e.g. Crohn’s disease, type-1 diabetes), all involve inflammation. Cannabinoids such as CBD, as well as tetrahydrocannabinol (THC), tetrahydrocannabivarin (THCV), cannabidivarin (CBDV) and their acidic counterparts, can help control this inflammatory response.
Of course, different cannabinoids affect different receptors in different ways, whether on their own or when used together, so different sets of cannabinoids at different dosages may well be required for different conditions. Simply put, there are different kinds of inflammation, and these require different cannabinoids and dosages.
As for epilepsy specifically, here are several reasons why CBD seems to work so well:
- High concentrations of CBD block sodium channels, helping regulate the neurons in the brain. CBDV also seems to exert anticonvulsant effects.
- Due to CBD’s weak affinity for CB1 and CB2 receptors, it is suggested that its anti-seizure activity is mediated by other mechanisms.CBD seems to work in particular on sodium, potassium and calcium ion channels.
- Blocking sodium and calcium channels reduces the release of excitatory glutamate. Anticonvulsants that act in such a manner could also be used to treat disorders such as bipolar disorder.
- As noted above, CBD acts as an anti-inflammatory as it “suppresses damaging inflammatory responses.”
It is interesting to note that THC also displays significant anticonvulsant properties, as do many other cannabinoids, psychoactive or non-psychoactive. Sadly, this has meant that THC has been unfairly separated from CBD when it could indeed have some use for epilepsy as both an anticonvulsant and pain reliever, even when used at non-psychoactive doses.
There is another primary reason why CBD and other cannabinoids may help for epilepsy. The cannabinoid tends to be extremely well-tolerated by the body, with an extremely high lethal dose. Many of the anti-epileptic drugs (AEDs) currently prescribed for hard-to-treat types of epilepsy are benzodiazepine-based, and in some circumstances gabapentinoids, opioids and barbiturates are also used. The side effects of benzodiazepines include addiction, drowsiness, confusion, dizziness, “brain fog” and impaired coordination.
To add to the problem of treating epilepsy with many of the AEDs that are currently prescribed, many people who suffer from epilepsy may have mutations in various liver enzymes, which are responsible for the metabolism of many anti-epileptic drugs (AEDs) like Clobazam. This means that, due to these malformations, many people with certain types of epilepsy may be given benzodiazepine- and barbiturate- based AEDs that might not work for them.
Are There Any Issues with Using CBD for Epilepsy?
Just like any other medicine, CBD may have some side-effects. These include:
- Changes in appetite
- Changes in mood
- Dry mouth
- Some people report high doses of CBD causing a “wiry” or “energetic” effect
It is important to remember that cannabinoids, including CBD, are biphasic. This means that cannabinoids can have different effects at different dosages. Moreover, to make matters more complicated, different people can have radically different reactions to the same cannabinoid taken at the same dosage. This means that what may work for one person may not work for another. Of course, this issue may arise with other medications and is not a property unique to cannabinoid-based medications.
There are other issues with cannabinoids’ biphasic effects. For some people suffering from different types of epilepsy (i.e., not the severe forms of Lennox-Gastaut or Dravet), CBD in too high a dose may not be effective for some kinds of seizures, or in rare instances possibly even make seizures worse. Too much THC may increase anxiety in some, and also make seizures feel worse. Another concern is synthetic CBD (and synthetic cannabinoids in general), which can have vastly different pharmacological effects from naturally-derived CBD, and can possibly also increase the likelihood of seizures.
Sadly, another issue is hemp-derived CBD. Pollutants and heavy metals often found in badly-made hemp-based products indicate a lack of regulation and testing. While there are possibly some good hemp-derived CBD products out there, the hemp plant is not necessarily grown for its trichomes (the “powerhouse” of cannabinoid production) but for its stalk and fiber. The methods used to extract CBD from hemp plants may also extract plant waxes into the final product.
Cannabis grown for its trichomes (i.e., female cannabis plants are left to flourish) is therefore a better and more readily available source of CBD. Of course, the difference between hemp and cannabis is also one of semantics, as both are Cannabis sativa. Cannabis is essentially considered “hemp” when a person has a license to grow it and has a maximum THC content of 0.3%, so it is technically feasible to grow a cannabis plant for its trichomes and flowers as opposed to the stalk, and still be considered hemp!
Does CBD React Negatively with Other Epilepsy Medications?
Yes, due to how certain liver enzymes may process anti-epileptic medications, CBD may negatively interact. If both AEDs and CBD are used at the same time, the AEDs are not metabolized properly and a dangerous amount of benzodiazepines build up in the blood, increasing the chance of overdose. Many people who decide to use CBD may need to reduce their intake of AEDs. However, CBD does not necessarily replace all AEDs and some may still need to be used, based upon physician’s advice.
Other drug-drug interactions with CBD include:
- Non-steroidal anti-inflammatory drugs (NSAIDs).
- Angiotensin II receptor blockers (ARBs)
- ACE inhibitors
- Beta blockers
- Calcium channel blockers
- HIV antivirals
- Proton-pump inhibitors
The above is not a comprehensive list, and not all drugs under the above classes will necessarily have negative effects when combined with CBD. This is because different drugs are metabolized in different pathways. Different cannabinoids are also likely to have different levels of interaction with other drugs.
As for alcohol, as ethanol is processed by the enzymes alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH), it is more likely that chronic or binge drinking will likely cause a negative drug-drug interaction between CBD and alcohol. This is because CYP 450 will only process alcohol if ADH and ALDH are overloaded. Moreover, CBD and other cannabinoids and terpenoids (e.g. beta-caryophyllene) may actually decrease the desire to drink more alcohol! Cannabinoids could possibly reduce cravings and withdrawal from other drugs as well, including opioids and benzodiazepines.
What Dose of CBD Should I Use for Epilepsy?
As we have noted, not all types of epilepsy are the same. Moreover, different people have different endocannabinoid systems (ECSs), so what may work for one person may not work for another, or one person may require a different dosage to another.
However, it does seem that, for at least a certain percentage of those suffering from hard-to-treat forms of epilepsy such as Dravet and Lennox-Gastaut syndrome, CBD:THC ratios such as 18:1 and 20:1 work rather well. Small amounts of THC and THCA may also work in combination with CBD to exert anti-seizure effects and could possibly help make CBD work more effectively. As far as method of ingestion goes, tinctures are most often used, with coconut oil or olive oil being used as the main carrier oil.
Until we have more clinical data, we cannot give more precise dosing guides. However, as some general advice, “slow and low” is a good start. For many types of conditions, 2-3 doses of cannabinoid-based tincture per day are used. If using cannabinoid products of any sort, it is important to look at total cannabinoid content and what ratio these are in. To make clear, this does not constitute medical advice, but to serve as an example to illustrate how cannabinoids can be taken. One thing is certain: a physician can help you determine the right doses of CBD and other cannabinoids to treat epilepsy.
The physicians at Leafwell are here to consult with you about what cannabis can do for epilepsy and many other conditions. Reach out today to apply for a medical marijuana card.
If you suffer from epilepsy and think you may benefit from cannabis and CBD, then don’t hesitate to check out our medical card page and book an appointment with a physician at Leafwell.