Revista Biomédica Revisada Por Pares
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En el último tiempo, se han descrito diversos beneficios con el uso de cannabinoides en diferentes situaciones clínicas. Dentro de ellas se ha planteado un posible efecto en el control de la esclerosis múltiple, pero la real utilidad clínica es tema de debate. Para responder a esta pregunta utilizamos la base de datos Epistemonikos, la cual es mantenida mediante búsquedas en múltiples bases de datos. Identificamos 25 revisiones sistemáticas que en conjunto incluyen 35 estudios que responden la pregunta de interés, entre ellos 26 estudios aleatorizados. Extrajimos los datos, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. Concluimos que el uso de cannabinoides en esclerosis múltiple no reduce la espasticidad ni el dolor, y probablemente se asocia a efectos adversos frecuentes.
La esclerosis múltiple es una enfermedad crónica desmielinizante del sistema nervioso central que puede presentarse de forma remitente-recurrente y/o progresiva. Las manifestaciones clínicas son diversas e incluyen pérdida de fuerza y/o sensibilidad en las extremidades, disminución de la agudeza visual, dolor secundario a espasticidad, ataxia y disfunción vesical. El tratamiento de los brotes se realiza de preferencia con corticoides, mientras que a largo plazo se dispone de diferentes alternativas como beta-interferones, inmunomoduladores, anticuerpos monoclonales, anti-neoplásicos y análogos de esfingosina. A pesar de todas las alternativas terapéuticas disponibles, hasta en un 30-40% de los casos persisten síntomas refractarios.
En los últimos años, se han descrito diversos beneficios del uso de tetrahidrocannabinol y cannabidiol en el manejo de la espasticidad, dolor y disfunción vesical debidos a esclerosis múltiple, especialmente en pacientes con síntomas refractarios a la terapia convencional, probablemente debido a la modulación de receptores CB1 y CB2 del sistema endocannabidiol. Sin embargo, su real utilidad clínica no está del todo clara.
Utilizamos la base de datos Epistemonikos, la cual es mantenida mediante búsquedas en múltiples bases de datos, para identificar revisiones sistemáticas y sus estudios primarios incluidos. Con esta información generamos un resumen estructurado, siguiendo un formato preestablecido, que incluye mensajes clave, un resumen del conjunto de evidencia (presentado como matriz de evidencia en Epistemonikos), metanálisis del total de los estudios, tablas de resumen de resultados con el método GRADE, y tabla de otras consideraciones para la toma de decisión.
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Mensajes clave
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Cuál es la evidencia. |
Encontramos 25 revisiones sistemáticas [1],[2],[3],[4],[5], [6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18], [19],[20],[21],[22],[23],[24],[25]; que en conjunto incluyen 35 estudios primarios que responden la pregunta de interés, reportados en 57 referencias [26],[27],[28],[29],[30],[31], [32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43], [44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55], [56],[57],[58],[59],[60],[61],[62],[63],[64],[65],[66],[67], |
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Qué tipo de pacientes incluyeron los estudios |
Todos los estudios incluyeron pacientes con esclerosis múltiple, pero sólo algunos especificaron el subtipo de esta; seis estudios incluyeron pacientes con esclerosis múltiple remitente-recurrente [39],[40],[52],[60],[73],[76],[80]; siete estudios incluyeron pacientes con esclerosis múltiple progresiva primaria [40],[49],[52],[65],[71],[76],[80]; y ocho estudios incluyeron pacientes con esclerosis múltiple progresiva secundaria [28],[33],[40],[49],[52],[71],[76],[80]. La edad de los pacientes incluidos fue reportada sólo en algunos estudios, siendo variable pero mayor a 18 años en todos ellos. En sólo siete estudios se reportó la gravedad de los pacientes incluidos a partir de la escala EDSS score, presentando un puntaje mayor a 5 en todos ellos [28],[36],[40],[49],[71], [76],[80]. En sólo ocho estudios se reportó la duración de la enfermedad, variando de 4,5 a 17 años en los diferentes estudios [28],[33],[36],[49],[52],[71],[76],[80]. |
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Qué tipo de intervenciones incluyeron los estudios |
Los distintos estudios usaron diferentes formas de presentación de cannabis a diferentes dosis, comparado contra placebo. Un estudio utilizó cannabis fumada [28]; nueve estudios usaron comprimidos de cannabis [39],[40],[49],[61],[73], [74],[76],[79],[80]; dos estudios usaron dronabinol [40], [71]; y diez estudios usaron nabiximol spray sublingual [26], [33],[36],[38],[47],[48],[52],[59],[62],[70]. El resto de los estudios usaron otras formas menos convencionales. |
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Qué tipo de desenlaces midieron |
Las distintas revisiones sistemáticas identificadas agruparon los desenlaces de la siguiente forma:
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*EDSS score: expanded disability status scale.
La información sobre los efectos de los cannabinoides en esclerosis múltiple está basada en siete estudios aleatorizados [33],[36],[52],[63],[69],[70],[80] que incluyen 1985 pacientes. El resto de los estudios no reportó los desenlaces de interés, o ninguna revisión identificada logró extraer los datos de manera que pudieran ser incorporados a un metanálisis. Cuatro estudios [33],[36],[63],[80] midieron el desenlace espasticidad (1247 pacientes), tres estudios [33],[52],[70] midieron el desenlace dolor (327 pacientes) y cuatro estudios [33],[36],[52],[63] reportaron los efectos adversos (1025 pacientes). El resumen de los resultados es el siguiente:
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A quién se aplica y a quién no se aplica esta evidencia |
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| Sobre los desenlaces incluidos en este resumen |
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| Balance riesgo/beneficio y certeza de la evidencia |
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| Qué piensan los pacientes y sus tratantes |
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| Consideraciones de recursos |
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| Diferencias entre este resumen y otras fuentes |
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| ¿Puede que cambie esta información en el futuro? |
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Mediante métodos automatizados y colaborativos recopilamos toda la evidencia relevante para la pregunta de interés y la presentamos en una matriz de evidencia.
Siga el enlace para acceder a la versión interactiva: Cannabinoides para la esclerosis múltiple
Si con posterioridad a la publicación de este resumen se publican nuevas revisiones sistemáticas sobre este tema, en la parte superior de la matriz se mostrará un aviso de “nueva evidencia”. Si bien el proyecto contempla la actualización periódica de estos resúmenes, los usuarios están invitados a comentar en Medwave o contactar a los autores mediante correo electrónico si creen que hay evidencia que motive una actualización más rápida.
Luego de crear una cuenta en Epistemonikos, al guardar las matrices recibirá notificaciones automáticas cada vez que exista nueva evidencia que potencialmente responda a esta pregunta. El detalle de los métodos para elaborar este resumen están descritos aquí: http://dx.doi.org/10.5867/medwave.2014.06.5997.
La Fundación Epistemonikos es una organización que busca acercar la información a quienes toman decisiones en salud, mediante el uso de tecnologías. Su principal desarrollo es la base de datos Epistemonikos (www.epistemonikos.org).
Los resúmenes de evidencia siguen un riguroso proceso de revisión por pares interno.
Declaración de conflictos de intereses
Los autores declaran no tener conflictos de intereses con la materia de este artículo.
Esta obra de Medwave está bajo una licencia Creative Commons Atribución-NoComercial 3.0 Unported. Esta licencia permite el uso, distribución y reproducción del artículo en cualquier medio, siempre y cuando se otorgue el crédito correspondiente al autor del artículo y al medio en que se publica, en este caso, Medwave.
Multiple beneficial effects have been proposed lately for cannabinoids in different clinical situations. Among them, it has been postulated they would control symptoms of multiple sclerosis. However, there is no consensus about their real clinical role. To answer this question, we searched in Epistemonikos database, which is maintained by screening multiple databases. We identified 25 systematic reviews including 35 studies overall, of which 26 were randomized trials. We extracted data, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. We concluded cannabinoids in multiple sclerosis do not reduce spasticity or pain, and are probably associated to frequent adverse effects.
Autores:
Rodrigo Meza[1,2], Javier Peña[1,2], Karen García[1,2], Oscar Corsi[2,4], Gabriel Rada[2,3,4,5,6]
Citación: Meza R, Peña J, García O, Corsi O, Rada G. Are cannabinoids effective in multiple sclerosis?. Medwave 2017; 17(Suppl1):e6865 doi: 10.5867/medwave.2017.6865
Fecha de envío: 27/12/2016
Fecha de aceptación: 27/12/2016
Fecha de publicación: 10/3/2017
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