Childhood Refractory Epilepsy and Cannabis
We speak of refractory epilepsy when the epileptic seizures are so frequent that they limit the patient’s ability to live fully in accordance with their wishes and their mental and physical capacity, or when the anticonvulsant treatment does not control the seizures, or its side effects are limiting for development. normal person.
Reflect for a moment on this definition. It is a disease that can be very limiting for the patient and their family environment, especially in the case of refractory epilepsies in children. Parents are in some cases with an uncertain future and without much progress in their children. The first seizure usually appears, depending on the type of epilepsy, between the 1st and 5th year of life. The little ones can have from 1 weekly crisis in the best of cases, or present up to 30/50/70 or more daily crises, in many cases, and they can present them at any time, or they can follow some pattern, such as the crises that appear when falling asleep and relaxing, or right after waking up.
In many cases, they are dependent patients 24 hours a day, and have cognitive or psychomotor problems, from mild to severe, which limits their ability to learn, or their mobility permanently, even requiring a wheelchair to move. We frequently find an absence of verbal language, so they cannot express what they feel, in addition to being very small in most cases. At these ages, they have to be interacting with the environment and developing skills for the future, but refractory epilepsy determines a huge problem for the normal development of the patient.
Epilepsy and Cannabis
Epilepsy is a neurological disease that manifests itself as a consequence of an alteration in the neuronal activity of some brain area. This neuronal hyperexcitability can be transmitted from an initial focus to different brain areas. Seizures or epileptic seizures then occur, which can be of many types, depending on epilepsy suffered.
Epilepsies can be due to many causes, they can appear after a head injury, meningitis, a problem during childbirth, a metabolic disorder, etc. Then we find other epilepsies of genetic origin and epilepsies of unknown or idiopathic origin. Epileptic seizures, and the disease itself, cause many cognitive and psychological problems, with neuronal morbidity always after each seizure, which will determine the prognosis in the short and medium-term.
Antiepileptic drugs are not always effective in eliminating or reducing seizures and are used alone or in combination with each other, which in many cases causes the appearance of interactions between drugs that make their management difficult. Side effects are also very frequent, among which we can find: tremor, weight gain, gastrointestinal disorders, drowsiness, toxic hepatitis, hyperammonemia (ammonium poisoning), skin rashes, encephalopathies, increased seizures, behavioral changes, decreased school performance, vertigo, loss of visual field, etc.
Patients suffering from refractory epilepsy, therefore, face a very complex problem in relation to the difficult management of antiepileptic drugs and the side effects that may appear during treatment, which may require hospitalization in some cases.
Some cannabinoids modulate neuronal activity, reducing the hyperexcitability of the epileptic patient. It is important to note that during and after epileptic seizures we find many free radicals and inflammatory foci, which are responsible for a large part of brain damage. Cannabinoids such as CBD and THC are effective in neuroinflammation situations and help reduce oxidative stress. There is, therefore, a neuroprotective effect, in addition to being antiepileptic. THC is necessary in many cases to be present in different ratios or proportions, to complete the effect of CBD.
When we use cannabinoids from plant extracts, it is important to know the composition of the product, which must be correctly analyzed, to know the percentage of cannabinoids, and to be able to dose accurately.
Below I describe some of the main syndromes that occur with refractory epilepsy so that you can get an idea of the situation:
It is a type of childhood epilepsy of genetic origin, resistant to antiepileptic drugs. Its symptoms begin in the first year of life, with clonic seizures, and also with absences, (with complex generalized seizures, or only loss of consciousness). There is a 14% death rate during seizures or seizures. Patients throughout their lives have seizures, in addition to intellectual disability that is usually severe in 50%, and moderate or mild in the rest.
Different antiepileptic drugs are used alone or in combination with each other, the ketogenic diet is also used in many cases. They are also patients treated with antipsychotics and sleep inducers also in some cases.
It is a disorder that occurs with multiple types of seizures and usually manifests before 4 years of age. Tonic seizures appear with flexion of the neck and body, with the extension of the arms and legs, and also a contraction of the facial muscles. All this can be accompanied by facial flushing, eye turns, and apneas. They are of short duration and can appear at night or during the day, they do not respect timetables. There is usually a loss of consciousness.
Absences may also appear, with momentary loss of consciousness and drooling. They are usually multi-resistant to the usual antiepileptic drugs, and these can also have serious side effects.
Some antiepileptic drugs that are effective for one type of seizure may in some cases make others worse.
It is a type of severe epilepsy, which appears most often between 3 and 12 months of life. This can be due to different causes such as brain malformations or dysplasias, infections, metabolic disorders, genetic origin. It occurs with the presence of seizures with abrupt and symmetrical contractions of the extremities, which may occur with flexion or extension of the limbs. There is also occasionally facial flushing, pupillary dilation or mydriasis, and hypersensitivity. This disease also causes psychomotor retardation, which affects the cognitive sphere, its interaction with the environment, and its mobility.
In the electroencephalogram or EEG, a specific record called hypsarrhythmia appears. Its treatment consists of antiepileptic drugs, benzodiazepines, vitamin B6, corticosteroids, etc. Mortality is in 5% of patients.
This type of epilepsy appears between the first and fifth year of life, affecting more men. It is usually resistant or refractory to antiepileptic drugs.
The seizures occur with seizures, sometimes falls, and loss of muscle tone. 40% of the patients are mentally retarded or disabled.
In addition to the syndromes described above, there are many epilepsies that have not yet been identified and are orphaned by causal diagnosis. So it is difficult to schedule a treatment with the most appropriate antiepileptic drugs for the type of crisis or syndrome.
What can we expect when we start treatment with CBD in the pediatric patient with refractory epilepsy?
In most cases, and we would speak of 65% of patients, it is possible to reduce the number of seizures and also their frequency of appearance. In some patients, the type of crisis changes, and its intensity is reduced, and therefore the children are calmer, and their brains can be dedicated to tasks and very necessary skills, being very frequent that parents comment that “it is more connected!”.
Most patients have severe cognitive deficits in many cases, and CBD really provides very valuable effects on a cognitive and psychomotor level, patients relate better to the environment, actively interact when they did not before, there is better school performance in many cases, and this is really a morale booster for the patient’s environment. We have to think that in these cases a small improvement is a big step, they are very complex cases, and keeping the children stable is complicated because the appearance of a crisis depends on many factors, including emotional factors, which we do not take into account in Many occasions.
Remember that many patients do not have verbal language, and by not speaking, they cannot express feelings, they cannot communicate correctly and this generates frustration in many children, and frustration can lead to self-injurious behaviors or aggressive behaviors. Here CBD also helps us to normalize these situations in many cases.
Most patients no longer have valid therapeutic alternatives, and CBD is a very interesting resource, insisting as always on its low toxicity and its effectiveness as an antiepileptic.
Is THC indicated in the treatment of refractory epilepsies?
We have to think that 5000 years ago Cannabis Sativa was already used for the treatment of epilepsy, it was the Chinese who were responsible, and surely that in these varieties there was THC at least in a ratio of 1/1, THC / CBD.
In most cases, CBD is used with a THC percentage lower than 0.2%, formulated in olive oil, for example, which represents that it is a legal product.
But there are patients who need a THC supply, which could represent a THC / CBD ratio of 1-2 / 15-17 for example. This would be the profile of oils that are working well in some kids. Therefore, we have to think that, if with “legal” CBD the patient evolves satisfactorily, we do not provide THC, but in other cases, it will be necessary to think about it, with the “legal” insecurity that it generates for the parents if a problem occurs that could be related to the use of cannabinoids. But we can say that we have not encountered problems that could put the patient’s health at risk or generate side effects that could not be easily solved by correcting the dose in most cases.
There is still a lack of clinical studies that certify that cannabinoids can be useful as antiepileptic drugs, although the use of CBD and THC, in different ratios or proportions, is being effective for the treatment of some refractory epilepsies. They may also be effective for treating other types of epilepsy in adults, for example.
We must insist on the low toxicity of cannabinoids, and it is necessary to study the interactions that can develop between antiepileptic drugs and cannabinoids, in order to be able to handle their combinations with even greater safety.
There is still no data on the use of CBD in the medium and long term, although so far no notable side effects have been detected, which could constitute a problem for long-term treatments.