The CanISleepinMS Study: Effect of Cannabidiol (CBD) on Sleep Quality in Patients With Multiple Sclerosis

The investigators conducted a series of 16 aggregated randomized, placebo-controlled N-of-1 trials to investigate the effect of purified cannabidiol (CBD) oil on nocturnal sleep quality in patients with multiple sclerosis. Each participant completed four treatment periods: two with CBD (300 mg daily) and two with placebo. The primary outcome is the insomnia severity index (ISI). Secondary outcomes included a sleep-wake diary and scores on the Checklist Individual Strength Fatigue subscale (CIS-F), Fatigue Severity Scale (FSS), and Epworth Sleepiness Scale (ESS).

Inclusion criteria

• A diagnosis of MS confirmed by a neurologist, based on the revised 2010 or 2017 McDonalds criteria
• Relapsing-remitting or primary or secondary progressive MS
• Expanded Disability Status Scale (EDSS) score <7.5
• No relapse for at least 6 months before the screening visit
• No changes in immunomodulating therapy stable
• For at least 3 months before the screening visit; no changes in use of other medications used for chronic conditions for at least 6 weeks before the screening visit (e.g. anti-depressant drugs, antidiabetics)
• Age minimally 18 years at the time of screening
• Body Mass Index (BMI) < 35.0 kg/m2 at the moment of screening
• Elevated levels of transaminases (ALAT, ASAT) until twice the Upper Limit of Normal (2x ULN) are allowed, as elevation of these levels is a common finding in MS patients
• No plans to (be involved in) getting pregnant during the trial
• No breast feeding during the trial
• A complaint of chronic impairment of sleep quality, leading to a diagnosis of insomnia by an MS neurologist and an experienced somnologist. In this context, insomnia is defined as difficulties initiating and/or maintaining sleep or too early awakenings, despite adequate opportunity and circumstances for sleep, resulting in some form of daytime impairment. Causes include psychophysiological insomnia, insomnia due to mental disorders like depression, and insomnia secondary to other MS-related symptoms like spasticity, pain or nocturnal voidings.
• Diagnosis will be based on fulfilment of the ICDS-3 criteria of insomnia and an ISI score of minimally 15 (threshold for clinical insomnia).
• Continuation of pharmacological treatments will be at the discretion of the study physicians.
• Willing and able to refrain from new, sleep-facilitating pharmacological treatments until the end of the treatment phase of the study
• Willing and able not to use any other cannabis product until completion of the study
• Willing and able not to use any supplement that could promote sleep (e.g. L-tryptophan,
• valerian, melatonin) during the treatment phase of the study.
• Continuation of non-pharmacological treatments will be at the discretion of the study physicians.
• Willing and able to refrain from new, sleep-facilitating nonpharmaceutical interventions until the end of the treatment phase of the study. Lifestyle should be kept as stable as possible.
• Willing and able to give informed consent
• Willing and able to fill in a daily digital diary during the treatment phase, to send this to the study nurse or research assistant once a week, and to be contacted by the research assistant minimally twice a week during the treatment phase of the study
• Willing and able to use the Neurokeys app (thus mobile phone) daily
• Willing to have blood sampled at the screening visit and have another
• two blood draws during the treatment phase of the study
• Willing and able not to drive a car or operate machinery within 8 hours after intake of the investigational product until the end of the treatment phase of the study
• Willing and able not to do evening/night shift work and not to cross time zones until the completion of the study
• Willing and able to refrain from excessive use of excessive use of caffeine (> 1 cup of coffee or 1 serving of energy drink) and alcohol (> 1 serving) in the evening, 6 hours before going to bed
• Willing and able to refrain from (products of) grapefruit, Seville oranges (used in marmalade), limes and pomelos during the treatment phase of the study
• Willing and able to refrain from experimenting with timing and type of diet, and beverages during the treatment phase of the study. A participant's dietary intake pattern should be kept as stable as possible during the treatment phase as there are numerous dietary components other than furanocoumarins that may influence CBD bioavailability

Exclusion criteria

• Circadian rhythm sleep-wake disorders, sleep related breathing disorders (such as moderate to severe obstructive sleep apnea, central breathing disorders during sleep, or sleep-related stridor that require prompt specific treatment), current delayed sleep phase syndrome where wake up time is regularly later than 8.00 a.m., or a sleep problem fulfilling the ICSD3 criteria of parasomnias
• Good response to initial treatment for the assessed sleep disorder
• Use of a benzodiazepine or other sleep medication, unless the patient has tapered off the sleep medication before the moment of inclusion
• Liver disease or blood levels of transaminases (ALAT, ASAT) above 3x ULN, as long term administration of high doses of CBD may affect (although reversible) liver function
• History of severe psychiatric comorbidity
• Increased risk of suicidal thoughts or behaviour
• History of drug or alcohol abuse
• Known or suspected hypersensitivity to cannabinoids or to excipients of the formulation of the investigational product - almond oil
• History of use with CBD oil prepared by pharmacy Clinical Cannabis Care
• Structural or recreational use of a cannabinoid product < 2 months before screening
• Whether the use of any of the following medications is a reason for exclusion will be at the discretion of the study physicians and delivery pharmacist.
• drugs with risk of liver injury; the decision of exclusion will be made in consultation with the MS neurologists and the pharmacist that provides the CBD product.
• drugs with risk of interaction with CBD. Data on the potential drug-CBD interactions below are based on mechanistic and clinical studies:
• drugs of which their biotransformation is primarily dependent on the cytochrome P450 enzymes CYP2C19 and CYP3A
• drugs that are inducers or inhibitors of enzymes of which CBD is a substrate: CYP2C19, CYP3A4.