Abstract | Cilj doktorskog rada bio je istražiti kratkoročne i dugoročne učinke nove formulacije DehydraTECH™2.0 CBD u odnosu na generički CBD i placebo kod ispitanika s hipertenzijom. Klinička istraživanja upotpunili smo spoznajama o znanju i stavovima studenata, liječnika i ljekarnika o CBD-u. DehydraTECH™2.0 CBD je patentirana formulacija kapsule koja povećava i ubrzava bioapsorpciju aktivnog sadržaja zbog poboljšanog lipofilnog sastava, što podrazumijeva patentirani proces kojim se dugolančane masne kiseline s visokim udjelom oleinske kiseline postupkom dehidracije povezuju s CBD-om, a za rezultat ima smanjen metabolizam prvog prolaza kroz jetru. U prvoj studiji (HYPER-H21-1) prvi je put analiziran učinak patentirane formulacije DehydraTECH™2.0 CBD-a te uspoređen s učinkom generičkog CBD-a. Utvrđeno je da je smanjenje otkucaja srca bio primarni pokazatelj povišene koncentracije CBD-a, s tim da je nova formulacija pokazala značajniji učinak u odnosu na generički CBD. DehydraTECH™2.0 CBD formulacija pokazala je i bolji učinak na početno smanjenje dijastoličkog krvnog tlaka i MAP-a u odnosu na generički CBD. Za vrijeme uzimanja DehydraTECH™2.0 gotovo svaki ispitanik imao je višu koncentraciju CBD-a u uzorcima plazme i u uzorcima urina. Takav učinak DehydraTECH™2.0 CBD formulacije posljedica je bolje apsorpcije u odnosu na generički CBD-a. Rezultati provedene studije ukazali su na razlike u metabolizmu CBD-a obzirom na spol. Muškarci su u odnosu na žene imali statistički značajno više koncentraciji CBD-a u uzorcima urina 180 minuta nakon ingestije DehydraTECH™2.0 CBD-a. Od ukupno 24 ispitanika šest ih je bilo na terapiji lijekovima (levotiroksin, lorazepam, diazepam, celekoksib, acetil salicilna kiselina). Vrijednosti koncentracija CBD-a u njihovim uzorcima uglavnom odstupaju od srednjih vrijednosti. Zaključujemo da korištenje tih lijekova (ali i svih drugih lijekova koji se metaboliziraju preko istih CYP P450 enzima) utječe na metabolizam CBD-a, što treba uzeti u obzir pri optimizaciji doziranja CBD-a. Tijekom i nakon studije nisu uočene ni prijavljene ozbiljne nuspojave. Prijavljene su samo one blage: proljev i relaksacija uz pospanost nakon generičkog CBD-a te relaksacija bez pospanosti nakon DehydraTECH™2.0 CBD. Kako bi se uočila veza između postignute koncentracije CBD-a u uzorcima i metabolizma s genetskom varijabilnosti citokroma P450, istraživanje je uključivalo analizu polimorfizma gena CYP2C9*2, CYP2C9*3, CYP2C19*2, CYP2C19*3, CYP2C19*17 i CYP3A4. Kod enzima CYP2C9*2*3 uočeno je da ispitanici sa sporim/slabim metabolizatorom (PM od eng. poor metabolizer) nakon konzumiranja DehydraTECH™2.0 CBD formulacije imaju veću koncentraciju CBD-a u plazmi u 180. minuti. U našoj drugoj studiji (HYPER-H21-4) prvi su put su analizirane koncentracije CBD-a i metabolita tijekom 12 tjedana. Analizom koncentracije CBD-a u plazmi u prvoj vremenskoj točki mjerenja, nakon dva i pol tjedna konzumiranja CBD-a, uočene su veće koncentracije CBD-a kod muškaraca nego kod žena. U sljedećoj vremenskoj točki (nakon pet tjedana) koncentracija CBD-a bila je viša u žena nego u muškaraca. Rezultati naše studije pokazuju da su nakon prestanka uzimanja CBD-a i dvotjednog ispiranja,koncentracije CBD-a u žena, u odnosu na muškarce, ostale znatno više. Zbog svoje visoke lipofilnosti CBD se lakše akumulira u lipofilnom okruženju, što utječe na kumulativnu koncentraciju i usporava eliminaciju. Postotak tjelesne masti kod žena bio je značajno viši u usporedbi s muškarcima, dok su postoci mišićnog tkiva i vode bili znatno niži, što vjerojatno objašnjava veće koncentracije CBD-a u plazmi žena u kasnijim vremenskim točkama mjerenja. Prisutnost CBD-a u plazmi kod žena uočena je čak i nakon 50 dana od zadnjeg uzimanja CBD preparata, za razliku od muškarca kod kojih ni jedan uzorak nije bio pozitivan na CBD ni na njegove metabolite. Kod muškaraca je niži postotak masnog tkiva te smanjena akumulacija u adipoznom tkivu rezultirala višim koncentracijama CBD-a u krvotoku te je metaboliziran i izlučen urinom, tj. eliminiran iz tijela brže u usporedbi sa ženama. U svim ispitivanim vremenskim točkama prisutnost metabolita 7-COOH-CBD bila je značajno veća kod žena u odnosu na muškarce. Ispitanici koji uzimaju terapiju za hipertenziju (inhibitore angiotenzin-konvertirajućeg enzima-ACE, blokatore kalcijskih kanala i tiazidne diuretike) nisu imali statistički značajnu razliku u koncentracijama CBD-a i njegovih metabolita u uzorcima u odnosu na ispitanike koji nisu bili na terapiji. U trećoj studiji prvi su put ispitane percepcije i znanja o terapijskoj primjeni CBD-a među studentima u Splitu, Zagrebu i Osijeku, kao i među ljekarnicima i liječnicima u Hrvatskoj. Rezultati ukazuju na nedostatak znanja o CBD-u među objema skupinama, s obzirom da većina ispitanika smatra da im je potrebna dodatna edukacija o CBD-u. Uočena je značajno veća upotreba CBD-a kod studenata u odnosu na liječnike i ljekarnike. Za razliku pak od studenata, značajno veći postotak liječnika i ljekarnika čita znanstvene radove o CBD-u. Liječnici i ljekarnici uglavnom ne propisuju i/ili preporučuju CBD iako imaju dovoljno znanja o indikacijama, nuspojavama i interakcijama. Pretpostavljamo da je razlog, osim nesigurnosti u znanju, i visoka cijena proizvoda. Stoga je razumljivo da liječnici i ljekarnici općenito smatraju da zdravstveno osiguranje treba pokriti troškove lijeka. Rezultati ovog doktorskog rada uključuju niz preporuka za ispravno doziranje i pravilnu primjenu nove formulacije kanabidiola. |
Abstract (english) | This doctoral dissertation's objective was to investigate the short-term and long-term effects of the new DehydraTECH™2.0 CBD formulation compared to generic CBD and placebo in subjects with hypertension. We completed the clinical research with the knowledge and attitudes of students, physicians, and pharmacists about CBD. The patented process that dehydrates long-chain fatty acids high in oleic acid with CBD, reduces the metabolism of the first pass through the liver. Therefore, the DehydraTECH™2.0 CBD formulation has increased and accelerated bioabsorption of the active content. The effects of the unique DehydraTECH™2.0 CBD formulation were evaluated and compared with the effects of generic CBD in our initial study (HYPER-H21-1). The primary indication of increased CBD content was found to be a decrease in heart rate, with the novel formulation demonstrating a greater impact than generic CBD. Additionally, the DehydraTECH™2.0 CBD formulation demonstrated a superior impact on the initial lowering of MAP and diastolic blood pressure. Due to CBD's improved absorption, nearly every participant ingesting DehydraTECH™2.0 CBD displayed higher concentrations of CBD in their plasma and urine samples. Based on gender, our study's findings revealed variations in CBD metabolism. In urine samples taken 180 minutes after ingesting DehydraTECH™2.0 CBD, men's CBD concentrations were significantly greater than women's. Six of the 24 participants in the initial study were receiving medication therapy (levothyroxine, lorazepam, diazepam, celecoxib, and acetylsalicylic acid). Their samples' CBD concentration values significantly differ from the mean values. We conclude that the metabolism of CBD can be affected by the consumption of these prescription drugs (as well as all other drugs metabolized by the same CYP P450 enzymes), and that this should be considered when calculating the optimal dosage of CBD. During or following the research, no significant adverse effects have been noticed or reported. The only minor adverse effects were noted: relaxation with drowsiness and diarrhea after taking generic CBD, and relaxation without drowsiness after taking DehydraTECH™2.0 CBD. To observe the relationship between the achieved concentration of CBD in the samples and the metabolism with the genetic variability of cytochrome P450, the study included the analysis of polymorphisms of CYP2C9*2, CYP2C9*3, CYP2C19*2, CYP2C19*3, CYP2C19*17 and CYP3A4 genes. After ingesting the DehydraTECH™2.0 CBD formulation, participants with a slow/weak metabolizer (engl. poor metabolizer-PM) at CYP2C9*2*3 enzyme showed increased CBD concentration in the plasma in 180 minutes. For the first time, during a 12-week period, the concentrations of CBD and metabolites were analyzed in our second study (HYPER-H21-1). Men had higher concentrations of CBD than women did, according to an analysis of the CBD concentrations in plasma at the first time point of testing, which was measured 2.5 weeks following CBD ingestion. At the next time point (after 5 weeks), the concentration of CBD was higher in women than in men. Even when they stopped taking their CBD medication and entered a two-week washout period, the study revealed noticeably greater CBD concentrations in women than men. CBD accumulates more easily in a lipophilic environment because of its high lipophilicity. This slows down the elimination process and affects the cumulative concentration. Women had much larger percentages of body fat than men did, but their percentages of muscle tissue and water were significantly lower. The increased levels of CBD in women's plasma at later test periods are presumably explained by this. Unlike men, who did not have a single sample that was positive for CBD or its metabolites, the woman's plasma revealed that it contained CBD even 50 days after the last consumption of the CBD preparation. Men had a lower percentage of fat tissue than women, and since there was less CBD accumulation in fat tissue, there was more CBD in the bloodstream. In addition, CBD is eliminated in the urine, excreting from the body faster in men than in women. Compared to men, women had significantly higher levels of 7-COOH-CBD metabolites at all time points. The concentrations of CBD and its metabolites in the samples did not differ significantly from the results for subjects who were not receiving therapy for hypertension, including angiotensin-converting enzyme-ACE inhibitors, calcium channel blockers, and thiazide diuretics. Our third study examined the opinions and understandings of Croatian physicians and pharmacists, as well as students in Split, Zagreb, and Osijek, regarding the medicinal use of CBD. The majority of participants claimed that they needed more information regarding CBD, indicating that both groups lacked knowledge about the substance. Students were found to consume CBD at a considerably higher rate than physicians and pharmacists. Compared to university students, a much higher proportion of doctors and pharmacists read scientific articles on CBD. Even though they have considerable knowledge about the benefits, side effects, and interactions of CBD, medical professionals commonly do not prescribe or promote it. We believe that, apart from a lack of knowledge, the explanation is the high price of the product. This is why medical professionals generally think that health insurance should cover the cost of this prescription drug. The results of this doctoral thesis provide several recommendations for the correct dosage and proper application of the new cannabidiol formulation. |