A C l i n i c i a n ’s G u i d e

t o C B D

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T H E M E D I C A L C A N N A B I S C L I N I C I A N S S O C I E T Y

U N D E R S T A N D I N G C A N N A B I D I O L

01 Introduction

02 The EndocannabinoidSystem 12

Legalities of CBDproducts in the UK

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Drug interactions

03 What is CBD?

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Side effects

06Key differencesbetween Hemp, CBDand cannabis oils

18What shouldconsumers look for inCBD products?

07 Indicated uses of CBD

19 Checklist for CBDproducts

t a b l e o f C O N T E N T S

08In what forms dopatients consumeCBD?

20 References 10 Dosing CBD

11 Discussing CBD withpatients

i n t r o d u c t i o n

Over the past few years, over the counter Cannabidiol (CBD) products have gained popularity in theUK and across the world. We have seen unprecedented growth in the quantity and range of CBDproducts available for purchase on the high street and from online retailers. CBD appears to have caught the imagination of the general public, who are using it for a number ofhealth conditions ranging from pain and anxiety to depression and sleep. According to the Centre forMedical Cannabis, surveys conducted in 2019 by Dynata and YouGov indicates that between 8- 11%of UK adults respectively - approximately 4-6 million people - have tried CBD products. Currently, doctors report receiving mixed messages as to whether these products are legal, safe andeffective and clinicians are largely unfamiliar with what patients are using. Given this widespread useof CBD, it is crucial that doctors are confident in understanding the properties of CBD and how it mayaffect our patients - including therapeutic effects, dosing, side effects and potential drug interactions. This guide provides an overview of CBD for clinicians, including its modes of action and therapeuticeffects, pharmacodynamics and dosing. We also summarise the current legal status of CBD in the UK. We hope that the information contained in this publication will help doctors understand CBD andhelp guide their patients to the safest and most effective and evidence-based products available.

CHAIRP R O F M I K E B A R N E S

VICE CHAIRD R D A N I G O R D O N

GP & GUIDE AUTHORD R L E O N B A R R O N

T H E M E D I C A L C A N N A B I S C L I N I C I A N S S O C I E T Y

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AnxietyAppetiteAutonomic functionsBladder functionCancer controlEnergy balanceFemale reproductive functionGI functionHomeostasisInflammationMemoryMetabolic functionsMotor controlNeurogenesisNeuroplasticityNeurotransmissionRegulation of painSleep

The endocannabinoid system (ECS) is a complexcell-signalling system and is universal to allvertebrates. The ECS consists of endocannabinoids, cannabinoidreceptors, and enzymes that regulate biosynthesisand degradation of endocannabinoids. The ECS has been implicated in a variety of diseasestates and important regulatory functions,including:

T h e E n d o c a n n a b i n o i d Sys t e m A C L I N I C I A N ’ S G U I D E T O C B D

Social behaviourStress responseThermoregulation

CB1 is primarily located in the central nervoussystem with some expression in peripheraltissues.CB2 receptors are found in the periphery oncells with immune function, in thegastrointestinal tract and at low densities in thecentral nervous system.

CB1 and CB2 are the two main cannabinoidreceptors found within our bodies which we knowmost about so far, although there are likely othersinvolved to a lesser degree. They are both G-protein coupled receptors locatedon presynaptic membranes that detect moleculesoutside the cell and activate internal signaltransduction pathways and cellular response.

Anandamide and 2-Arachidonoylglycerol (2AG) areour two main endogenous endocannabinoids,which act as neurotransmitters/ ligands binding toCB1 and CB2 receptors. They are both synthesised on demand to maintainhomeostasis.

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The cannabis plant Cannabis sativa contains over500 natural compounds including terpenes,flavonoids and 113 known phytocannabinoids.   Phytocannabinoids are lipophilic molecules,synthesised in the glandular trichomes of theunfertilised female cannabis flower and are able tomodulate our endocannabinoid system due tomolecular similarities to anandamide and 2AG. The best-known and most widely studied of thesephytocannabinoids are CBD and THC(Tetrahydrocannabinol). CBD is a non-psychomimetic or non-psychotropiccannabinoid and is of great research interest dueto its multi-modal properties in various medicalconditions.

Tetrahydrocannabinol (THC) is responsible for themain psychotropic effect of cannabis. Over the counter CBD which can be bought withouta prescription is primarily extracted from the driedfemale flower tops of hemp or from the leaves andstems – a fast growing strain of Cannabis sativa thathas been selectively bred over time for its industrialproperties. Hemp strains of cannabis contain substantially lessTHC and higher levels of CBD than other cannabisstrains and the trace percentages of THC havealmost zero chance of causing a psychomimeticeffect.

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W h a t i s C B D? C o n t i n u e d

CBD is sometimes confused with hemp seed oilbut there are distinct differences. Hemp oil is extracted from cannabis seeds andhas only trace amounts of CBD of the hemp plant, whereas CBD is produced in glandular trichomesof female flowers and to a lesser extent from theleaves and stems.

Hemp oil is similar to olive oils and vegetable oilsand contains a rich source of nutrients includingfatty acids, omega 3 and 6, vitamins and minerals. Hemp oil is widely used as an addition tocosmetics, balms and skin creams and in itsrefined form has a number of useful industrialapplications.

C B D O I L V S H E M P S E E D O I L

C A N N A B I S B A S E D M E D I C A L P R O D U C T S ( M E D I C A L C A N N A B I S )

Chemovars, also known as chemotypes, refer tothe breakdown of a plant species according tochemical composition. Cannabis chemovars have been selectively bredover centuries to produce active compounds suchas THC, CBD and other lesser known minorcannabinoids and terpinoids in different but muchsmaller concentrations and proportions. All Cannabis sativa chemovars produce activecompounds, but each variety produces thesecompounds in different concentrations andproportions. The major difference between over-the-counterCBD oils and cannabis based medical products isthat the latter can contain varying concentrationsof THC, above the 0.2% trace amount allowed inOTC products. In November 2018, cannabis-based products formedical use (CBMP) were moved from Schedule Ito Schedule 2 classification of Misuse of DrugRegulations. The re-scheduling meant that CBMPcould be prescribed medicinally by any doctor onthe GMC specialist register for an unmet clinicalneed.

is or contains cannabis, cannabis resin,cannabinol or a cannabinol derivative (notbeing dronabinol or its stereoisomers); is produced for medicinal use in humans; and is:

GPs can continue to prescribe CBMPs undershared care arrangements. The Government has defined a CBMP in humansas a product which:

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2.3.

(i) a medicinal product, or (ii) a substance or preparation for use as aningredient of, or in the production of an ingredientof, a medicinal product (1). Home Office and MHRA approvals require thecontent and ratio of THC/CBD to be declared, acertificate of analysis, a valid GMP certificate fromthe site of manufacture, a justification for specialclinical need and prescription by a doctorregistered on the GMC Specialist register. All CBMP are Schedule 2 controlled drugs and aresubject to the full controlled drug requirements ofany other Schedule 2 drug which includes strictrules around labelling, storage and prescriptions.

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W h a t i s C B D?

Full spectrum CBD products contain the full arrayof cannabinoids (including THC), terpenes andflavonoids. Full spectrum CBD benefits from the entourageeffect - the synergistic effect from combination ofdifferent cannabinoids. Broad spectrum products are similar to fullspectrum but THC has been removed. These will still likely give some of the entourageeffect (synergy of the various bioactive molecules),although the processing methods vary and minorcannabinoids and terpenes are lost to varyingdegrees. Broad spectrum products are oftenlabelled as ‘THC free’.

CBD isolate is purified CBD so the productcontains no trace of other cannabinoids, terpenesand other active compounds. These  products do not benefit from theentourage effect, but consumers can feelconfident that there are no traces of THC. This may be of particular relevance important forsome professionals such as athletes and pilotswhere drug testing is a mandatory requirement,so offers another ‘THC free’ choice.  Patients and users often report that CBD isolateproducts don’t produce as noticeable an effect vs.broad or full spectrum CBD hemp products, butthere is no large human data to support this.

F U L L S P E C T R U M V S B R O A D S P E C T R U M V S I S O L A T E

Is CBD safe?An extensive report by the WHO found CBD to be generally well tolerated with a good safety profile withno evidence that CBD causes intoxication, psychotic symptoms or impairments of motor orpsychomotor performance in humans. To date there is no evidence of recreational use, no effectsindicative of any abuse or dependence potential of CBD or any public health issue (2).

A drug company must have a product licence toadvertise and sell a medicine. Obtaining a licence for a medication is both timelyand costly and involves running clinical trials for aspecific illness or condition. In the UK, the MHRA assess data from clinical trialsand licences are only granted if strict safety andquality standards are met. There are currently two licenced cannabis basedmedical products available in the UK - Sativex andEpidyolex.

Sativex is a schedule 4 medication licenced forspasticity in MS and is composed of a 1:1 ratio ofTHC to CBD. Epidyolex is a 98% pure CBD preparation,schedule 5 drug and has been approved for thetreatment of severe epilepsy in Dravet andLennox- Gastaut syndromes. Nabilone is a synthetic cannabinoid withantiemetic properties with a licence in the UK totreat nausea and vomiting caused bychemotherapy unresponsive to conventionalantiemetics.

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KEY DIFFERENCES BETWEEN HEMP,CBD AND CANNABIS OILS IN THE UK

V A R I A B L E H E M P / C B D O I L S C A N N A B I S O I L S

PART OF PLANTEXTRACTED Seeds

Flowers and leaves ofhemp plant

Flowers and leaves ofcannabis plant

H E M P S E E D O I L S

MAIN COMPONENTSOmega-6 and omega-3fatty acids

Mostly CBD and B-caryophyllene with other smaller quantityphytocannabinoids and terpeneoids

Mostly THC with someCBD and otherphytocannabinoidsand terpeneoids

THC LEVELS

Less than 1 mg percontainer. Seeds usedmust produce less than0.2% THC

Variable – can be upto 30% dry weight) Noupper limit

CBD LEVELS

USES

Little to none Up to 20% dry weightVariable - up to 20% dryweight

Nutritional supplementsGeneral health andwellbeing supplement

Medical use forconditions such asepilepsy and pain

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None

anticonvulsantanalgesicanti-inflammatoryanti-anxietyantipsychoticneuroprotectiveimmunosuppressive

Doctors should be aware that CBD is oftenpromoted for a broad range of health benefits,yet the evidence base remains at large confinedto pre-clinical studies or animal models. CBD is however known to have a wide range ofuseful therapeutic modes of actions whichinclude the following properties:

I n d i c a t e d u s e s o f C B DA C L I N I C I A N ’ S G U I D E T O C B D

There has been rapid acceleration into CBDresearch over recent years. The strongest evidencefor CBD exists for treatment resistant epilepsies (3-4).  For most other indications, there is onlypre-clinical evidence, while for some there is acombination of pre-clinical and limited clinicalevidence.   Phase 2 and 3 clinical trials are currently underwayin diverse areas including schizophrenia, drugdependency, tumour reduction, pain conditions,and PTSD (5).

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CBD is available for use in a wide variety of formsand the pharmacokinetics and pharmacodynamicsof CBD and other cannabinoids vary as a functionof the route of administration. Oral CBD is a highly lipophilic molecule with low oralbioavailability. Oral and gastrointestinal tractabsorption is therefore slow, erratic and leads tovariable pharmacokinetics. Bioavailability from oral delivery has beenestimated at 6% due to low water solubility andsignificant first-pass metabolism in the liver.Maximal plasma concentrations are usuallyachieved after 60–120 min and may be up to 6hours for oral ingestion. Oils with graduated demarcated pipettes andcapsules allow for convenient and more accuratedosing in terms of the amount consumed but donot account for individual differences in likelyabsorption and bioavailability.

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CBD products infused into food and beverages willcause the CBD to be digested and metabolized.  The amounts in these products tends to vary butgenerally are quite low per serving. Sublingual / transmucosal This route of administration allows direct uptakeinto the blood which eliminates first passmetabolism. CBD tinctures generally are created using eitherethanol or vegetable glycerin as a solvent and canbe directly absorbed under the tongue or onmucosal surfaces. CBD suppositories may be suitable for those whoare unable to swallow CBD capsules or take CBDoils orally. CBD tampons are also being utilised tohelp with painful menstrual cramps although thehuman data is lacking currently in this area.

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c o n s u m e C B D?

Intranasal route Bypassing the oral route may be of benefit topatient patients who experience nausea, vomiting,oral mucositis or impaired gastrointestinalfunction. Vaping / inhalation Vaporizing CBD (in both oil or dried flower form)has become a popular method of use. CBDcartridges are heated to the point of vaporizationwhich results in rapid onset as cannabinoids areabsorbed through the lungs into the bloodstream.  Vaping results in fast onset of action and highsystemic bioavailability. Cannabis-related effectsgenerally begin within a few minutes of the firstinhalation. Peak plasma levels after 10 mins andremain active for 3-5 hours. CBD oils are viscous and are commonly mixedwith a thinning agent to allow the cartridge tofunction as intended. Consumers must be cautious concerning thesafety of the products they purchase and shouldavoid products containing propylene glycol (PG),polyethylene glycol 400 (PEG 400), or other suchadditives as there is evidence they producenoxious compounds when they are heated past acertain temperature. Smoking - which involves direct combustion ofCBD/ dried hemp flowers - can produce harmfultoxins which are damaging to the lungs andshould be actively discouraged.

Topical / transdermal Topical application through creams andtransdermal patches provides a pathway for localrather than systemic absorption of CBD. The avoidance of the first-pass metabolism effectimproves drug bioavailability. Transdermal applications allow a steady infusionof a drug to be delivered over a prolonged periodof time, while also minimising the adverse effectsof higher drug peak concentrations, which canimprove patient adherence. There may be low skin penetration of drugs with ahydrophilic structure.  There are many over-the-counter patch products available but many are notformulated to deliver active ingredient (CBD)transdermally and will have variable bioavailabilitydepending on the product.   Research into cannabinoid delivery systems isgrowing and it is expected that recentdevelopments in pharmacological, pharmaceuticaland technological sciences will result innew therapeutic strategies.

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We must emphasise that doctors must treat overthe counter CBD products in the same way as anyother general health or food supplement.  Claims that these non-medical products can treat,mitigate, cure or prevent disease can result in legalconsequences. Doctors should exercise extremecaution around giving advice on specific dosing forover the counter CBD products.  However, we also recognise the widespread use ofCBD amongst the general public for healthpurposes and patients may understandably asktheir doctors for their opinion or advice aroundefficacy, safety and interactions with otherprescribed medications. Holistic and compassionate medical care goesbeyond just knowing about prescribedmedications and keeping up-to-date withadvances in medicine and science is a professionalduty and also forms part of the GMC Good MedicalPractice Guidelines.

D O S I N G C B DA C L I N I C I A N ’ S G U I D E T O C B D

Gaining knowledge in CBD and cannabis-basedmedicines are no exception, as this duty appliesto all evidence-based therapies appropriate to apatient’s care. Doctors must ensure they are able to haveinformed conversations with patients aroundthis subject matter. They should also explorefurther why CBD is being used or considered foruse as this may highlight an unaddressedclinical need. With this in mind, we have prepared a guidewhich continues on the next page.

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DISCUSSING CBD WITH PATIENTS It may be useful to discuss CBD as a supplement to a diet which can help maintain generalhealth and well being due to its wide range of physiological effects and multiple potentialsites of action both centrally and peripherally within the body.

It can be useful to explain how CBD works in a similar way to anandamide and 2AG,modulating our own endogenous endocannabinoid system and affecting a wide range ofphysiological functions such as mood, sleep, inflammation and pain.

Different types of CBD products will impact dosing requirements.

CBD products and other cannabinoids will show a typical individualised and variable drugresponse which will be affected by age, tolerance, body fat percentage, genetics andmetabolism) – i.e. something that works well for one person may not produce the sameeffect for someone else.

CBD is excreted by the kidneys and moderate to severe impairment of kidney or liverfunction may theoretically reduce its clearance. Patients with reduced eGFR or liverimpairment may therefore be advised to take caution and start on a lower dose of CBD.

Typical starting regime should start with slow titration.

For CBD naïve patients we recommend a starting dose of 10mgs daily which can be built upgradually over about 4 weeks to around 60mgs and reassess. A few people are very sensitive(about 10%) hence the importance of starting at a low dose.

Patients may need guidance on how to accurately work out mg per ml from the container.

It may be useful for patients to keep a journal and track usage, dosage and effect.

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D R U G I N T E RAC T I O N SA C L I N I C I A N ’ S G U I D E T O C B D

There is a general lack of data on the types ofdrug-drug interactions that may occur betweenCBD and other pharmaceutical drugs in terms ofpublished evidence of clinically significantinteractions at the doses being used by consumersvia over-the-counter CBD products.  Generally, at doses of CBD below 50mg or even100mg a day, the chance of a clinically significantdrug/herb interaction is probably quite low.  However, if the patient is taking certainmedications such as antiepileptics,immunosuppressive agents post-transplant orcancer immunotherapy drugs or anticoagulantins,it is best practice to be especially careful and toensure that specialists involved in a patient’s careand prescribing are made aware of any CBD use. The main considerations are as follows: CBD is known to act as an inhibitor of P450isozymes. Patients should talk to their doctorsabout whether any of the medications they aretaking are metabolized by the cytochrome P450system before taking CBD.

Sodium valporate Ciprofloxacin St John’s Wort Sulphonamide CimetidineOmeprazoleAntifungalsAmiodaroneIsoniazidErythromycinClarithromycin

Common inhibitors include:

CBD is a potent inhibitor of CYP2C19 and CYP3A4and caution should be taken when cannabis-basedmedicines are co-administered with anymedications that are CYP inhibitors or inducers (6). Common examples of P450 inducersinclude Carbamazepine, Rifampicin and Phenytoin.

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Broad spectrum CBD products may increase theactions of warfarin and other anticoagulantsleading to increased risk of bleeding and forsuch patients the INR should be monitoredclosely (7).

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D R U G I N T E RAC T I O N S

A rise in liver function tests and serumconcentration of some anticonvulsants has beenobserved with Epidyolex. In a small study of 39adults and 42 children, raised drug levels were allwithin therapeutic range and AST/ ALT levelswere significantly increased in patientsconcurrently prescribed valproate and CBD (8).

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In another small study in children with refractoryepilepsy (n13), CBD was demonstrated toincrease clobazam and norclobazamconcentrations (9).

P o t e n t i a l s i d e e f f e c t s o f C B D

b a s e d p r o d u c t sA C L I N I C I A N ’ S G U I D E T O C B D

Information regarding CBD safety is limited to afew short-term human studies and informationshould be interpreted cautiously. Further study isneeded on larger cohorts of CBD patients, andevaluation of CBD effects following long-termexposure. To date, CBD has been found to have relatively lowtoxicity and multiple small studies havedemonstrated that it is well tolerated across awide dosage range. CBD exhibits no effectsindicative of any abuse or dependence potentialand there is no evidence of recreational use or anypublic health related problems associated with theuse of pure CBD (2). In a meta-analysis of studies involving 550 patientswith Lennox-Gastaut or Dravet syndrome takingEpidyolex, adverse effects associated with CBDincluded somnolence, decreased appetite,

diarrhoea and increased serumaminotransferases. Reports of somnolence weremore frequent in patients also receiving theantiepileptic clobazam (10). CBD differs to THC by lacking any intoxicatingfeatures. Patients may need to be reassured thatCBD will not make them feel “high”. Two of the most common adverse effects afterCBD administration are somnolence and sedationbut generally these are seen at high doses ofhundreds of milligrams. Other factors such as the chemovar includingthose high in myrcene (a terpene with potentiallysedating properties), may also be involved in thisresponse in some people based on preclinical andcase report/clinical observation but no largestudies exist to confirm this.

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P O T E N T IAL S I D E E F F E C T S O F

C B D BAS E D P R O D U C T S

These effects are dose-related and may bepotentiated by co-administration of the anti-epileptic drugs clobazam and valproate, and otherCNS depressants (including alcohol). Patients should be advised that their ability todrive or operate machinery could be impairedwhile under CBD treatment.

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The pharmacokinetics and toxicity of CBD inchildren is not well understood as in adults andtherefore we do not recommend that childrenshould be using over the CBD products It is recommended that any significant sideeffects/ adverse reactions are reported via theyellow card scheme.

In the UK, CBD falls into a novel food categorywhich allows it to be purchased legally without aprescription. A novel food is defined as a type offood that does not have a significant history ofconsumption or is produced by a method that hasnot previously been used for food. Novel foods aresubject to Food Standards Agency regulations.   CBD is legal to sell over the counter in the UK aslong as the product meets certain criteria. It cancontain very small amounts of a controlled drug(like THC) as long as: a) the preparation or other product is notdesigned for administration of the controlled drugto a human being or animal; b) the controlled drug in any component part ispackaged in such a form, or in combination withother active or inert substances in such a manner,that it cannot be recovered by readily applicablemeans or in a yield which constitutes a risk tohealth; and

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c) no one component part of the product orpreparation contains more than one milligram ofthe controlled drug (11). One milligram of the controlled drug (mainly THCbut also THCV and THCA) is allowed per containerregardless of the size of the container. It is widely thought that the limit of THC in legalCBD products is 0.2% but this refers to thepermitted seed type which must have a maximumTHC content of 0.2%.  Over the counter CBD products have not beenthrough the rigorous processes that medicines arerequire to be put through to gain market entry bythe MHRA and as such cannot be advertised ashaving medicinal properties. Advertising or promoting CBD wellnesssupplements products that claim to prevent, treator cure human disease is not permitted.

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t h e U K

As a result of a lack of regulatory enforcement andrapid growth in the CBD sector over the past fewyears, the overall safety and quality of productscannot be guaranteed. A number of laboratory analyses of CBD productshave identified concentrations of cannabinoidsthat differ from the amounts advertised – in somecases involving unlawfully high levels of controlledsubstances, other phytocannabinoids and harmfulchemicals including solvents and heavy metals. In a recently published study, 29 different CBDproducts available in the UK were tested. Thestudy found that only 38% products were within10% of the advertised CBD content. 55% ofproducts had measurable levels of controlledsubstances and detectable levels of heavy metalswere found in many CBD products (12). The Foods Standards Agency (FSA) announced adeadline of 31 March 2021 for the CBD industry tosubmit valid novel food authorisation applicationsto ensure products meet legal standards on safetyand content. After this time only products with avalid application will be allowed to remain on themarket to be sold directly to consumers.

This application process is both expensive andtime consuming and this may result in a reducedrange of products available to consumers as onlylarger companies can afford to take the necessaryregulatory steps. The FSA has also issued further guidancerecommending a daily dose of CBD as 70mgunless under medical direction, and that CBDshould not be taken by pregnant women nortaken with any other medications. The MCCS is not aware of any scientific evidencethat doses above 70mgs daily are unsafe. The usual dose range for adults with anxiety andpain, for example, is 60-100mgs daily. Childrenwith epilepsy take much higher doses – up to12mgs/kg is common.

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Due to the largely unregulated CBD market in theUK, consumers need to take extra caution ondeciding about which type of CBD product to use. With such a wide variety of products available,some people will naturally feel confused on whatconstitutes an effective and high quality and safeCBD product. One of the most important considerations isensuring the product has what is called a COA, orcertificate of analysis, which should be availablefor any reputable supplier or brand. 

W h a t s h o u l d c o n s u m e r s

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This document is proof that the batch has beentested by an approved third party laboratory andcontains the stated amount of CBD on the label aswell as being free from contaminants, THC abovetrace limits, and heavy metals as well as biotoxins. Whilst novel food authorisation will come intoforce on 31 March 2021 which will ensure stricterlegal standards on safety and content, in theinterim we recommend that consumers refer tothe checklist on the next page.

Is there a batch, lot, or control number?

CHECKLIST FOR CBD PRODUCTS

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Is there a production date or expiration date?

Is there GMP certification?

Are there appropriate warnings for use, including any individuals for whom the product iscontraindicated, as appropriate; and instructions for use and appropriate storage?

Is a robust, third-party lab testing report, which outlines the cannabinoid profile includinglab measured total amount of CBD available for this product?

If full-spectrum product, is there a terpene profile?

Does the company have an independent adverse events reporting programme?

Have products been lab tested by batch to confirm THC levels are within legal limits andcontain no pesticides, heavy metals or residual solvents?

Is there accurate labelling which ensure that consumers understand what they are buying?

Does the product make any medical claims?

Is it in compliance with EU food safety laws?

R E F E R E N C E SA C L I N I C I A N ’ S G U I D E T O C B D

http://www.legislation.gov.uk/uksi/2018/1055/https://www.who.int/medicines/access/controlled-substances/CannabidiolCriticalReview.pdfDevinsky, O., et al., Trial of Cannabidiol for Drug-Resistant Seizures in the Dravet Syndrome. NewEngland Journal of Medicine, 2017. 376(21): p. 2011-2020. Thiele, E.A., et al., Cannabidiol in patients with seizures associated with Lennox-Gastaut syndrome(GWPCARE4): a randomised, double-blind, placebo-controlled phase 3 trial. Lancet, 2018.391(10125): p.1085-1096.Iffland, K. and F. Grotenhermen, An Update on Safety and Side Effects of Cannabidiol: A Review ofClinical Data and Relevant Animal Studies. Cannabis and Cannabinoid Research, 2017. 2(1): p. 139-154. Alsherbiny MA, Li CG. Medicinal Cannabis-Potential Drug Interactions. Medicines (Basel).2018;6(1):3. Published 2018 Dec 23. doi:10.3390/medicines6010003 https://www.sps.nhs.uk/articles/cannabis-based-medicinal-products-potential-drug-interactions/ Gaston TE, Bebin EM, Cutter GR, Liu Y, Szaflarski JP, Program UC. Interactions between cannabidioland commonly used antiepileptic drugs. Epilepsia. 2017;58(9):1586-92Geffrey AL, Pollack SF, Bruno PL, Thiele EA. Drug-drug interaction between clobazam andcannabidiol in children with refractory epilepsy. Epilepsia. 2015;56(8):1246‐1251.doi:10.1111/epi.13060Lattanzi S, Brigo F, Trinka E, et al. Efficacy and Safety of Cannabidiol in Epilepsy: A SystematicReview and Meta-Analysis. Drugs. 2018;78(17): 1791-1804. doi:10.1007/s40265-018-0992-5http://www.legislation.gov.uk/uksi/2001/3998/contents/madeLiebling JP, Clarkson NJ, Gibbs BW, Yates AS, O'Sullivan SE (2020) An analysis of over-the countercannabidiol products in the United Kingdom, Cannabis and Cannabinoid Research X:X, 1–7, DOI:10.1089/can.2019.0078

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As part of the UK’s leading group of medicalcannabis experts, members have access toinformation to inform treatment decisions,up-to-date product guidance and support toensure clinicians can become as confident inprescribing medical cannabis as they are withfirst line treatments. With the most respected medical cannabisclinicians in the country providing support,members are better able to help theirpatients. Annual membership is £90 for consultants,GPs and others and £45 for nurses and AHPs.Membership is free for medical students andwe welcome international members. Join online at www.ukmccs.org.

The Medical Cannabis Clinicians Society is anindependent community of medical cannabispioneers – the first prescribers of thistreatment in the UK. We believe that every patient who couldbenefit from medical cannabis should haveaccess to it. We provide the medical and scientificcommunity interested in supporting patientswith medical cannabis with high-qualitytraining and expert support. Membership is open to those with aprofessional interest in medical cannabis,including clinicians, nurses, GPs, allied healthprofessionals (AHPs), medical students,healthcare scientists, pharmacists and thoseworking across acute, primary andcommunity healthcare.

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