Abcb1 Gene Polymorphisms Are Associated With Clinical Response to Nabiximols in Patients With Multiple Sclerosis-related Spasticity

Abcb1 Gene Polymorphisms Are Associated With Clinical Response to Nabiximols in Patients With Multiple Sclerosis-related Spasticity | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Abcb1 Gene Polymorphisms Are Associated With Clinical Response to Nabiximols in Patients With Multiple Sclerosis-related Spasticity Alessandra Gemma, Marco Mauri, Paola Banfi, Maurizio Versino, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7008522/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 29 Sep, 2025 Read the published version in Journal of Cannabis Research → Version 1 posted 9 You are reading this latest preprint version Abstract Background : Multiple Sclerosis (MS) is an autoimmune disease of the central nervous system causing severe symptoms, including spasticity-related pain. Nabiximols (NBX), a drug combining Tetrahydrocannabinol and Cannabidiol, is approved for MS-associated spasticity. Despite NBX efficacy, only 60–70% of patients respond to treatment. This study explores whether genetic polymorphisms in key genes involved in NBX pharmacology influence response to drug. Materials & Methods: This is a genetic, exploratory study in which MS patients, treated with NBX, were retrospectively enrolled. Polymorphisms in genes related to NBX metabolism (CYP2C9, CYP2C19), efflux (ATP Binding Cassette subfamily B member 1 - ABCB1), and cannabinoid receptors (CNR1, CNR2) were analyzed using Real-Time PCR. Results : Among 45 enrolled patients, 29 responded to NBX and 16 did not. Of responders, 38% were homozygous for the T allele in ABCB1 1236C>T (rs1128503), and 48% for the T allele in ABCB1 3435A>T (rs1045642). None of the non-responders carried T allele. The odds ratios for response to NBX of TT homozygotes was 20.5 (95% CI:1.1–376.1, P=0.0039) for rs1128503 and 30.9 (95% CI:1.7–563.2, P=0.0006) for rs1045642. Discussion : This study suggests a link between genetic profiles and NBX response. If validated in larger studies, these findings could pave the way for personalized therapy for MS-related spasticity. Multiple Sclerosis Single Nucleotide Polymorphisms Nabiximols Spasticity ABCB1 Figures Figure 1 Introduction Multiple Sclerosis (MS) is a chronic inflammatory, demyelinating, and neurodegenerative disease affecting the central nervous system (Filippi et al., 2018). MS patients experience a wide range of symptoms, with spasticity affecting at least two-thirds of individuals (Kister et al., 2013). Nabiximols, NBX oromucosal spray (Sativex®), drug containing Tetrahydrocannabinol (THC) and cannabidiol (CBD), is approved for adult patients with moderate-to-severe MS-associated spasticity (eMC, 2022). Despite NBX efficacy, only 60–70% of MS patients respond to treatment with this drug (Almog et al., 2020), and up to now there are no reliable predictors its efficacy that could be useful in clinical practice. Genetic factors represent crucial contributors to variability in drug. In particular, single nucleotide polymorphisms (SNPs) may predict drug, efficacy and safety in many clinical settings (Reviewed in Owusu Obeng et al., 2021). Both THC and CBD act on cannabinoid receptors (CBR) 1 and 2, which are encoded by the cannabinoid receptor genes ( CNR ) 1 and 2 (Martini et al 2023). SNPs in CNR1 , such as rs1049353 and rs2023239 and in CNR2 (rs2501431), influence various receptor functions, including depression (Mitjans et al, 2012), happiness perception (Matsunaga et al., 2014) and childhood obesity (Col Araz et al, 2012). THC and CBD are substrates for P-glycoprotein (P-gp), an efflux pump encoded by the ATP Binding Cassette Subfamily B Member 1 ( ABCB1 ) gene (Martini et al., 2023). SNPs in the ABCB1 gene, such as rs1128503 and rs1045642, have been associated with interindividual variability in drug response (Brambila-Tapia, 2013), including response to cannabinoids (Babayeva et al., 2023). These polymorphisms have also been proposed as potential predictors of individual responses to analgesics, including opioids (Fernandez et al., 2012) and cannabis-based treatments (Poli et al., 2022). Additionally, THC and CBD are metabolized by the CYP450 enzyme family, by CYP2C9, CYP2C19, and CYP3A4 (Martrini at al., 2023; Babayeva et al., 2023), and it has been shown that SNPs, such as rs1799853 (CYP2C9) and rs4244285 (CYP2C19), dramatically reduce metabolic activity of these enzymes (Zanger et al., 2008). In the present study, we investigated the relationship between all abovementioned SNPs and response to drug treatment in a cohort of MS patients in which MS-related spasticity was treated with NBX. Methods Patients This exploratory genetic study retrospectively enrolled all patients diagnosed with MS based on the McDonald criteria 2017 and treated with NBX for MS-related spasticity at the "Centro Sclerosi Multipla, Ambulatorio Malattie Demielinizzanti - Ospedale di Circolo e Fondazione Macchi, Varese, Italy" from May 2014 to June 2024. Exclusion criteria were: i) use of other spasticity-related pain medications, such as anticonvulsants/antiepileptic, antidepressants, or opioids, ii) presence of kidney or liver diseases; iii) concurrent treatments with drugs known to affect NBX metabolism or transport; iv) other conditions/disease causing chronic pain (e.g., cancer, trigeminal neuralgia, fibromyalgia, diabetes, arthritis). Response to NBX was evaluated using the Patient-rated spasticity 0-10 Numeric Rating Scale (NRS) as well as through clinical evaluation (Dworkin et al., 2005; Ferré et al., 2016). According to the current accepted definition, a reduction of ≥ 20% from baseline on the NRS after 4 weeks of treatment represents a minimal clinically difference, while a reduction of ≥ 30% indicates a clinically important difference (Dworkin et al., 2005; Ferré et al., 2016). On this basis, we decided to consider patients who achieved at least a 30% reduction in NRS at week 4 compared to baseline and continued with NBX treatment as responders. Patients who did not achieve a 30% reduction in NRS scores within the fourth week of treatment and were switched to alternative spasticity therapy were considered as non-responders. SNPs selection criteria and genotyping The SNPs were selected based on their frequency in the Caucasian population, which must be greater than 10%, and the availability of information regarding their biological and clinical effects. Drawing from our previous experience (Ferrari et al., 2016; Comi et al., 2017; Ferrari et al., 2024), the choice of SNPs with high frequencies increases the probability of identifying potential differences in their frequency in relation to relevant phenotypic aspects, even within a relatively small patient cohort. Furthermore, selecting SNPs with well-established biological effects enhances the likelihood of their contribution to determining patients' phenotype. A detailed description of SNPs included in the study are reported in Table 1 . Table 1. SNPs included in the study. Gene Variant N.C. A.F. (%) Biological effect CNR1 rs1049353 1359G>A 27 Associated to addiction [23] and happiness [8]. rs2023239 -3163A>G 17 Major risk of adverse effects [24]. CNR2 rs2501431 24201643G>A 58 Major risk of depression [7]. ABCB1 rs1128503 1236C>T 43 Lower expression [17]. rs1045642 3435A>T 52 Lower expression [25, 17]. CYP2C9 rs1799853 9133C>T 12 Reduced activity [14] CYP2C19 rs4244285 681G>A 15 No activity [14]. Abbreviations: N.C., nucleotide change; A.F., allelic frequency in Caucasian population; ABCB1 , ATP Binding Cassette subfamily B member 1; CYP , CYtochrome P450; CNR1 , CaNnabinoid Receptor 1 gene; CNR2 , CaNnabinoid Receptor 2 gene. DNA was extracted using FTA Elute Cards (GE Healthcare Bio-Sciences AB, SE-751 84 Uppsala, Sweden) according to the manufacturer's instructions (https://it.vwr.com/store/product/7997552/fta-elute-cards-whatmantm). Selected SNPs were genotyped using a Real-Time PCR system (StepOne®, Thermo Fisher Scientific, Waltham, MA, USA) with a pre-designed TaqMan® genotyping assay (Thermo Fisher Scientific, Waltham, MA, USA). Statistical analysis Data are shown as the mean ± standard deviation (SD), unless otherwise stated. The statistical significance of the differences between groups was assessed by the Mann–Whitney U-test or by One-way analysis of variance followed by Bonferroni's Multiple Comparison Test as appropriate. The evaluation of Hardy-Weinberg equilibrium was assessed using the χ2-test (P<0.05). Differences in allele frequencies between groups were analyzed by the χ2-test for trend or the Fisher's exact test (recessive model). The odds ratio (OR) with a 95% confidence interval (CI) was calculated using a recessive model (wild type/heterozygous vs homozygous for SNP). Statistical analyses were performed using GraphPad Prism version 5.00 for Windows (GraphPad Software, San Diego, California, USA, www.graphpad.com). Results Patients From clinical records, we identified 47 patients treated with NBX for MS-related spasticity from May 2014 to June 2024. Of these, one patient was excluded due to concomitant opioid treatment for cancer-associated pain, and another was excluded for using carbamazepine to manage trigeminal neuralgia-related pain. Table 2 shows demographic and clinical characteristics of the 45 patients finally enrolled. Among the enrolled patients, 29 achieved an NRS score reduction of 30% or greater after 4 weeks of NBX treatment and were included in the responder group. For 16 patients, the NRS score reduction did not reach 30%. These patients switched to alternative pain treatments and were included in the non-responder group. We did not find any difference between groups in terms of gender, age, MS type, disease duration, MS therapy, Multiple Sclerosis Severity Score (MSSS), Expanded Disability Status Scale (EDSS), or NBX dosage ( Table 2 ). Table 2 . Clinical and demographic characteristics of MS patients. * = P<0.001 vs non-responders. All Responders Non-responders Number of subjects 45 29 16 Gender (male/female) 18/27 14/15 4/12 Age (years, mean±SD) 53,0±11,1 53,1±12,2 52,9±9,2 Disease duration (years, mean±SD) 17,3±10,1 16,3±10,6 19,0±9,2 EDSS (mean±SD) 5,6±1,8 5,4±1,8 5,9±1,6 MSSS (mean±SD) 6,2±2,1 6,1±2,2 6,2±2.0 MS type RR 25 19 6 PP 11 6 5 SP 9 4 5 NBX dosage (puffs/dye, mean±SD)* 5.6±2.5 5.8±1.8 5.4±3.0 NRS score before NBX (mean±SD) 7,1±1,2 7,1±1,4 7,1±1,2 after NBX (mean±SD) 4,1±2,1 2,6±1,8* 5,9±0,8 % reduction (mean±SD) 47,0±28,5 64,7±21,1* 14,7±2,0 Abbreviations: EDSS, Expanded Disability Status Scale; MSSS, Multiple Sclerosis severity scale; MS, multiple sclerosis; RR, relapsing-remitting; PP, primary progressive; SP, secondary progressive; THC, Δ9-tetrahydrocannabinol; CBD, cannabidiol; NRS, numerical rating scale. *, 1 puff NBX = 100 μl spray including 2,7 mg THC and 2,5 mg CBD. Correlation between patient genotype and response to NBX All SNPs were in Hardy–Weinberg equilibrium (data not shown). Among the 29 patients who responded to NBX therapy, 18 (62%) were carriers of the C allele in the rs1128503 SNP in ABCB1 , and 15 (52%) were carriers of the A allele in the rs1045642 SNP in ABCB1 , while 11 (38%) and 14 (48%), respectively, were homozygous for the T allele. None of the 16 patients who did not respond to NBX therapy were homozygous of the T allele ( Table 3 ). Using a χ2 test for trend, we found that the frequency of the T allele in both rs1128503 (1236C>T) and rs1045642 (3435A>T) in ABCB1 was significantly higher in responders compared to non-responders (P < 0.0010 and P < 0.0012 respectively). This result was confirmed by the Fisher exact test. The odds ratio (O.R.) for response to NBX was 20.5 (95% C.I.: 1.1–376.1, P = 0.0039) for rs1128503, and 30.9 (95% C.I.: 1.7–563.2, P = 0.0006) for rs1045642. SNPs in CNR1, CNR2, CYP2C9, and CYP2C19 were not significantly associated with the response to NBX ( Table 3 ). Table 3 . Correlations between patient’s genotype and NBX response. * = χ2-test for trend; # = Fisher Exact Test. Gene SNP Genotype Responder n. (%) Non-responder n. (%) P* P# Odds ratio (95% C.I.) CNR1 rs1049353 G/G G/A A/A 21 (72.4) 7 (24.1) 1 (3.5) 8 (50) 7 (43.7) 1 (6.3) 0.1580 1.000 1.9 (0.1-32.0) rs2023239 A/A A/G G/G 24 (82.8) 5 (17.2) 0 (0) 9 (56.2) 5 (31.3) 2 (12.5) 0.0629 0.1212 10.2 (0.5-226.1) CNR2 rs2501431 G/G G/A A/A 3 (10.3) 18 (62.1) 8 (27.6) 2 (12.5) 9 (56.2) 5 (31.3) 0.9364 1.000 1.2 (0.3-4.5) ABCB1 rs1128503 C/C C/T T/T 1 (3.4) 17 (58.6) 11 (38) 4 (25) 12 (75) 0 (0) 0.0010 0.0039 20.5 (1.1-376.1) rs1045642 A/A A/T T/T 3 (10.3) 12 (41.4) 14 (48.3) 5 (31.3) 11 (68.7) 0 (0) 0.0012 0.0006 30.9 (1.7-563.2) CYP2C9 rs1799853 C/C C/T T/T 24 (82.8) 4 (13.7) 1 (3.5) 11 (68.7) 5 (31.3) 0 (0) 0.4787 1.000 0.6 (0.02-15.0) CYP2C19 rs4244285 G/G G/A A/A 19 (65.5) 8 (27.6) 2 (6.9) 10 (62.5) 6 (37.5) 0 (0) 0.4858 0.5313 1.140 (0.01-7.4) Abbreviations: CNR1, CaNnabinoid Receptor 1 gene; CNR2, CaNnabinoid Receptor 2 gene; ABCB1 , ATP Binding Cassette subfamily B member 1 gene; CYP, CYtochrome P450. Subjects with the T/T and C/T genotypes for the rs1128503 SNP in ABCB1 exhibited a significantly greater percentage reduction in NRS scores following NBX treatment compared to those with the ancestral C/C genotype (P < 0.05 and P < 0.001 respectively). Similarly, patients with the T/T genotype for the rs1045642 SNP showed a significantly greater percentage reduction in NRS scores compared to both the C/C and C/T genotypes (P < 0.0001) ( Figure 1 ). SNPs in the CNR and CYP genes don’t showed any notable association with NRS scores ( data not shown ). Discussion The main finding of this study is that the T allele in the ABCB1 SNPs rs1128503 (1236C>T) and rs1045642 (3435A>T) is predictive of response to NBX treatment in MS-related spasticity. Specifically, the T allele, previously associated with reduced P-glycoprotein (P-gp) efflux activity (Wang and Sadée, 2006), was more frequent among treatment responders. Moreover, patients carrying the T allele in either SNPs showed significantly greater percentage reductions in NRS scores following NBX treatment compared to those with ancestral or heterozygous genotypes. To date, only a limited number of studies have evaluated the role of SNPs in ABCB1 in response to cannabinoid treatments. Among these, Poli and colleagues (2022) demonstrated that haplotypes containing the rs1045642 SNP may influence the effectiveness of cannabis in managing chronic pain, as well as its associated side effects (Poli et al., 2022). Beyond ABCB1 SNPs, other SNPs have also been linked to cannabinoid response. For instance, the CYP2C9*2 and CYP2C9*3 SNPs were associated with higher plasma levels of CBD (Batinic et al., 2023) and THC-induced side effects (Wolowich et al., 2019), moreover, in epilepsy patients, SNPs in ABC family gene were found to enhance CBD response (Davis et al., 2021). Finally, SNPs in the CNR1 gene have been shown to affect THC's impact in patients with irritable bowel syndrome (Wong et al., 2012). In light of these findings, several factors, including SNPs in ABCB1, CYP2C9, and CNR1, have been proposed as potential determinants of cannabinoid-related dependence and side effects (Kitdumrongthum & Trachootham, 2023). However, reliable indicators to predict the efficacy of NBX in clinical practice have to be identified yet. In this study, we found, for the first time, that patients carrying the T allele in the ABCB1 SNPs rs1128503 and rs1045642 exhibited a better response to NBX. Our hypothesis is that higher frequencies of SNPs known to reduce P-gp activity may increase NBX bioavailability and facilitate its passage across the blood-brain barrier. This could result in higher drug concentrations at its site of action, thereby improving NBX efficacy. These findings hold promise for advancing precision medicine by helping to identify patients most likely to benefit from NBX treatment, potentially improving its efficacy by enhancing its presence at the site of action. However, further validation in larger patient cohorts is necessary before this method can be considered a reliable tool for predicting patient response to NBX therapy in clinical settings. We acknowledge that our study has some limitations, primarily the retrospective design and the small sample size. However, it must be considered that this is an exploratory study with strict inclusion criteria (i.e. Analgesic monotherapy with NBX, exclusion of concomitant treatments with drugs influencing NBX metabolism/transport, and/or diseases causing chronic pain). The strict inclusion criteria reduce possible confounders and, in turn, increase the likelihood of evaluating the role of genetics in response to NBX treatment. Moreover, although the number of enrolled patients was relatively low, the allelic frequency of the selected SNPs is always above 10%, thus reducing the number of subjects needed to reach the study goals. In conclusion, in this exploratory study, we have shown, for the first time, a relationship between a patient's genetic profile and response to NBX treatment. If confirmed in a prospective study involving a larger cohort of patients, our results could pave the way for the identification of new, useful tools for predicting the response to NBX treatment in MS patients suffering from spasticity, ultimately allowing for personalized therapy in patients with indications for this drug. Declarations Funding This study was supported by a grant of the University of Insubria (FAR 2022-2023) to Marco Ferrari Conflict of Interest All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest, or non-financial interest in the subject matter or materials discussed in this manuscript. Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional committee (ASST Sette Laghi Hospital, Varese, Italy on February 21, 2023 - Study number 164) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study prior to their inclusion in the study. Data Availability Statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Data are in controlled access data storage at Centre for Research in Medical Pharmacology, University of Insubria, Varese, Italy. Authorship contributions MC, MV, MM, FMB, AG, and MF contributed to the conceptualization of the manuscript. MM, PB, AZ, and AG were responsible for the collection and interpretation of clinical data. AG performed the genetic analysis and interpreted the results. MF and AG drafted the first version of the manuscript. MC, FM, MV, AG, AZ, FMB, MM, and MF were involved in the critical review and substantial revision of the manuscript. All authors read and approved the final version of the manuscript. Acknowledgements The authors are grateful to Dr. Margherita Italia, Neurology and Stroke Unit, ASST Sette Laghi Hospital, Varese, Italy for her helpful collaboration in the collection and evaluation of clinical data. Alessandra Gemma developed a research program focused on innovative approaches to evaluating the role of polymorphisms in the ABCB1 gene in clinical responses to nabiximols in patients with multiple sclerosis-related spasticity as part of her work for the PhD Course in Clinical and Experimental Medicine and Medical Humanities, University of Insubria (XXXVII Cycle). Additional information The Authors wish to dedicate this study to the loving memory of Paola Banfi, dearest friend, caring physician, and invaluable scientist. References Almog S, Aharon-Peretz J, Vulfsons S, Ogintz M, Abalia H, Lupo T, Hayon Y, Eisenberg E. The pharmacokinetics, efficacy, and safety of a novel selective-dose cannabis inhaler in patients with chronic pain: A randomized, double-blinded, placebo-controlled trial. Eur J Pain. 2020;24:1505-1516. doi.org/10.1002/ejp.1605. Babayeva M, Loewy ZG. Cannabis Pharmacogenomics: A Path to Personalized Medicine. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7008522","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":481054075,"identity":"88316bbd-46a8-41f9-9769-411af04868d8","order_by":0,"name":"Alessandra Gemma","email":"","orcid":"","institution":"University of Insubria","correspondingAuthor":false,"prefix":"","firstName":"Alessandra","middleName":"","lastName":"Gemma","suffix":""},{"id":481054076,"identity":"1b9bb121-59d6-4e17-92c6-1b338ba725ad","order_by":1,"name":"Marco Mauri","email":"","orcid":"","institution":"ASST Sette Laghi Hospital","correspondingAuthor":false,"prefix":"","firstName":"Marco","middleName":"","lastName":"Mauri","suffix":""},{"id":481054077,"identity":"d935816c-6849-4e9e-aee8-eee013923196","order_by":2,"name":"Paola Banfi","email":"","orcid":"","institution":"ASST Sette Laghi Hospital","correspondingAuthor":false,"prefix":"","firstName":"Paola","middleName":"","lastName":"Banfi","suffix":""},{"id":481054080,"identity":"9cc4f1fa-fb78-4675-ba7a-6dda923a5054","order_by":3,"name":"Maurizio Versino","email":"","orcid":"","institution":"ASST Sette Laghi Hospital","correspondingAuthor":false,"prefix":"","firstName":"Maurizio","middleName":"","lastName":"Versino","suffix":""},{"id":481054081,"identity":"af306a65-2d4c-4bfb-ac8b-4bbfb928bde8","order_by":4,"name":"Alen Zollo","email":"","orcid":"","institution":"University of Milan","correspondingAuthor":false,"prefix":"","firstName":"Alen","middleName":"","lastName":"Zollo","suffix":""},{"id":481054082,"identity":"3d00a66b-85e3-4a5b-b8bd-92af75b1a786","order_by":5,"name":"Filippo Martinelli Boneschi","email":"","orcid":"","institution":"University of Milan","correspondingAuthor":false,"prefix":"","firstName":"Filippo","middleName":"Martinelli","lastName":"Boneschi","suffix":""},{"id":481054083,"identity":"33b40df5-d9b0-4725-849e-a37f6b57e285","order_by":6,"name":"Franca Marino","email":"","orcid":"","institution":"University of Insubria","correspondingAuthor":false,"prefix":"","firstName":"Franca","middleName":"","lastName":"Marino","suffix":""},{"id":481054084,"identity":"2b6545f8-0e6f-4956-9673-aa8eeb4369ad","order_by":7,"name":"Marco Cosentino","email":"","orcid":"","institution":"University of Insubria","correspondingAuthor":false,"prefix":"","firstName":"Marco","middleName":"","lastName":"Cosentino","suffix":""},{"id":481054085,"identity":"cd7ec218-2d35-416d-bcfb-53c5682f2ba6","order_by":8,"name":"Marco Ferrari","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDUlEQVRIiWNgGAWjYPACOQiVUMHAwAakmRkYJMAkHmAM1XIGRQtePVAtjG0QmhmFQgO67WcffvjAYCBnPvvwsw8P5x3O45NufyZduMdCnoGd/wA2LWZn0o0lZzAYGMucSzOekbjtcDGbzBkz6RnPJAwbcDjM7EAaGzMPw5/EGTxA1wG1JLZJ5LBJ8xyQYMSp5fwzkBaD+hk87J8ZEueAtKQ/A2mxx6nlBtgWgwQJHh6gLQ0gLQlmIC2JuLU8Y5acYWBgOIOHp5gh4Vg6yGHG1jMOSCS3MTMbYHdYGuOHDxUG8hI87JsZf9RYJ86fkf7wdsGBOtt+/oMPsFoDBlhNY8OtfhSMglEwCkYBAQAAjNJP9hoY3L4AAAAASUVORK5CYII=","orcid":"","institution":"University of Insubria","correspondingAuthor":true,"prefix":"","firstName":"Marco","middleName":"","lastName":"Ferrari","suffix":""}],"badges":[],"createdAt":"2025-06-30 09:08:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7008522/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7008522/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s42238-025-00333-4","type":"published","date":"2025-09-29T15:58:16+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":86215603,"identity":"682c60ff-21d1-4b81-91fd-da5eae31529d","added_by":"auto","created_at":"2025-07-08 05:56:01","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":23738,"visible":true,"origin":"","legend":"\u003cp\u003eRelationship between SNPs \u003cem\u003eABCB1\u003c/em\u003e and % of reduction in NRS score. § = P \u0026lt; 0.05 vs C/C;\u003c/p\u003e\n\u003cp\u003e§§ = P \u0026lt; 0.01 vs C/C; *** = P \u0026lt; 0.0001 vs A/A; ### = P \u0026lt; 0.0001 vs A/T.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7008522/v1/bdc77ad8cd3883f0bd506817.png"},{"id":92884536,"identity":"1b4bec3b-b81b-49af-852a-b8104690682a","added_by":"auto","created_at":"2025-10-06 16:13:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":751443,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7008522/v1/8e7b13d3-e917-41e9-ab51-076125e08acd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eAbcb1 Gene Polymorphisms Are Associated With Clinical Response to Nabiximols in Patients With Multiple Sclerosis-related Spasticity\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMultiple Sclerosis (MS) is a chronic inflammatory, demyelinating, and neurodegenerative disease affecting the central nervous system (Filippi et al., 2018). MS patients experience a wide range of symptoms, with spasticity affecting at least two-thirds of individuals (Kister et al., 2013). Nabiximols, NBX oromucosal spray (Sativex\u0026reg;), drug containing Tetrahydrocannabinol (THC) and cannabidiol (CBD), is approved for adult patients with moderate-to-severe MS-associated spasticity (eMC, 2022). Despite NBX efficacy, only 60\u0026ndash;70% of MS patients respond to treatment with this drug (Almog et al., 2020), and up to now there are no reliable predictors its efficacy that could be useful in clinical practice.\u003c/p\u003e \u003cp\u003eGenetic factors represent crucial contributors to variability in drug. In particular, single nucleotide polymorphisms (SNPs) may predict drug, efficacy and safety in many clinical settings (Reviewed in Owusu Obeng et al., 2021).\u003c/p\u003e \u003cp\u003eBoth THC and CBD act on cannabinoid receptors (CBR) 1 and 2, which are encoded by the cannabinoid receptor genes (\u003cem\u003eCNR\u003c/em\u003e) 1 and 2 (Martini et al 2023). SNPs in \u003cem\u003eCNR1\u003c/em\u003e, such as rs1049353 and rs2023239 and in \u003cem\u003eCNR2\u003c/em\u003e (rs2501431), influence various receptor functions, including depression (Mitjans et al, 2012), happiness perception (Matsunaga et al., 2014) and childhood obesity (Col Araz et al, 2012). THC and CBD are substrates for P-glycoprotein (P-gp), an efflux pump encoded by the ATP Binding Cassette Subfamily B Member 1 (\u003cem\u003eABCB1\u003c/em\u003e) gene (Martini et al., 2023). SNPs in the ABCB1 gene, such as rs1128503 and rs1045642, have been associated with interindividual variability in drug response (Brambila-Tapia, 2013), including response to cannabinoids (Babayeva et al., 2023). These polymorphisms have also been proposed as potential predictors of individual responses to analgesics, including opioids (Fernandez et al., 2012) and cannabis-based treatments (Poli et al., 2022).\u003c/p\u003e \u003cp\u003eAdditionally, THC and CBD are metabolized by the CYP450 enzyme family, by CYP2C9, CYP2C19, and CYP3A4 (Martrini at al., 2023; Babayeva et al., 2023), and it has been shown that SNPs, such as rs1799853 (CYP2C9) and rs4244285 (CYP2C19), dramatically reduce metabolic activity of these enzymes (Zanger et al., 2008).\u003c/p\u003e \u003cp\u003eIn the present study, we investigated the relationship between all abovementioned SNPs and response to drug treatment in a cohort of MS patients in which MS-related spasticity was treated with NBX.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003ePatients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis exploratory genetic study retrospectively enrolled all patients diagnosed with MS based on the McDonald criteria 2017 and treated with NBX for MS-related spasticity at the \u0026quot;Centro Sclerosi Multipla, Ambulatorio Malattie Demielinizzanti - Ospedale di Circolo e Fondazione Macchi, Varese, Italy\u0026quot; from May 2014 to June 2024. Exclusion criteria were: i) use of other spasticity-related pain medications, such as anticonvulsants/antiepileptic, antidepressants, or opioids, ii) presence of kidney or liver diseases; iii) concurrent treatments with drugs known to affect NBX metabolism or transport; iv) other conditions/disease causing chronic pain (e.g., cancer, trigeminal neuralgia, fibromyalgia, diabetes, arthritis).\u003c/p\u003e\n\u003cp\u003eResponse to NBX was evaluated using the Patient-rated spasticity 0-10 Numeric Rating Scale (NRS) as well as through clinical evaluation (Dworkin et al., 2005; Ferr\u0026eacute; et al., 2016). According to the current accepted definition, a reduction of \u0026ge; 20% from baseline on the NRS after 4 weeks of treatment represents a minimal clinically difference, while a reduction of \u0026ge; 30% indicates a clinically important difference (Dworkin et al., 2005; Ferr\u0026eacute; et al., 2016).\u003c/p\u003e\n\u003cp\u003eOn this basis, we decided to consider patients who achieved at least a 30% reduction in NRS at week 4 compared to baseline and continued with NBX treatment as responders.\u003c/p\u003e\n\u003cp\u003ePatients who did not achieve a 30% reduction in NRS scores within the fourth week of treatment and were switched to alternative spasticity therapy were considered as non-responders.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSNPs selection criteria and genotyping\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe SNPs were selected based on their frequency in the Caucasian population, which must be greater than 10%, and the availability of information regarding their biological and clinical effects.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDrawing from our previous experience (Ferrari et al., 2016; Comi et al., 2017; Ferrari et al., 2024), the choice of SNPs with high frequencies increases the probability of identifying potential differences in their frequency in relation to relevant phenotypic aspects, even within a relatively small patient cohort. Furthermore, selecting SNPs with well-established biological effects enhances the likelihood of their contribution to determining patients\u0026apos; phenotype. A detailed description of SNPs included in the study are reported in \u003cstrong\u003eTable 1\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eSNPs included in the study.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"633\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 13.1122%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGene\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.7441%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariant\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8515%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN.C.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0063%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eA.F. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43.2859%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBiological effect\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 13.1122%;\"\u003e\n \u003cp\u003e\u003cem\u003eCNR1\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.7441%;\"\u003e\n \u003cp\u003ers1049353\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8515%;\"\u003e\n \u003cp\u003e1359G\u0026gt;A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0063%;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43.2859%;\"\u003e\n \u003cp\u003eAssociated to addiction [23] and happiness [8].\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 13.1122%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.7441%;\"\u003e\n \u003cp\u003ers2023239\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8515%;\"\u003e\n \u003cp\u003e-3163A\u0026gt;G\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0063%;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43.2859%;\"\u003e\n \u003cp\u003eMajor risk of adverse effects [24].\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 13.1122%;\"\u003e\n \u003cp\u003e\u003cem\u003eCNR2\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.7441%;\"\u003e\n \u003cp\u003ers2501431\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8515%;\"\u003e\n \u003cp\u003e24201643G\u0026gt;A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0063%;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43.2859%;\"\u003e\n \u003cp\u003eMajor risk of depression [7].\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 13.1122%;\"\u003e\n \u003cp\u003e\u003cem\u003eABCB1\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.7441%;\"\u003e\n \u003cp\u003ers1128503\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8515%;\"\u003e\n \u003cp\u003e1236C\u0026gt;T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0063%;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43.2859%;\"\u003e\n \u003cp\u003eLower expression [17].\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 13.1122%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.7441%;\"\u003e\n \u003cp\u003ers1045642\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8515%;\"\u003e\n \u003cp\u003e3435A\u0026gt;T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0063%;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43.2859%;\"\u003e\n \u003cp\u003eLower expression [25, 17].\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 13.1122%;\"\u003e\n \u003cp\u003e\u003cem\u003eCYP2C9\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.7441%;\"\u003e\n \u003cp\u003ers1799853\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8515%;\"\u003e\n \u003cp\u003e9133C\u0026gt;T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0063%;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43.2859%;\"\u003e\n \u003cp\u003eReduced activity [14]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 13.1122%;\"\u003e\n \u003cp\u003e\u003cem\u003eCYP2C19\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.7441%;\"\u003e\n \u003cp\u003ers4244285\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8515%;\"\u003e\n \u003cp\u003e681G\u0026gt;A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0063%;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43.2859%;\"\u003e\n \u003cp\u003eNo activity [14].\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e N.C., nucleotide change; A.F., allelic frequency in Caucasian population; \u003cem\u003eABCB1\u003c/em\u003e, ATP Binding Cassette subfamily B member 1; \u003cem\u003eCYP\u003c/em\u003e, CYtochrome P450; \u003cem\u003eCNR1\u003c/em\u003e, CaNnabinoid Receptor 1 gene; \u003cem\u003eCNR2\u003c/em\u003e, CaNnabinoid Receptor 2 gene.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDNA was extracted using FTA Elute Cards (GE Healthcare Bio-Sciences AB, SE-751 84 Uppsala, Sweden) according to the manufacturer\u0026apos;s instructions (https://it.vwr.com/store/product/7997552/fta-elute-cards-whatmantm).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSelected SNPs were genotyped using a Real-Time PCR system (StepOne\u0026reg;, Thermo Fisher Scientific, Waltham, MA, USA) with a pre-designed TaqMan\u0026reg; genotyping assay (Thermo Fisher Scientific, Waltham, MA, USA).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are shown as the mean \u0026plusmn; standard deviation (SD), unless otherwise stated. The statistical significance of the differences between groups was assessed by the Mann\u0026ndash;Whitney U-test or by One-way analysis of variance followed by Bonferroni\u0026apos;s Multiple Comparison Test as appropriate.\u0026nbsp;The evaluation of Hardy-Weinberg equilibrium was assessed using the \u0026chi;2-test (P\u0026lt;0.05). Differences in allele frequencies between groups were analyzed by the \u0026chi;2-test for trend or the Fisher\u0026apos;s exact test (recessive model). The odds ratio (OR) with a 95% confidence interval (CI) was calculated using a recessive model (wild type/heterozygous vs homozygous for SNP).\u003c/p\u003e\n\u003cp\u003eStatistical analyses were performed using GraphPad Prism version 5.00 for Windows (GraphPad Software, San Diego, California, USA, www.graphpad.com).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePatients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom clinical records, we identified 47 patients treated with NBX for\u0026nbsp;MS-related spasticity from May 2014 to June 2024. Of these, one patient was excluded due to concomitant opioid treatment for cancer-associated pain, and another was excluded for using carbamazepine to manage trigeminal neuralgia-related pain. \u003cstrong\u003eTable 2\u003c/strong\u003e shows demographic and clinical characteristics of the 45 patients finally enrolled.\u003c/p\u003e\n\u003cp\u003eAmong the enrolled patients, 29 achieved an NRS score reduction of 30% or greater after 4 weeks of NBX treatment and were included in the responder group. For 16 patients, the NRS score reduction did not reach 30%. These patients switched to alternative pain treatments and were included in the non-responder group.\u003c/p\u003e\n\u003cp\u003eWe did not find any difference between groups in terms of gender, age, MS type, disease duration, MS therapy, Multiple Sclerosis Severity Score (MSSS), Expanded Disability Status Scale (EDSS), or NBX dosage (\u003cstrong\u003eTable 2\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e. Clinical and demographic characteristics of MS patients. * = P\u0026lt;0.001 vs non-responders.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"680\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47.2754%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResponders\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-responders\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47.2754%;\"\u003e\n \u003cp\u003eNumber of subjects\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4404%;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47.2754%;\"\u003e\n \u003cp\u003eGender (male/female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e18/27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e14/15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4404%;\"\u003e\n \u003cp\u003e4/12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47.2754%;\"\u003e\n \u003cp\u003eAge (years, mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e53,0\u0026plusmn;11,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e53,1\u0026plusmn;12,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4404%;\"\u003e\n \u003cp\u003e52,9\u0026plusmn;9,2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47.2754%;\"\u003e\n \u003cp\u003eDisease duration (years, mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e17,3\u0026plusmn;10,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e16,3\u0026plusmn;10,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4404%;\"\u003e\n \u003cp\u003e19,0\u0026plusmn;9,2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47.2754%;\"\u003e\n \u003cp\u003eEDSS (mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e5,6\u0026plusmn;1,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e5,4\u0026plusmn;1,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4404%;\"\u003e\n \u003cp\u003e5,9\u0026plusmn;1,6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47.2754%;\"\u003e\n \u003cp\u003eMSSS (mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e6,2\u0026plusmn;2,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e6,1\u0026plusmn;2,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4404%;\"\u003e\n \u003cp\u003e6,2\u0026plusmn;2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47.2754%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMS type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4404%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47.2754%;\"\u003e\n \u003cp\u003eRR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4404%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47.2754%;\"\u003e\n \u003cp\u003ePP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4404%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47.2754%;\"\u003e\n \u003cp\u003eSP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4404%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47.2754%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNBX dosage\u0026nbsp;\u003c/strong\u003e(puffs/dye, mean\u0026plusmn;SD)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e5.6\u0026plusmn;2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e5.8\u0026plusmn;1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4404%;\"\u003e\n \u003cp\u003e5.4\u0026plusmn;3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47.2754%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNRS score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4404%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47.2754%;\"\u003e\n \u003cp\u003ebefore NBX (mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e7,1\u0026plusmn;1,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e7,1\u0026plusmn;1,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4404%;\"\u003e\n \u003cp\u003e7,1\u0026plusmn;1,2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47.2754%;\"\u003e\n \u003cp\u003eafter NBX (mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e4,1\u0026plusmn;2,1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e2,6\u0026plusmn;1,8*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4404%;\"\u003e\n \u003cp\u003e5,9\u0026plusmn;0,8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47.2754%;\"\u003e\n \u003cp\u003e% reduction (mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e47,0\u0026plusmn;28,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6421%;\"\u003e\n \u003cp\u003e64,7\u0026plusmn;21,1*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4404%;\"\u003e\n \u003cp\u003e14,7\u0026plusmn;2,0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e EDSS, Expanded Disability Status Scale; MSSS, Multiple Sclerosis severity scale; MS, multiple sclerosis; RR, relapsing-remitting; PP, primary progressive; SP, secondary progressive; THC, \u0026Delta;9-tetrahydrocannabinol; CBD, cannabidiol; NRS, numerical rating scale. *, 1 puff NBX = 100 \u0026mu;l spray including 2,7 mg THC and 2,5 mg CBD.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorrelation between patient genotype and response to NBX\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll SNPs were in Hardy\u0026ndash;Weinberg equilibrium (data not shown). Among the 29 patients who responded to NBX therapy, 18 (62%) were carriers of the C allele in the rs1128503 SNP in \u003cem\u003eABCB1\u003c/em\u003e, and 15 (52%) were carriers of the A allele in the rs1045642 SNP in \u003cem\u003eABCB1\u003c/em\u003e, while 11 (38%) and 14 (48%), respectively, were homozygous for the T allele. None of the 16 patients who did not respond to NBX therapy were homozygous of the T allele (\u003cstrong\u003eTable 3\u003c/strong\u003e). Using a \u0026chi;2 test for trend, we found that the frequency of the T allele in both rs1128503 (1236C\u0026gt;T) and rs1045642 (3435A\u0026gt;T) in ABCB1 was significantly higher in responders compared to non-responders (P \u0026lt; 0.0010 and P \u0026lt; 0.0012 respectively). This result was confirmed by the Fisher exact test. The odds ratio (O.R.) for response to NBX was 20.5 (95% C.I.: 1.1\u0026ndash;376.1, P = 0.0039) for rs1128503, and 30.9 (95% C.I.: 1.7\u0026ndash;563.2, P = 0.0006) for rs1045642. SNPs in CNR1, CNR2, CYP2C9, and CYP2C19 were not significantly associated with the response to NBX (\u003cstrong\u003eTable 3\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e. Correlations between patient\u0026rsquo;s genotype and NBX response. * = \u0026chi;2-test for trend; # = Fisher Exact Test.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"671\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.6866%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGene\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.7313%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSNP\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.9403%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGenotype\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.1343%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResponder\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6119%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-responder\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.65672%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.65672%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP#\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.5821%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdds ratio\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(95% C.I.)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.6866%;\"\u003e\n \u003cp\u003e\u003cem\u003eCNR1\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.7313%;\"\u003e\n \u003cp\u003ers1049353\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.9403%;\"\u003e\n \u003cp\u003eG/G\u003c/p\u003e\n \u003cp\u003eG/A\u003c/p\u003e\n \u003cp\u003eA/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.1343%;\"\u003e\n \u003cp\u003e21 (72.4)\u003c/p\u003e\n \u003cp\u003e7 (24.1)\u003c/p\u003e\n \u003cp\u003e1 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6119%;\"\u003e\n \u003cp\u003e8 (50)\u003c/p\u003e\n \u003cp\u003e7 (43.7)\u003c/p\u003e\n \u003cp\u003e1 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.65672%;\"\u003e\n \u003cp\u003e0.1580\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.65672%;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.5821%;\"\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003cp\u003e(0.1-32.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.6866%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.7313%;\"\u003e\n \u003cp\u003ers2023239\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.9403%;\"\u003e\n \u003cp\u003eA/A\u003c/p\u003e\n \u003cp\u003eA/G\u003c/p\u003e\n \u003cp\u003eG/G\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.1343%;\"\u003e\n \u003cp\u003e24 (82.8)\u003c/p\u003e\n \u003cp\u003e5 (17.2)\u003c/p\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6119%;\"\u003e\n \u003cp\u003e9 (56.2)\u003c/p\u003e\n \u003cp\u003e5 (31.3)\u003c/p\u003e\n \u003cp\u003e2 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.65672%;\"\u003e\n \u003cp\u003e0.0629\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.65672%;\"\u003e\n \u003cp\u003e0.1212\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.5821%;\"\u003e\n \u003cp\u003e10.2\u003c/p\u003e\n \u003cp\u003e(0.5-226.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.6866%;\"\u003e\n \u003cp\u003e\u003cem\u003eCNR2\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.7313%;\"\u003e\n \u003cp\u003ers2501431\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.9403%;\"\u003e\n \u003cp\u003eG/G\u003c/p\u003e\n \u003cp\u003eG/A\u003c/p\u003e\n \u003cp\u003eA/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.1343%;\"\u003e\n \u003cp\u003e3 (10.3)\u003c/p\u003e\n \u003cp\u003e18 (62.1)\u003c/p\u003e\n \u003cp\u003e8 (27.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6119%;\"\u003e\n \u003cp\u003e2 (12.5)\u003c/p\u003e\n \u003cp\u003e9 (56.2)\u003c/p\u003e\n \u003cp\u003e5 (31.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.65672%;\"\u003e\n \u003cp\u003e0.9364\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.65672%;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.5821%;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003cp\u003e(0.3-4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.6866%;\"\u003e\n \u003cp\u003e\u003cem\u003eABCB1\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.7313%;\"\u003e\n \u003cp\u003ers1128503\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.9403%;\"\u003e\n \u003cp\u003eC/C\u003c/p\u003e\n \u003cp\u003eC/T\u003c/p\u003e\n \u003cp\u003eT/T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.1343%;\"\u003e\n \u003cp\u003e1 (3.4)\u003c/p\u003e\n \u003cp\u003e17 (58.6)\u003c/p\u003e\n \u003cp\u003e11 (38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6119%;\"\u003e\n \u003cp\u003e4 (25)\u003c/p\u003e\n \u003cp\u003e12 (75)\u003c/p\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.65672%;\"\u003e\n \u003cp\u003e0.0010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.65672%;\"\u003e\n \u003cp\u003e0.0039\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.5821%;\"\u003e\n \u003cp\u003e20.5\u003c/p\u003e\n \u003cp\u003e(1.1-376.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.6866%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.7313%;\"\u003e\n \u003cp\u003ers1045642\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.9403%;\"\u003e\n \u003cp\u003eA/A\u003c/p\u003e\n \u003cp\u003eA/T\u003c/p\u003e\n \u003cp\u003eT/T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.1343%;\"\u003e\n \u003cp\u003e3 (10.3)\u003c/p\u003e\n \u003cp\u003e12 (41.4)\u003c/p\u003e\n \u003cp\u003e14 (48.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6119%;\"\u003e\n \u003cp\u003e5 (31.3)\u003c/p\u003e\n \u003cp\u003e11 (68.7)\u003c/p\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.65672%;\"\u003e\n \u003cp\u003e0.0012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.65672%;\"\u003e\n \u003cp\u003e0.0006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.5821%;\"\u003e\n \u003cp\u003e30.9\u003c/p\u003e\n \u003cp\u003e(1.7-563.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.6866%;\"\u003e\n \u003cp\u003e\u003cem\u003eCYP2C9\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.7313%;\"\u003e\n \u003cp\u003ers1799853\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.9403%;\"\u003e\n \u003cp\u003eC/C\u003c/p\u003e\n \u003cp\u003eC/T\u003c/p\u003e\n \u003cp\u003eT/T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.1343%;\"\u003e\n \u003cp\u003e24 (82.8)\u003c/p\u003e\n \u003cp\u003e4 (13.7)\u003c/p\u003e\n \u003cp\u003e1 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6119%;\"\u003e\n \u003cp\u003e11 (68.7)\u003c/p\u003e\n \u003cp\u003e5 (31.3)\u003c/p\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.65672%;\"\u003e\n \u003cp\u003e0.4787\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.65672%;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.5821%;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003cp\u003e(0.02-15.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.6866%;\"\u003e\n \u003cp\u003e\u003cem\u003eCYP2C19\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.7313%;\"\u003e\n \u003cp\u003ers4244285\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.9403%;\"\u003e\n \u003cp\u003eG/G\u003c/p\u003e\n \u003cp\u003eG/A\u003c/p\u003e\n \u003cp\u003eA/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.1343%;\"\u003e\n \u003cp\u003e19 (65.5)\u003c/p\u003e\n \u003cp\u003e8 (27.6)\u003c/p\u003e\n \u003cp\u003e2 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6119%;\"\u003e\n \u003cp\u003e10 (62.5)\u003c/p\u003e\n \u003cp\u003e6 (37.5)\u003c/p\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.65672%;\"\u003e\n \u003cp\u003e0.4858\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.65672%;\"\u003e\n \u003cp\u003e0.5313\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.5821%;\"\u003e\n \u003cp\u003e1.140 (0.01-7.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e CNR1, CaNnabinoid Receptor 1 gene; CNR2, CaNnabinoid Receptor 2 gene; \u003cem\u003eABCB1\u003c/em\u003e, ATP Binding Cassette subfamily B member 1 gene; CYP, CYtochrome P450.\u003c/p\u003e\n\u003cp\u003eSubjects with the T/T and C/T genotypes for the rs1128503 SNP in ABCB1 exhibited a significantly greater percentage reduction in NRS scores following NBX treatment compared to those with the ancestral C/C genotype (P \u0026lt; 0.05 and P \u0026lt; 0.001 respectively). Similarly, patients with the T/T genotype for the rs1045642 SNP showed a significantly greater percentage reduction in NRS scores compared to both the C/C and C/T genotypes (P \u0026lt; 0.0001) (\u003cstrong\u003eFigure 1\u003c/strong\u003e). SNPs in the CNR and CYP genes don\u0026rsquo;t showed any notable association with NRS scores (\u003cstrong\u003edata not shown\u003c/strong\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe main finding of this study is that the T allele in the ABCB1 SNPs rs1128503 (1236C\u0026gt;T) and rs1045642 (3435A\u0026gt;T) is predictive of response to NBX treatment in MS-related spasticity. Specifically, the T allele, previously associated with reduced P-glycoprotein (P-gp) efflux activity (Wang and Sad\u0026eacute;e, 2006), was more frequent among treatment responders. Moreover, patients carrying the T allele in either SNPs showed significantly greater percentage reductions in NRS scores following NBX treatment compared to those with ancestral or heterozygous genotypes.\u003c/p\u003e\n\u003cp\u003eTo date, only a limited number of studies have evaluated the role of SNPs in ABCB1 in response to cannabinoid treatments. Among these, Poli and colleagues (2022) demonstrated that haplotypes containing the rs1045642 SNP may influence the effectiveness of cannabis in managing chronic pain, as well as its associated side effects (Poli et al., 2022). Beyond \u003cem\u003eABCB1\u003c/em\u003e SNPs, other SNPs have also been linked to cannabinoid response. For instance, the CYP2C9*2 and CYP2C9*3 SNPs were associated with higher plasma levels of CBD (Batinic et al., 2023) and THC-induced side effects (Wolowich et al., 2019), moreover, in epilepsy patients, SNPs in \u003cem\u003eABC\u003c/em\u003e family gene were found to enhance CBD response (Davis et al., 2021). Finally, SNPs in the \u003cem\u003eCNR1\u003c/em\u003e gene have been shown to affect THC\u0026apos;s impact in patients with irritable bowel syndrome (Wong et al., 2012).\u003c/p\u003e\n\u003cp\u003eIn light of these findings, several factors, including SNPs in ABCB1, CYP2C9, and CNR1, have been proposed as potential determinants of cannabinoid-related dependence and side effects (Kitdumrongthum \u0026amp; Trachootham, 2023). However, reliable indicators to predict the efficacy of NBX in clinical practice have to be identified yet.\u003c/p\u003e\n\u003cp\u003eIn this study, we found, for the first time, that patients carrying the\u0026nbsp;T allele in the ABCB1 SNPs rs1128503 and rs1045642 exhibited a better response to NBX. Our hypothesis is that higher frequencies of SNPs known to reduce P-gp activity may increase NBX bioavailability and facilitate its passage across the blood-brain barrier. This could result in higher drug concentrations at its site of action, thereby improving NBX efficacy. These findings hold promise for advancing precision medicine by helping to identify patients most likely to benefit from NBX treatment, potentially improving its efficacy by enhancing its presence at the site of action. However, further validation in larger patient cohorts is necessary before this method can be considered a reliable tool for predicting patient response to NBX therapy in clinical settings.\u003c/p\u003e\n\u003cp\u003eWe acknowledge that our study has some limitations, primarily the retrospective design and the small sample size. However, it must be considered that this is an exploratory study with strict inclusion criteria (i.e. Analgesic monotherapy with NBX, exclusion of concomitant treatments with drugs influencing NBX metabolism/transport, and/or diseases causing chronic pain). The strict inclusion criteria reduce possible confounders and, in turn, increase the likelihood of evaluating the role of genetics in response to NBX treatment. Moreover, although the number of enrolled patients was relatively low, the allelic frequency of the selected SNPs is always above 10%, thus reducing the number of subjects needed to reach the study goals.\u003c/p\u003e\n\u003cp\u003eIn conclusion, in this exploratory study, we have shown, for the first time, a relationship between a patient\u0026apos;s genetic profile and response to NBX treatment. If confirmed in a prospective study involving a larger cohort of patients, our results could pave the way for the identification of new, useful tools for predicting the response to NBX treatment in MS patients suffering from spasticity, ultimately allowing for personalized therapy in patients with indications for this drug.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by a grant of the University of Insubria (FAR 2022-2023) to Marco Ferrari\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest, or non-financial interest in the subject matter or materials discussed in this manuscript.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional committee (ASST Sette Laghi Hospital, Varese, Italy on February 21, 2023 - Study number 164) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study prior to their inclusion in the study.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request. Data are in controlled access data storage at Centre for Research in Medical Pharmacology, University of Insubria, Varese, Italy.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthorship contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMC, MV, MM, FMB, AG, and MF contributed to the conceptualization of the manuscript. MM, PB, AZ, and AG were responsible for the collection and interpretation of clinical data. AG performed the genetic analysis and interpreted the results. MF and AG drafted the first version of the manuscript. MC, FM, MV, AG, AZ, FMB, MM, and MF were involved in the critical review and substantial revision of the manuscript. All authors read and approved the final version of the manuscript.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are grateful to Dr. Margherita Italia, Neurology and Stroke Unit, ASST Sette Laghi Hospital, Varese, Italy for her helpful collaboration in the collection and evaluation of clinical data. Alessandra Gemma developed a research program focused on innovative approaches to evaluating the role of polymorphisms in the ABCB1 gene in clinical responses to nabiximols in patients with multiple sclerosis-related spasticity as part of her work for the PhD Course in Clinical and Experimental Medicine and Medical Humanities, University of Insubria (XXXVII Cycle).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdditional information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Authors wish to dedicate this study to the loving memory of Paola Banfi, dearest friend, caring physician, and invaluable scientist.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAlmog S, Aharon-Peretz J, Vulfsons S, Ogintz M, Abalia H, Lupo T, Hayon Y, Eisenberg E. The pharmacokinetics, efficacy, and safety of a novel selective-dose cannabis inhaler in patients with chronic pain: A randomized, double-blinded, placebo-controlled trial. 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Genet Test Mol Biomarkers. 2012;16:1408-12. doi.org/10.1089/gtmb.2012.0244 \u003c/li\u003e\n\u003cli\u003eComi C, Ferrari M, Marino F, Magistrelli L, Cantello R, Riboldazzi G, Bianchi ML, Bono G, Cosentino M. Polymor-phisms of Dopamine Receptor Genes and Risk of L-Dopa-Induced Dyskinesia in Parkinson\u0026apos;s Disease. Int J Mol Sci 2017;18:242. doi.org/10.3390/ijms18020242 \u003c/li\u003e\n\u003cli\u003eDavis BH, Beasley TM, Amaral M, Szaflarski JP, Gaston T, Perry Grayson L, Standaert DG, Bebin EM, Limdi NA; UAB CBD Study Group (includes all the investigators involved in the UAB EAP CBD program). Pharmacogenetic Predictors of Cannabidiol Response and Tolerability in Treatment-Resistant Epilepsy. Clin Pharmacol Ther. 2021;110:1368-1380. doi.org/10.1002/cpt.2408.\u003c/li\u003e\n\u003cli\u003eDworkin RH, Turk DC, Farrar JT, Haythornthwaite JA, Jensen MP, Katz NP, Kerns RD, Stucki G, et al. Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. 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Anal Bioanal Chem. 2008;392:1093-108. doi.org/10.1007/s00216-008-2291-6 \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cannabis-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcan","sideBox":"Learn more about [Journal of Cannabis Research](https://jcannabisresearch.biomedcentral.com/)","snPcode":"42238","submissionUrl":"https://submission.springernature.com/new-submission/42238/3","title":"Journal of Cannabis Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Multiple Sclerosis, Single Nucleotide Polymorphisms, Nabiximols, Spasticity, ABCB1","lastPublishedDoi":"10.21203/rs.3.rs-7008522/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7008522/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Multiple Sclerosis (MS) is an autoimmune disease of the central nervous system causing severe symptoms, including spasticity-related pain. Nabiximols (NBX), a drug combining Tetrahydrocannabinol and Cannabidiol, is approved for MS-associated spasticity. Despite NBX efficacy, only 60–70% of patients respond to treatment. This study explores whether genetic polymorphisms in key genes involved in NBX pharmacology influence response to drug.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials \u0026amp; Methods:\u003c/strong\u003e This is a genetic, exploratory study in which MS patients, treated with NBX, were retrospectively enrolled. Polymorphisms in genes related to NBX metabolism (CYP2C9, CYP2C19), efflux (ATP Binding Cassette subfamily B member 1 - ABCB1), and cannabinoid receptors (CNR1, CNR2) were analyzed using Real-Time PCR.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Among 45 enrolled patients, 29 responded to NBX and 16 did not. Of responders, 38% were homozygous for the T allele in ABCB1 1236C\u0026gt;T (rs1128503), and 48% for the T allele in ABCB1 3435A\u0026gt;T (rs1045642). None of the non-responders carried T allele. The odds ratios for response to NBX of TT homozygotes was 20.5 (95% CI:1.1–376.1, P=0.0039) for rs1128503 and 30.9 (95% CI:1.7–563.2, P=0.0006) for rs1045642.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e: This study suggests a link between genetic profiles and NBX response. If validated in larger studies, these findings could pave the way for personalized therapy for MS-related spasticity.\u003c/p\u003e","manuscriptTitle":"Abcb1 Gene Polymorphisms Are Associated With Clinical Response to Nabiximols in Patients With Multiple Sclerosis-related Spasticity","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-08 05:55:56","doi":"10.21203/rs.3.rs-7008522/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-24T12:15:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-23T16:27:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-18T17:55:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"231024126570558280551995851616313354745","date":"2025-07-16T15:06:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"337872184289000076151805348981914407253","date":"2025-07-15T16:35:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-03T09:12:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-01T13:25:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-01T13:25:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cannabis Research","date":"2025-06-30T08:53:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cannabis-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcan","sideBox":"Learn more about [Journal of Cannabis Research](https://jcannabisresearch.biomedcentral.com/)","snPcode":"42238","submissionUrl":"https://submission.springernature.com/new-submission/42238/3","title":"Journal of Cannabis Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"eff5db79-3cdf-4ab5-ae6f-1c4c3e23c9ed","owner":[],"postedDate":"July 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-06T16:11:06+00:00","versionOfRecord":{"articleIdentity":"rs-7008522","link":"https://doi.org/10.1186/s42238-025-00333-4","journal":{"identity":"journal-of-cannabis-research","isVorOnly":false,"title":"Journal of Cannabis Research"},"publishedOn":"2025-09-29 15:58:16","publishedOnDateReadable":"September 29th, 2025"},"versionCreatedAt":"2025-07-08 05:55:56","video":"","vorDoi":"10.1186/s42238-025-00333-4","vorDoiUrl":"https://doi.org/10.1186/s42238-025-00333-4","workflowStages":[]},"version":"v1","identity":"rs-7008522","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7008522","identity":"rs-7008522","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}