The Effects of Cannabidiol (CBD) on Electrical and Autonomic Cardiac Function in Children
Phase: PHASE1
Conditions: Lennox-Gastaut Syndrome, Dravet Syndrome
Sponsor: Gillette Children's Specialty Healthcare

Protocol version 9/28/2016 
 
 
 
 
The effects of cannabidiol (CBD) on electrical and autonomic 
cardiac function in children with severe epilepsy 
NCT02815540 
Protocol Version 9/28/2016 
 
 

Protocol version 9/28/2016 
 
The effects of cannabidiol (CBD) on electrical and autonomic 
cardiac function in children with severe epilepsy 
PI Name and Institutional Affiliation: 
Beverly S. Wical, MD 
Gillette Children's Specialty Healthcare 
Co-Investigators: 
▪ Cardiac Electrophysiologist – to be determined 
▪ Shani Norberg, MD 
▪ Kari Williams, MPH, CCRC 
▪ Sam Roiko, PhD 
Study Coordinator: 
Heather Wendorf, MPH, CCRC 
Background and Significance 
Children with medically intractable epilepsy do not obtain adequate seizure 
control with available therapeutics. Other treatment options are needed to 
manage their condition. Two pediatric epilepsy syndromes where this is most 
evident are Dravet syndrome (DS) and Lennox Gastaut syndrome (LGS). 
Children with Dravet syndrome (DS) are affected by a severe epileptic 
encephalopathy. Children initially appear healthy, but then seizures emerge in 
the first year of life followed by a relentless course of epilepsy and cognitive 
impairments (1). Up to 80% of those affected by this disorder have a mutation 
on the SCN1A gene, which encodes for neuronal sodium channels—similar 
sodium channels are found in heart muscle. This severe epilepsy has a major 
adverse impact on health and quality of life, and carries with it a significant risk 
of early mortality. 
Lennox Gaustaut syndrome (LGS) is a severe form of epilepsy with onset of 
seizures occurring between 1 and 7 years of age. Multiple disorders are 
associated with LGS including brain malformations, perinatal asphyxia, severe 
head injury, central nervous system infection, or inherited degenerative or 
metabolic conditions (2). LGS is characterized by multiple seizure types, and a 
severe epileptic encephalopathy leads to significant developmental disabilities, 
impaired intellectual functioning, and information processing and behavioral 
disturbances (2). 
Sudden unexpected death in epilepsy (SUDEP) is a major cause of mortality in 
patients with epilepsy. Patients with DS experience one of the highest rates of 
SUDEP (3, 4). While mechanisms of SUDEP are complex and multifactorial, 
autonomic nervous system abnormalities are considered an important 

Protocol version 9/28/2016 
 
contributor to mortality (5, 6). It has been reported that children with DS 
exhibited a significantly higher number of signs and symptoms of autonomic 
nervous system abnormalities than children in a control group (7). Studies of 
electrical and autonomic cardiac function in patients with DS demonstrated an 
imbalance of cardiac autonomic function toward a relative predominance of 
adrenergic tone compared to both healthy children and patients with other forms 
of epilepsy, and this finding was independent of the use of antiepileptic 
medications (8, 9). This suggests that dysfunction in the autonomic nervous 
system, or dysautonomia, is a significant factor in this condition. A number of 
these patients have seizures triggered by autonomic stimulation (e.g., strong 
emotion), and many have pronounced autonomic features (e.g., flushing of face, 
pallor or tachycardia) during ictal events. Modulating autonomic nervous system 
tone may potentially affect seizure control and risk for SUDEP. 
Investigators have been unable to accurately determine the incidence of 
SUDEP in patients with LGS, perhaps due to variation in the etiology and 
definition of LGS. In addition, the literature available on LGS and autonomic 
nervous system dysfunction is sparse, as is the literature on LGS and cardiac 
function. Patients with LGS may be at an increased risk for cardiac 
abnormalities (10). Nei (2012) documented sinus-tachycardia, T wave inversion 
and ST segment depression during tonic seizures, as well as 3 to 4.8 seconds 
of asystole during sleep in subjects wearing a subcutaneously implanted loop 
recorder (10). Studies of SUDEP have identified increased risk in those with 
early onset and medically intractable epilepsy, neurologic abnormalities, and a 
need for multiple medications. Children with LGS meet all these criteria. 
Available antiepileptic drugs (AEDs) have not proven to be particularly effective 
in offering seizure control to those with severe pediatric epileptic 
encephalopathies. Recently, the use of cannabidiol (CBD) has generated great 
interest as a novel treatment for highly refractory epilepsy such as DS or LGS. 
Preliminary studies suggest that CBD may be effective in treating the seizures 
associated with DS. Major phase III drug trials of FDA-approved orphan drug 
products are close to implementation or are in the initial phase of recruitment. 
Families are also seeking out CBD products to use on their own through state-
licensed pharmacies (e.g., through the state of Minnesota or 
www.epilepsycolorado.org). 
Thus, a significant number of children with DS and LGS will soon be enrolling in 
stage III clincial trials or using CBD acquired as an artisanal oil. However, a 
number of questions regarding the safety and efficacy of CBD for treating 
seizures remain unanswered since FDA approval and labeling have not yet 
been granted. In addition, current phase III studies do not address potential 
autonomic adverse effects. While information on adverse effects may be 

Protocol version 9/28/2016 
 
forthcoming in the future for industry-manufactured products, the existence of 
state-licensed pharmacies that currently dispense CBD as an artisanal oil 
creates an urgency to address these questions. The purpose of this protocol is 
to determine whether CBD affects cardiac autonomic function, which may pose 
another mechanism of action for seizure reduction and prevention of SUDEP. 
To date, there is no medical literature that has determined whether CBD has 
cardiac autonomic effects on pediatric patients using CBD for neurological 
disorders including epilepsy. Several previous studies only suggest that CBD 
may modulate cardiac autonomic effects. One preclinical study reported that 
CBD attenuates cardiac responses to restraint stress in rats (11). In adult 
humans, CBD has been shown to attenuate anxiety (12). It has also been 
demonstrated in healthy adult volunteers that while an acute dose of the more 
well-known cannabinoid delta-9-tetrahydrocannabinol (THC) increases heart 
rate, CBD does not, suggesting that CBD may not result in deleterious adverse 
effects (13). These findings indicate the importance of characterizing the cardiac 
autonomic effects of CBD in pediatric patients with medically refractory epilepsy. 
If CBD modulates cardiac autonomic effects, it may also reduce the risk of 
SUDEP. 
Summary of Background 
DS and LGS are severe forms of epilepsy that are largely unresponsive to 
current AEDs 
SUDEP is a major cause of mortality with intractable forms of epilepsy such as 
DS and LGS 
Dysautonomia and increased risk for cardiac abnormalities may play a role in 
causing SUDEP in patients with highly refractory epilepsy 
Modulating autonomic nervous system tone may affect seizure control and risk 
for SUDEP 
Cannabidiol may have an effect on the autonomic nervous system and is now 
being studied as a potential treatment for refractory epilepsy 
Cannabidiol is being obtained from state-licensed pharmacies without having 
undergone study in clinical trials, and thus, has not been well-characterized 
This study will determine if Cannabidiol obtained from state-licensed 
pharmacies has any effects on cardiac rhythm and reduction in seizures 
Rationale for Conducting the Study 
Although marijuana has been in use for centuries, CBD has not been well 
studied as an antiepileptic medication for use in children. Little is known about 
the autonomic effects of CBD in general, and virtually nothing is known about 

Protocol version 9/28/2016 
 
the effects that CBD might have on the cardiac function of children with DS or 
other severe forms of epilepsy. Currently, industry sponsors are conducting 
studies of CBD in connection with clinical trials of their study drugs. However, 
similar studies of CBD when administered as an artisanal oil derived from other 
sources have not been reported.  
We propose to study the effects of CBD on cardiac electrical function and the 
autonomic nervous system in children with DS and LGS, when the CBD was 
administered as an artisanal oil obtained through state dispensiaries or other 
sources. Our intent is to begin to assess potential risks and benefits of this 
therapy in a vulnerable patient population by characterizing the effects of CBD 
on EKG findings, heart rate variability and the occurrence of seizures. 
Specific Aims/Study Objectives 
This is a pilot study to explore the effects of cannabidiol (CBD) on autonomic 
cardiac function in children with DS or LGS when the CBD was administered as 
an artisanal oil. This will be achieved by addressing the following specific aims. 
Aim #1:  To determine the effects of CBD on cardiac function in 30 
children with DS and LGS. This is the primary aim of the study: The effects of 
CBD on the cardiac function of 30 children with DS or LGS will be assessed 
using a 12-lead electrocardiogram (EKG), an optional signal average EKG,  and 
a 24-hour Holter monitor. We hypothesize that there will be no alterations in 
ventricular repolarization and heart rate variability on the EKGs and Holter 
monitoring, respectively, after taking CBD for 4-8 weeks, compared to when 
participants were not taking CBD. Milestone: Records from 12-lead EKG and 
24-hour Holter monitor in 30 patients. 
Note: The following aims are secondary to the primary outcome and goal of 
assessing the effects of CBD on cardiac function. 
Aim #2:  To assess signs and symptoms of dysautonomia in the presence 
and absence of CBD. Signs and symptoms of dysautonomia include parental 
perception of body temperature, skin color in hands and feet, sweating, pupil 
size, flushing, feeding issues, heart rate, and constipation. These signs and 
symptoms will be collected using a previously-established dysautonomia 
survey. We hypothesize there will be no change in qualitative assessments of 
signs and symptoms of dysautonomia after taking CBD for 4-8 weeks, 
compared to when participants were not taking CBD. Milestone: Completed 
dysautonomia surveys in 30 patients before and after CBD administration.  
Aim #3:  To determine the effects of CBD on the occurrence of seizures. 
The number of seizures in children who obtain CBD will be assessed using a 7-
day seizure diary (Seizure tracker). Caregivers will record the number of 

Protocol version 9/28/2016 
 
seizures for a 7-day period prior to CBD administration, and repeat the seizure 
tracking after having received CBD for 4-8 weeks. Change in seizure numbers 
will be compared pre- and post-CBD administration. We hypothesize that study 
participants will have lower seizure counts after being on CBD compared to 
when weren't taking CBD. Milestone: Completed 7-day seizure diaries in 30 
patients before and after CBD administration. 
Study Design and Methodology 
Study Design:  Thirty patients with DS or LGS who are going to register to take 
medical cannabis (cannabidiol, or CBD) in the state of Minnesota will be offered 
the opportunity to participate in this study. If consent is obtained, the patient or 
guardian will be asked to complete a questionnaire developed for this study that 
documents observable signs and symptoms of dysautonomia, and to complete 
a seizure diary for 7 days prior to initially receiving the CBD. Each participant 
will also have a 12-lead electrocardiogram (EKG), an optional signal average 
EKG, and wear a 24-hour Holter monitor, all non-invasive measures of cardiac 
function, prior to being administered the CBD. The EKGs and 24-hour Holter 
monitor will be interpreted by a cardiac electrophysiogist and will be reviewed 
for heart rate variability parameters. The dysautonomia questionnaire, seizure 
diary and cardiac measurements will be repeated 4-8 weeks after the subject 
has been on a stable regimen of CBD. This time-frame is based on availability 
of subjects schedules and clinic visits, and it is also greater than 5 half-lives 
previously reported for CBD (apparent half-life, 21 hours, (15)). Steady-state 
levels are achieved after 5 half-lives of drug dosing, thus we expect to be at 
steady-state concentrations. 
Subjects who are already on a stable regimen of CBD, yet plan to stop taking 
CBD at some point for some reason, are also eligibile to particpiate. The patient 
or guardian will complete the dysautonimia questionnaire and seizure diary (and 
research staff will be available to help with questions), and the patient will have 
the 12-lead EKG, an optional signal average EKG, and 24-hour Holter monitor 
while still on the CBD. The subjects will then come back 4-8 weeks after their 
last dose of CBD to have these assessments repeated while off of the CBD. 
Again, this time frame is based on availability of subjects schedules and clinic 
visits as well as being substantially greater than 5 half-lives of CBD, the 
standard wash-out period for pharmacological studies. 
Sample Size:  A power analysis was not used to determine sample size. 
Current sample size expectations will be 40 subjects based on the number of 
patients who enroll in the Minnesota state registry and who are also patients at 
Gillette. This available sample size will allow us to account for potential 
participant dropout or incomplete data so that we can achieve our target of 30 

Protocol version 9/28/2016 
 
patients. This is a pilot study with a limited number of participants, and data 
collected will be used in a subsequent power analysis to determine the number 
of subjects needed in a larger study to determine statistical significance. This 
will be the first study of medical cannabis’ effects on autonomic function in 
children with severe seizures, and due to the anticipated small sample size, 
these findings will primarily be used as pilot data to guide further 
characterization of CBD effects on autonomic parameters. 
Methodologies:  The 12-lead EKG will be used to collect information on 
rhythm, a detailed assessment of heart rate (RR interval), PR interval, QRS 
duration, QT and QTc interval, and ST segment changes in order to detect 
cardiac arrhythmias and other abnormalities (see graphic below).  The signal 
average EKG will take this same information and average them during a 20 
minute time period, provided our subject is able to lie still for that amount of 
time. 
 
Heart rate variability (HRV) will be assessed using the 24-hour Holter ECG 
recordings. Both time-domain parameters (RR interval [heart rate], SDNN 
[standard deviation of RR intervals] and SDNN-I [the mean of standard 
deviation of all RR intervals for all 5 minute segments]) and frequency-domain 
parameters (VLF [total spectral power of all NN intervals between 0.003 and 
0.04Hz], HF [total spectral power of all NN intervals between 0.15 and 0.4Hz] 
and LF [total spectral power of all NN intervals between 0.04 and 0.15 Hz] 
amplitude) will be obtained. HRV is a measure of sympathetic/parasympathetic 
cardiac autonomic balance, with lower HRV parameters indicating increased 
adrenergic tone.  
Data Analysis:  The number of participants (30 subjects) is small due to the 
limited number of patients available for enrollment into this specialized study. 
The study is an observational study with a cross-over design, where the patients 
will serve as their own controls. Primary assessments will include determination 
of any changes in EKG parameters and Holter heart rate variability parameters 

Protocol version 9/28/2016 
 
pre- and post-treatment with CBD, as well as the percentage of items in the 
dysautonomia survey that changed and the number of seizures that occurred 
pre- and post-treatment with CBD. Appropriate data assessments will be 
performed to determine whether parametric or nonparametric analyses are the 
proper approach. Due to the small sample size and potentially highly variable or 
skewed data due to the complex patient population under investigation, we plan 
to normalize Holter heart rate variability parameters and EKG parameters and 
calculate change from “baseline” (off – CBD) to those collected while CBD is 
being administered at steady-state levels. 
We also will compare reported seizure data collected from subjects who 
enrolled in the study prior to initiation of CBD to those who were already on 
CBD and then discontinued CBD use to determine if substantial differences are 
apparent in the two groups, since parent report may be biased. We will  also 
confirm that EKG and Holter monitor data 4-8 weeks post-CBD (from patients 
who were on CBD but subsequently discontinued use) are not significantly 
different from baseline data acquired from patients with no previous CBD use, 
prior to combining all “off – CBD” as baseline values. 
Study Participation 
The Principal Investigator or research team members will identify subjects who 
have registered or plan to register with the State of Minnesota to take medical 
cannabis. Each participant will be in the study for approximately 2 months, and 
will need to visit Gillette twice. If subjects have not been on CBD, they will make 
one visit one week prior to starting CBD treatment and one visit after having 
been on CBD for 4-8 weeks. For subjects that are already on a stable regimen 
of CBD, yet plan to stop taking CBD at some point, their participation will last 4-
8 weeks after their last dose. 
Risks and Discomforts 
EKG:  There is no pain during an EKG; however, the EKG patches may be cold 
and removing the pads may make the skin red and sore. In some cases, the 
locations where the EKG patches are placed may need to be shaved. 
24-hour Holter monitor: There is no pain during the use of a 24-hour Holter 
monitor; however, the patches may be cold and removing the pads may make 
the skin red and sore. In some cases, the locations where the patches are 
placed may need to be shaved. 
Subject Protection 
A consent form will be used to explain the risks and benefits of study 
participation to the subject in simple terms before the subject will be entered into 

Protocol version 9/28/2016 
 
the study. The consent form contains a statement that the consent is freely 
given, that the subject is aware of the risks and benefits of entering the study, 
and that the subject is free to withdraw from the study at any time. The consent 
form will incorporate (or be accompanied by a separate document incorporating) 
wording that complies with relevant data protection and privacy legislation. 
Written consent must be given by the subject and/or legal representative after 
the receipt of detailed information on the study and all questions have been 
resolved.  
The Principal Investigator is responsible for ensuring that informed consent is 
obtained from each subject or legal representative, and for obtaining the 
appropriate signatures and dates on the informed consent document prior to the 
performance of any protocol procedures. The Investigator or research team 
member will provide each subject with a copy of the signed and dated consent 
form. 
Confidentiality 
The records of this study will be kept private. Extra precautions will be taken to 
preserve confidentiality. All identifiable information will be replaced with a code. 
A list linking the code and identifiable information will be kept separate from the 
data. All research data and records will be stored electronically on a secure 
network with encryption and/or password protection to help prevent 
unauthorized access to personal information. All paper records will be stored in 
a secured area. Study participation will be recorded in the subject’s medical 
record. Study records and samples will be kept until all data have been 
monitored, analyzed and published. 
Data Handling and Record Keeping 
It is the Principal Investigator’s responsibility to maintain essential study 
documents (protocol and protocol amendments, completed eCRFs, signed 
informed consent forms, relevant correspondence, and all other supporting 
documentation). Record retention will follow ICH E6 Section 4.9.5 and all other 
applicable regulations.  
Investigator Obligations 
This study will be conducted in accordance with the ICH Harmonized Tripartite 
Guideline for GCP (GCP, 1997; the US CFR Title 21 parts 50, 56, and 312) and 
the ethical principles that have their origin in the Declaration of Helsinki.  
The Principal Investigator agrees to conduct the clinical study in compliance 
with this protocol after the approval of the protocol by the IRB/IEC in compliance 
with local regulatory requirements. 

Protocol version 9/28/2016 
 
Data and Safety Monitoring Plan 
Data will be monitored by the Principal Investigator. All EKGs and 24-hour 
Holter monitors will be read by a cardiac electrophysiologist. 
Clinical Implications and Dissemination 
As described above, this is a pilot study with a limited number of participants 
and data collected will be used in a subsequent power analysis to determine the 
number of subjects needed in a larger study to determine statistical significance. 
This will be the first report of medical cannabis’ effects on autonomic function in 
children with severe seizures, and due to the anticipated small sample size, 
these findings will primarily be used as pilot data to guide further 
characterization of CBD effects on autonomic parameters. Findings will be 
reported internally and at external conferences, likely the annual American 
Epilepsy Society meeting. Data regarding the effects of CBD on cardiac function 
(whether protective or detrimental) will be important for future development and 
use of CBD in clinical settings with patients with potential cardiac dysfunction. 
Bibliography 
1. 
Dravet C, Bureau M, Oguni H, Fukuyama Y, Cokar O. Severe myoclonic 
epilepsy in infancy (Dravet syndrome). In: Roger J, Bureau M, Dravet C, 
Genton P, Tassinari CA, Wolf P (eds) Epileptic syndromes in infancy, 
childhood and adolescence, 4th ed. John Libbey, London, 2005, pp 89 – 
109. 
2. 
http://www.ninds.nih.gov/disorders/lennoxgastautsyndrome/lennoxgastauts
yndrome.htm, Retrieved 6.10.2015 
3. 
Sakauchi M, Oguni H, Kato I, Osawa M, Hirose S, Kaneko S, Takahashi Y, 
Takayama R, Fujiwara T. Mortality in Dravet syndrome: search for risk 
factors in Japanese patients. Epilepsia. 2011 Apr;52 Suppl 2:50-4. doi: 
10.1111/j.1528-1167.2011.03002.x. PMID: 21463280 
4. 
Skluzacek JV, Watts KP, Parsy O, Wical B, Camfield P. Dravet syndrome 
and parent associations: the IDEA League experience with comorbid 
conditions, mortality, management, adaptation, and grief. Epilepsia. 2011 
Apr;52 Suppl 2:95-101. doi: 10.1111/j.1528-1167.2011.03012.x. PMID: 
21463290 
5. 
Jehi L. Sudden death in epilepsy, surgery, and seizure outcomes: the 
interface between heart and brain. Cleve Clin J Med. 2010 Jul;77 Suppl 
3:S51-5. doi: 10.3949/ccjm.77.s3.09. Review. PMID: 20622077 
6. 
Kalume F. Sudden unexpected death in Dravet syndrome: respiratory and 
other physiological dysfunctions. Respir Physiol Neurobiol. 2013 Nov 

Protocol version 9/28/2016 
 
1;189(2):324-8. doi: 10.1016/j.resp.2013.06.026. Epub 2013 Jul 9. Review. 
PMID: 23850567 
7. 
Wical, B, Wendorf H, Leighty D, Tervo M, Tervo R. Signs of Dysautonomia 
in Children with Dravet Syndrome. Presented at the Annual Meeting of the 
American Epilepsy Society, Boston, MA, Dec 2009. 
8. 
Delogu AB, Spinelli A, Battaglia D, Dravet C, De Nisco A, Saracino A, 
Romagnoli C, Lanza GA, Crea F. Electrical and autonomic cardiac function 
in patients with Dravet syndrome. Epilepsia. 2011 Apr;52 Suppl 2:55-8. doi: 
10.1111/j.1528-1167.2011.03003.x. PMID: 21463281 
9. 
Nei M, Sperling MR, Mintzer S, Ho RT. Long-term cardiac rhythm and 
repolarization abnormalities in refractory focal and generalized epilepsy. 
Epilepsia. 2012 Aug;53(8):e137-40. doi: 10.1111/j.1528-
1167.2012.03561.x. Epub 2012 Jun 18. PMID: 22709423 
10. Ergul Y, Ekici B, Tatli B, Nisli K, Ozmen M. QT and P wave dispersion and 
heart rate variability in patients with Dravet syndrome. Acta Neurol Belg. 
2013 Jun;113(2):161-6. doi: 10.1007/s13760-012-0140-z. Epub 2012 Oct 
13. PMID: 23065439 
11. Granjeiro EM, Gomes FV, Guimarães FS, Corrêa FM, Resstel LB. Effects 
of intracisternal administration of cannabidiol on the cardiovascular and 
behavioral responses to acute restraint stress. Pharmacol Biochem Behav. 
2011 Oct;99(4):743-8. doi: 10.1016/j.pbb.2011.06.027. Epub 2011 Jul 12. 
PMID: 21771609 
12. Bergamaschi MM, Queiroz RH, Chagas MH, de Oliveira DC, De Martinis 
BS, Kapczinski F, Quevedo J, Roesler R, Schröder N, Nardi AE, Martín-
Santos R, Hallak JE, Zuardi AW, Crippa JA. Cannabidiol reduces the 
anxiety induced by simulated public speaking in treatment-naïve social 
phobia patients. Neuropsychopharmacology. 2011 May;36(6):1219-26. doi: 
10.1038/npp.2011.6. Epub 2011 Feb 9. PMID: 21307846 
13. Martin-Santos R, Crippa JA, Batalla A, Bhattacharyya S, Atakan Z, 
Borgwardt S, Allen P, Seal M, Langohr K, Farré M, Zuardi AW, McGuire 
PK. Acute effects of a single, oral dose of d9-tetrahydrocannabinol (THC) 
and cannabidiol (CBD) administration in healthy volunteers. Curr Pharm 
Des. 2012;18(32):4966-79. Review. PMID: 22716148 
14. Gloss D, Vickrey B. Cannabinoids for epilepsy. Cochrane Database Syst 
Rev. 2014 Mar 5;3:CD009270. doi: 10.1002/14651858.CD009270.pub3. 
Review. PMID: 24595491 
15. Ohlsson A, Lindgren JE, Andersson S, Agurell S, Gillespie H, Hollister L. 
(1984). Single dose kinetics of cannabidiol in man. Cannabinoids: chemical, 
pharmacologic, and therapeutic aspects. S. Agurell, W. L. Dewey and R. 
Willette. Orlando, FL, Academic Press Inc.: 219-225. doi: 10.1016/B978-0-
12-044620-9.50003-8