What are the constant treatment recommendations for individuals with a seizure history using cannabis?

Management of Seizures in Individuals Using Cannabis

For individuals with seizure history using cannabis, discontinuation of cannabis is strongly recommended as the primary treatment approach to reduce seizure risk and improve outcomes.

Cannabis and Seizure Risk

• Cannabis use may complicate seizure management and potentially worsen seizure control in individuals with epilepsy 1
• While some cannabis-derived products (particularly high-CBD/low-THC formulations) have been studied for epilepsy treatment, regular recreational cannabis use is not recommended for individuals with seizure disorders 2, 3
• Heavy cannabis use (>4 times weekly for over a year) can lead to cannabinoid hyperemesis syndrome, which may complicate diagnosis and treatment of underlying conditions 1

Assessment of Cannabis-Using Patients with Seizure History

• Quantify cannabis consumption patterns: amount used per day (grams of dried cannabis, mg of CBD/THC in oils) and frequency of use 1
• Screen for cannabis use disorder using validated tools like the revised Cannabis Use Disorder Identification Test 1
• Evaluate for potential cannabis withdrawal syndrome (CWS), which can begin after 48 hours of abstinence and may exacerbate underlying conditions 1
• Consider neurological consultation for patients with seizure history using cannabis, especially with any localizing neurologic symptoms 1

Treatment Recommendations

Primary Approach

• Complete cannabis cessation is the recommended first-line approach for individuals with seizure history 1
• Cannabis cessation should be maintained for at least 6 months or 3 typical seizure cycle lengths to properly assess impact on seizure control 1
• Weaning should be collaborative with the patient, with the rate of cannabis taper guided by the patient's tolerance of dose reduction 1

Weaning Protocol for High-Dose Users

• For patients using >1.5 g/day of inhaled cannabis, >300 mg/day CBD oil, or >20 mg/day THC oil 1:
  • Begin weaning at least 7 days before any planned procedures 1
  • Initial target should be reducing consumption below these threshold doses 1
  • Do not attempt cannabis weaning or cessation within 24 hours of any planned procedure 1

Supportive Care During Cannabis Cessation

• For cannabis withdrawal syndrome management, consider:
  • Gabapentin for symptom management 1
  • Monitoring for nausea, stomach pain, and other withdrawal symptoms 1
  • Addressing underlying conditions that may have led to cannabis use (anxiety, chronic pain) 1

Medication Management

• Anti-seizure medications should be optimized according to seizure type and patient characteristics 1
• Cannabis use is not a contraindication to standard seizure medications, but monitoring for potential interactions is recommended 1
• For patients with moderate-severe seizures (>4 episodes per year lasting >2 days each), prophylactic anti-seizure medication is indicated regardless of cannabis use status 1

Special Considerations

Potential Benefits of Medical Cannabis Products

• Some evidence suggests that specific medical cannabis formulations (particularly high-CBD/low-THC products) may benefit certain types of treatment-resistant epilepsy 4, 5
• However, a prospective observational study of high-CBD/low-THC formulations found no evidence of efficacy in reducing seizures at the doses studied 6
• If considering medical cannabis for seizure management, this should be done under specialist neurological supervision with pharmaceutical-grade products 3

Monitoring and Follow-up

• Regular liver enzyme monitoring is recommended if using CBD products, as CBD presents risks for hepatotoxicity 1
• Doses of CBD >300 mg/day have been associated with reversible liver enzyme abnormalities 1
• Patients should be monitored for common side effects of cannabis including dizziness, confusion, dry mouth, and fatigue 1

Pitfalls to Avoid

• Do not assume that all cannabis products have the same effect on seizure threshold - different ratios of CBD:THC may have varying impacts 2
• Avoid stigmatizing patients using cannabis, as this may reduce treatment adherence 1
• Do not delay treatment of seizures while waiting for complete cannabis cessation - optimize anti-seizure medications concurrently 1
• Be aware that cannabis use may affect anesthetic requirements if procedures are needed 1