Day: September 2, 2019

What is the Dosing of CBD Oil?

Patient Presentation
An attending physician overheard a resident talking with a father on the telephone in clinic. The parent had asked the resident to give a dosing schedule for over-the-counter cannabidiol (CBD) oil for a 7 year old with attentional issues because the bottle said to consult a physician for children under 12 years of age. The resident discussed that that he could not do this as the preparations varied so much from vendor to vendor and this was not an approved use. The parent was fairly insistent that with the dosing for adults that the resident could “just figure it out,” and give him a dose for his child. The resident said that these preparations are not regulated the way other medications are in the United States and therefore couldn’t give a dosing recommendation. He went on to try to engage the father in discussing why he wanted to give the CBD oil and eventually was able to convince the father to come to clinic to discuss the underlying problems with their regular primary care physician.

Discussion
Cannabis sativa makes small fruits which are usually named “seeds” although they are not technically a seed. Hemp oil is derived from the hemp seeds by cold-pressing or other means of macerating or squashing the seeds. Cold pressed oil is high in polyunsaturated fatty acids including various omega-3 and linolenic acids and antioxidants. It is used by some people for its nutritional value and “[a]ccording to an old legend, Buddha (Prince Siddharta Gautama) founder of Buddism, was able to survive eating only one hemp seed each day for six years.” The seeds themselves do not contain any psychoactive compounds (specifically THC or tetrahydrocannabinol) but during processing they can become contaminated with these compounds. The THC impurity concentration is highly variable among different cultivars, processing and storage methods and thermal stress also increases the THC levels. In Europe there are strict limits on THC impurity levels and the oil is recommended to be consumed without heating.

A review of cannabis can be found here.

Learning Point
“…Cultivars used for seed production with a low THC levels generally contain a high concentration of cannabidiol (CBD) which has no THC activity.” An analysis study of cannabinoids in 13 commercial hemp seed oil preparations found that “concentrations of cannabinoids can be extremely variable among different oil varieties.” The authors also state that other methodologies they outline can be used to help determine storage conditions of the oil.

Medical use of cannabis has been proposed and mainly studied in adult populations. Potential indications include cancer-related nausea, appetite enhancement, neurogenic pain, glaucoma and epilepsy. In pediatrics some of the most common use is for seizures, but also chronic pain and muscle spasms. CBD is the more common form of cannabis used for seizures. Epidiolex® is a liquid cannabis-derived medication, that is FDA approved in the United States for the treatment of patients 2 years and older with Lennox-Gastaut syndrome seizures or Dravot Syndrome. The starting dose is 2.5 mg/kg twice a day orally with increases based on response and side effects.

Questions for Further Discussion
1. What is Lorenzo’s oil used for?
2. What is the legal status of medical cannabis in your location?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Marijuana and Pregnancy and Substance Abuse.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Citti C, Pacchetti B, Vandelli MA, Forni F, Cannazza G. Analysis of cannabinoids in commercial hemp seed oil and decarboxylation kinetics studies of cannabidiolic acid (CBDA). J Pharm Biomed Anal. 2018;149:532-540. doi:10.1016/j.jpba.2017.11.044

Samanta D. Cannabidiol: A Review of Clinical Efficacy and Safety in Epilepsy. Pediatr Neurol. March 2019. doi:10.1016/j.pediatrneurol.2019.03.014

Hoffenberg EJ, McWilliams S, Mikulich-Gilbertson S, Murphy B, Hoffenberg A, Hopfer CJ. Cannabis Oil Use by Adolescents and Young Adults With Inflammatory Bowel Disease. J Pediatr Gastroenterol Nutr. 2019;68(3):348-352. doi:10.1097/MPG.0000000000002189

RxList. Epidiolex (Cannabidiol Oral Solution): Side Effects, Interactions, Warning, Dosage & Uses. https://www.rxlist.com/epidiolex-drug.htm. Accessed June 10, 2019.

Commissioner of the Federal Drug Administration. Statement from FDA Commissioner Scott Gottlieb, M.D., on new steps to advance agency’s continued evaluation of potential regulatory pathways for cannabis-containing and cannabis-derived products. FDA. http://www.fda.gov/news-events/press-announcements/statement-fda-commissioner-scott-gottlieb-md-new-steps-advance-agencys-continued-evaluation. Published May 3, 2019. Accessed June 10, 2019.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa