WO2019159185A1 - Compositions and methods for the treatment of protein energy wasting - Google Patents

Abstract

The invention provides therapeutic approaches to the prevention and treatment of protein energy wasting (PEW) in patients on maintenance dialysis or patients with chronic or end-stage kidney disease. The therapeutic products and methods of the invention are based on certain cannabinoid compositions with particular emphasis on cannabis-based compositions, wherein the two main cannabinoids, THC and CBD, are present in specific proportions across defined ranges of concentrations and amounts.

Description

COMPOSITIONS AND METHODS FOR THE TREATMENT OF PROTEIN

ENERGY WASTING

TECHNOLOGICAL FIELD

The present invention generally relates to therapeutic products and methods applicable to the prevention and treatment of protein energy wasting (PEW), particularly in patients with chronic kidney disease (CKD) subjected to maintenance hemodialysis (MHD).

BACKGROUND

Patients with chronic kidney disease (CKD) or end stage renal disease (ESRD) have exceptionally high mortality rates. Among multiple risk factors implicated in this excess mortality, such as cardiovascular disease (CVD) and infections, in these patients nutritional status has invariably emerged as one of the strongest predictors of mortality. Particularly in patients under maintenance hemodialysis (MHD) a manifestation referred to as protein-energy wasting (PEW) is considered the strongest risk factor for mortality and adverse outcomes.

PEW denotes an inadequate amount of protein and energy intake, and in CKD patients is manifested as gradual and continuing decline in protein and calorie intake that becomes apparent below certain threshold of kidney insufficiency, typically once the glomerular filtration rate (GFR) reaches <25-38 mL/min (moderate to severe CKD). Compounding the problem are many nutritional deficiencies arising from dietary habits characteristic of dialysis patients, in particular.

The treatment of PEW in dialysis patients imposes a significant challenge. Nutritional counseling and adjustment of dialysis to daily or nocturnal dialysis have provided only partial solutions to this problem. Megestrol acetate (MA), a synthetic, orally active derivate of progesterone, has been implemented as appetite stimulant in dialysis patients after positive experience with this drug in patients with anorexia, cachexia and also in AIDS and cancer. However, due to its multiple side effects (headaches, dizziness, diarrhea, hyperglycemia, and thromboembolic effects) MA cannot be recommended as a routine treatment, particularly not in patients under MHD. More recently there has been encouraging evidence on a short-term orexigenic effect of subcutaneous ghrelin administration in CKD patients. It is still unknown, however, if the reported improvement in appetite can translate into a long-term improved nutritional status and better outcomes, and also if a long-term ghrelin therapy can eventually lead to ghrelin resistance. Further, the recognized mitogenic effect of ghrelin needs attention. Medicinal value of cannabis is well documented in the medical literature. Cannabinoids, the active ingredients of cannabis, are present in significantly higher concentrations in resin-producing inflorescences of female cannabis plants. Various types of cannabis, such as C. Sativa, C. Indica and C. Ruderalis, may contain more than 100 different cannabinoids in specific concentrations and proportions. The two predominant cannabinoids, tetrahydrocannabinol (THC) and cannabidiol (CBD), have been relates to a wide range of clinically beneficial effects, e.g., analgesic, antiemetic, antioxidative, neuroprotective and anti-inflammatory effects, in mammals and humans. W002064109 generally related to pharmaceutical formulations of cannabinoids, including those derived from cannabis plants. W0200801946 described aqueous dronabinol (THC) formulations for wasting syndrome in AIDS. W02015142501 described certain cannabinoid compositions for alleviation of specific symptoms shared by epilepsy, arthrosclerosis Alzheimer's and depression. W02017145160 further related to certain type of cannabinoid compositions with immediate- and sustained- release for the treatment of cancer related cachexia and anorexia syndrome.

GENERAL DESCRIPTION

Patients under maintenance hemodialysis (MHD), and CKD in general, suffer from anorexia and protein-energy wasting (PEW) resulting from, at least in part, kidney dysfunction and chronic use of dialysis. Kidney failure leads to retention of uremic toxins and various comorbid conditions. Dialytic therapies and various metabolic alterations such as metabolic acidosis lead, particularly in advanced CKD and ESRD, lead to catabolism- inducing effects and thereby to concomitant increase in protein and energy requirements. For example, to maintain a positive nitrogen balance dialysis patients are advised to consume a daily amount of protein as 1.1-1.3 g/kg/day and energy as 35 kcal/kg/day. In actuality, the protein and energy intake in these patients is significantly lower due to diminished appetite and other physiological or psychosocial conditions, resulting in permanently growing PEW. Apart from a quantitative nutritional deficiency, there is also a qualitative nutritional deficiency in specific components, such as specific micronutrients (vitamins and trace elements) and macronutrients imbalances (carbohydrates, fats, proteins and amino acids).

The present invention is based on findings that compositions and products derived from certain cannabis strains can be effective and safe appetite-stimulants in patients under MHD, in which drug intolerance and safety impose significant challenges. One of the important features of the compositions of the invention has been revealed in their specific cannabinoid content or specific ratios between the two main cannabinoids, THC and CBD. It has been known that medical cannabis improves mood and general wellbeing, and in patients suffering from pain in the context of cancer or multiple sclerosis it was recognized as anxiolytic medication and antidepressant. The effect of THC on the improvement of appetite was documented in conditions such as AIDS, metastatic cancer or Alzheimer’s disease.

The compositions of the invention are essentially different from the above in terms specific proportions of the two main actives, THC and CBD, and specific amounts and concentrations of said compositions that were effective and safe for improving appetite and nutritional status in patients under MHD, wherein nutritional status and appetite are considered the key predictors of clinical outcomes.

It should be noted that there was no documented experience with cannabis in dialysis patients. In the presently described carefully monitored double-blind placebo- controlled study the compositions of the invention have been demonstrated to impact on self-reported appetite, PEW, nutrition-related markers and markers of inflammation, and over-all nutritional status, and other clinical outcomes closely associated with hospitalization rate and survival, e.g., muscle mass and strength, anthropometric measures, protein catabolism rate, serum albumin levels and health-related quality of life.

More specifically, this clinical trial has demonstrated the applicability of certain cannabis strains characterized as having THC and CBD in approximately equal proportions. An exemplary member of this group is the strain referred to herein as 'Midnight' generally described in US Plant Patent Application No. 2017/0295742 (a continuation of application No. 14/757,041, which is a continuation of application No. 14/193,228). Midnight can be provided in a form of crude dried plant material suitable for smoking or as an oil extract - for oral consumption alone or as an additive to liquids and foods, and also by topical administrations.

Two oral dose forms of olive oil extract of Midnight have been developed for the purpose of low and high dosing regimens:

i. a low oral dose form, wherein one drop of Midnight oil (about 0.04 ml) comprises THC and CBD content of about 3% (w/w), and in terms of total amount - about 1.2 mg THC and 1.2 mg CBD, or about 2.5 mg of both cannabinoids; and

ii. a high oral dose form, wherein one drop of Midnight oil comprises THC and CBD content of about 15% (w/w), and in terms of total amount - about 6 mg THC and 6 mg CBD, or about 12 mg of both cannabinoids. These two oral dose forms have been meticulously evaluated in terms of efficacy and safety as add-on medications to conventional drugs in relation to drug schedule (pre- or post dialysis, or before or after meals), drug dosage (low or high dose forms, single or multiple doses per administration), number of administrations and use of concurrent medications, and other parameters. A detailed description of this clinical trial is provided in Example 1.

Essentially, the trial consisted of two parts: I. - the pharmacokinetic (PK) part for modeling and assessment of the efficacious dosing range, and II. - the nutritional evaluation part for evaluation of treatment outcomes using an extended array of markers. Specifically:

I. The PK part included careful monitoring of drug dosing starting from a low dose (e.g., 1 drop of the 3% oil once a day) and proceeding to a higher dose (e.g., multiple drops of the 3% oil or 1 drop of the 15% oil) while relating to safety and tolerability, and PK data (e.g., THC, CBD or metabolites accumulation between hemodialysis sessions). In absence of adverse events drug dose was increased by 2-fold per administration. The PK part further related to administration schedule (e.g., before or after meals, pre- or post-dialysis).

II. The nutritional evaluation part included an extended array of parameters: VAS (visual analogue scale) and SNAQ (simplified nutritional appetite questionnaire) for appetite assessment; daily energy and protein intake for dietary assessment; EQ-5D and SF-36 for health-related QoL assessment; biochemical nutritional markers (serum albumin, creatinine, transferrin, total lymphocyte count, uric acid, lipid profile, IGF-l), appetite-regulating peptides (leptin, acyl-ghrelin, obestatin, NPY); inflammatory biochemical mediators (CRP, IL-6, and TNFα); handgrip strength as functional assessment of muscle mass; anthropometric parameters (body weight, BMI, skinfold thickness, mid arm circumference); lean body mass, % fat mass, fat free mass, phase angle measured by BIA, malnutrition inflammation score, geriatric nutritional risk index and objective score of nutrition on dialysis as quantitative assessment of nutritional status (see Annexes A-D).

This trial has demonstrated that compositions derived from certain cannabis strains with approximately equal proportions of THC:CBD (1:1) are effective for improving PEW, immediate appetite perception, and long-term nutritional status in MHD patients. One example of such naturally-based compositions was provided and tested with olive oil extracts of the strain Midnight. Another more recent example is provided with extracts of the strain Mango obeying the ratio of THC:CBD of about 1:1. Still another example of such compositions is currently being tested with extracts of yet another type of cannabis, specifically an CBD enriched strain referred to as 'Avidekel' generally described in US Plant Patent Application 2017/0290286 (a continuation of application No. 14/757, 039, which is a continuation of application No. 14/193, 252). More precisely, Avidekel encompasses a group of strains produced from the original Avidekel strain further cultivated and enriched for high CBD content, starting from CBD:THC ratio of about 4:1 and more recently reaching an unprecedented ratio of about 20:1.

It should be noted that owing to their origin and production methods, the compositions of the invention are expected to include additional naturally occurring actives. The majority of cannabis strains include more than 100 different types of cannabinoids, although at much lesser concentrations than THC and CBD, and also numerous kinds of terpenes.

Thus from a more general point of view, the present invention addresses the specific needs of dialysis patients and provides a targeted therapeutic solution for the problem of PEW in terms of immediate and long-term alleviation and improvement of overall nutritional status. Certain cannabis-based or derived compositions have been shown as effective for improving PEW, immediate appetite perception, and long-term nutritional status in these patients.

The compositions of the invention were tested in the form of drops of low- and high- concentration oil extracts that are optimal for sublingual administration. A crude dry material of cannabis can be also administered by smoking, inhalation, vaporization. Still another particularly advantageous form of administration especially in the context of MHD is via transdermal route, e.g., in a form of a transdermal patch.

Finally, the presently described clinical trial provides an exemplary framework for applying the compositions and dosage forms of the invention in dialysis patient in a rationalized manner considering various indices of PEW and nutritional status, without risking patient's safety and onset of potential adverse reactions.

BRIEF DESCRIPTION OF FIGURES

Figure 1 is a graphic representation of the double-blind placebo-controlled study described in detail in Example 1 (abbreviations are decoded in Annex A).

Figure 2 is a graphic representation of various modulators acting in the anorexigenic (dashed line) and orixigenic (solid line) signaling pathways (adapted from Flores A et al. Front Neurosci 2013 Dec 20; 7:256)

DESCRIPTION OF SPECIFIC EMBODIMENTS

On a general note, appetite regulation constitutes an intricate cross-talk between multiple peripheral and central mechanisms, including hypothalamic regulators of appetite at the arcuate and paraventricular axes (Arc/PVN) (see Figure 2). Leptin, for example, has opposite effects on Arc neurons in down-regulating neuropeptide Y(NPY) and agouti-related peptide (AgRP), and on pro-opiomelanocortin (POMC) neurons in up-regulating cocaine- amphetamine -related transcripts (CART). Grehlin, being released during fasting, also produces opposite effects. Individual outcomes of these signaling cascades are unpredictable, and amount to changes in sensation of hunger and satiety in various degrees in each induvial.

In dialysis patients appetite regulation is even more complicated by the abnormal metabolism and renal retention of certain substances, including leptin, ghrelin. Most notably, according to previous studies in these patients there was no relationship between appetite regulating factors and patient’s appetite or other dietary parameters. No correlation was found between appetite and food intake with acyl-ghrelin and obestatin. Moreover, MHD patients with poor/very poor appetite had unexpectedly higher ghrelin levels compared to patients with good appetite. More recently, it has been demonstrated that serum leptin levels were not different in anorexic and in non-anorexic MHD patients. Overall, peripheral appetite regulators in uremic environment do not correlate with appetite as in the general population mainly due to compensatory counter-regulation (see for example Beberashvili I, et al. Nutr J 2011; 10:68; Borges N, et al.. J Ren Nutr 2014; 24:100-4; Bossola M, et al. J Ren Nutr 2005; 15:244-52; Bossola M, et al. J Ren Nutr 2009; 19:248-55; Mak RH, et al. Kidney Int 2011; 79:697-9; Wright M, et al. Nephrol Dial Transplant 2004; 19(1): 133-140).

All these suggest that applicability of the presently proposed compositions and methods on appetite and nutritional status, particularly in dialysis patients, is highly unexpected and could not be predicted on the basis of any scientifically-based rationale.

Thus one of its main aspects the invention provides a type of cannabis-based compositions with a particular content of THC and CBD for use in treating PEW and/or improving nutritional status in patients subjected to MHD.

In numerous embodiments the invention provides a type of cannabis-based compositions comprising THC and CBD in approximately equal proportions (about 1:1) for use in treating PEW and/or improving nutritional status in a MHD patient.

In other embodiments to that end the invention can provide cannabis-based composition enriched in CBD comprising THC:CBD ratio of about 1:4 up to 1:20 (w/w), respectively.

In the broadest sense, the compositions of the invention can comprise THC:CBD ratios of at least about 1:1 and further 1:2, 1:3, 1:4, 1:5, 1:6, 1:7, 1:8, 1:9, 1:10, 1:11, 1:12, 1:13, 1:14, 1:15, 1:16, 1:17, 1:18, 1:19 or 1:20 (w/w), respectively. The terms 'maintenance hemodialysis (MHD)' or 'chronic MHD' relate to CKD or ESKD patients subjected to hemodialysis in regular intervals. This term herein encompasses a variety of protocols in ter s of duration and frequency of dialysis; and also in terms of adjustment of flow rates of blood and dialysis solutions; sodium, potassium and bicarbonate levels in dialysis solution; and changes accounting for a dialyzer size and patient's weight/ height. This term further refers to short daily home hemodialysis, and nocturnal dialysis.

With respect to the population to which this term applies, according to conventional guidelines patients with severe CKD to ESKD, Stage 4 and 5 (glomerular filtration rate, GFR = 15-29 mL/min and <15 mL/min, respectively) are recommended to start MHD. More recent guidelines recommend delaying dialysis in patients without symptoms until the GFR drops to 6 mL/min. The initiation of dialysis therapy, however, remains an individual decision.

It should be further noted that the decline in protein and calorie intake and the ensuing PEW become gradually manifested once the GFR declines to <25-38 mL/min. Thus the compositions and methods of the invention could also apply to CKD patients who are already manifesting PEW but still abstain from dialysis.

The term 'PEW' herein encompasses a wide range of different aspects of malnutrition and metabolic or nutritional aberrations, including inflammation. One way to identify symptoms of PEW is by application of one or more of the following criteria: (1) biochemical measures (serum albumin, transferrin and cholesterol); (2) measures of body mass (body mass index [BMI], unintentional weight loss and total body fat), (3) measures of muscle mass (total muscle mass, mid-arm muscle circumference and creatinine appearance); (4) measures of dietary intake (dietary protein and energy intake) and (5) integrative nutritional scoring systems (subjective global assessment of nutrition and malnutrition-inflammation score).

Nutritional status in the broadest sense is a condition influenced by intake and utilization of nutrients meant to provide macro- and micro-nutrients to maintain body structure and growth, and to sustain energy-requiring processes. With respect to PEW criteria (as above), nutritional status roughly corresponds to the nutrient intake and assessment of nutrition in (4) and (5). However, nutritional status proved to be difficult to study, because direct assessment of what and how much person ingests over extended periods of time can be feasible only in small numbers of subjects and under carefully controlled circumstances. To bypass such impracticalities use of surrogate markers of nutrient intake has become wide spread in clinical practice and research studies. The present disclosure teaches the assessment of nutritional status on the basis of comprehensive nutritional scoring systems, such as Malnutrition-Inflammation Score (MIS), Geriatric Nutritional Risk Index (GNRI) and Objective Score of Nutrition on Dialysis (OSND). It also teaches measuring biochemical markers of nutritional status, markers of inflammatory response, appetite-regulating peptides, anthropometric measurements, muscle strength (handgrip), bioelectrical impedance, and also a number of questionnaires for the assessment of appetite and health related quality of life (see Example 1-D).

It should be appreciated that in numerous embodiments, owing to the treatment with compositions and methods of the invention, the improvement of nutritional status can further comprise an increased appetite. Various methods to assess changes in appetite have been developed, one such method has been presently exemplified by use of the Visual Analogue Scale (VAS) questionnaire (see Annex B).

With respect to the presently disclosed compositions, by virtue of being cannabis- based compositions implies the presence of the two main cannabinoids, THC and CBD, and other active components such as terpenes, flavonoids and other cannabinoids.

'Cannabis-based' and 'cannabis-derived', these terms herein are interchangeable and signify an active, a composition or a combination thereof obtained from a cannabis plant by means of known in the art purification or extraction methods. These terms herein also apply to a crude dry plant material and extracts. There are number of methods for producing a concentrated cannabis-derived material, e.g., filtration, maceration, infusion, percolation, decoction in various solvents, Soxhlet extraction, microwave- and ultrasound-assisted extractions and other methods. Certain oil extracts have been presently exemplified.

The following relates to the two main actives referred to in the present disclosure. Tetrahydrocannabinol (THC) refers herein to a class of psychoactive cannabinoids characterized by high affinity to CB1 and CB2 receptors, having a molecular formula C21H30O2, an average mass of approximately 314.46 Da, and a general structure of Formula I.

Cannabidiol (CBD) refers herein to a class of non-psychoactive cannabinoids with a low affinity to CB1 and CB2 receptors, having a formula C21H30O2, an average mass of approximately 314.46 Da, and a general structure of Formula II.

The terms 'THC' and 'CBD' herein further encompass isomers, derivatives, or precursors of these molecules, such as (-)-trans-A9-tetrahydrocannabinol (A9-THC), A8-THC, and A9-CBD, and further to THC and CBD derived from their respective 2- carboxylic acids (2-COOH), THC-A and CBD-A.

As has been noted, a particular quality of the compositions of the invention is revealed in their distinctive content of THC/CBD shown to be effective and safe for MHD patents, who are generally more intolerant to toxicity and drugs. In terms of THC/CBD content per total plant material (w/w), the compositions of the invention can comprise THC or CBD of about up to 30%, 25%, 20%, 15%, 14%, 13%, 12%, 11%, 10%, 9%, 8%, 7%, 6%, 5%, 4%, 3%, 2%, 1% or <1% (w/w).

Of particular advantage are compositions comprising THC or CBD in the range of about 30% to 10%, or 10% to 1% (w/w), as high and low dose forms respectively.

In numerous embodiments the compositions comprise THC or CBD in the range of about 30%-25%, 25%-20%, 20-15% or 15%-10% as high dose forms, and 10%-8%, 8%-6%, 6%-4%, 4%-2%, 2%-l% or less as low dose forms (w/w).

In certain embodiments, the compositions comprise THC or CBD in the range of about 14-16% or about 2-4% (w/w) as high and low dose forms, respectively.

As has been presently demonstrated this type of compositions can be obtained in a form of an oil extract of a cannabis plant.

With respect to the type comprising the THC:CBD ratio of approximately 1:1, this ratio is inherent to only some strains of cannabis such as Midnight or Mango. Applicability of Midnight as a source for this type of compositions has been presently exemplified .

It should be noted that the ranking of THC: CBD ratio as 1:1 is a rough approximation. In the Midnight strain for example, used in the present trail, the relative content of THC is 8% and CBD is 11% (w/w) yielding a ratio of approximately 3:4. In the strain Mango the relative content of THC and CBD is 7% each thus yielding the ratio of 1:1.

Another important source of compositions of the invention is provided with the CBD enriched strains represented by the strain Avidekel. This type of compositions can comprise THC:CBD ratio of about 1:4 up to 1:20, respectively; or in terms of relative THC/CBD content - THC up to 5%, 4%, 3%, 2% or 1.9%, 1.8%, 1.7%, 1.6%.1.5%, 1.4%, 1.3%, 1.2%, 1.1%, 1% or less, and CBD up to at least 10%, 11%, 12%, 13%, 14%, 15%, 16%, 17%, 18%, 19%, 20%, 21%, 22%, 23%, 24%, 25% or more (w/w).

It should be appreciated that the above described compositions of the invention can be adapted for specific administration routes, including enteral (systemic but delivered through the gastrointestinal (GI) tract), parenteral, (systemic but delivered by routes other than the GI tract), topical (local) routes; or in other words, taken via mouth (orally), by injection into a vein (intravenously), into a muscle (intramuscularly), into the space around the spinal cord (intrathecally), topically or beneath the skin (subcutaneously).

In numerous embodiments the compositions of the invention are oral compositions in the form of solid tablets, capsules, chewable tablets or lozenges to be swallowed whole or sucked on, or consumed as liquids in the form of drops or as add-on to syrups or solutions.

In certain embodiments the compositions of the invention are adapted for a sublingual administration, applicability of such compositions have been presently exemplified.

The term 'sublingual' encompasses herein sublingual and buccal administrations, wherein sublingual - involves placing the compositions under the tongue and buccal - placing between gums and cheek. In these both administration routes the liver is bypassed, and bioavailability is higher; or in other words, these types of administration have rapid absorption. Sublingual drugs could be particularly advantageous for patients who have trouble swallowing a medication.

In numerous embodiments the sublingual and buccal compositions of the invention come in tablets, films or sprays. The latter include, among others, oil extracts employed in the present examples (Example 1-C).

In still other embodiments the compositions of the invention can be adapted for transdermal administration, in the sense of formulations designed to penetrate through the skin layer and exert their effects on deeper or more distant tissues. Utilizing the transdermal route affords minimal first-pass metabolism, eliminates or minimizes comorbidities, adverse drug reactions and side effects resulting in GI, hepatic, renal, or other complications. The compositions of the invention can be incorporated into various transdermal delivery systems by means of known in the art technologies, including first-, second- and more recent third-generation delivery systems. A detailed description of such systems is provided further below.

It should be noted that the presently exemplified oil extracts are particularly advantageous as they can be easily incorporated into fixed dosage forms (see below), and also into transdermal delivery systems, and transdermal patches.

Specifically on oral compositions, the presently described trial has provided an important insight into the optimal total amount of THC and CBD to achieve the desired therapeutic effect.

In the broadest sense the oral compositions of the invention can comprise a total amount of both actives, THC and CBD, up to about up to 1000 mg, 900 mg, 800 mg, 700 mg, 600 mg, 500 mg, 400 mg, 300 mg, 200 mg, 100 mg, 90 mg, 80 mg, 70 mg, 60 mg, 50 mg, 40 mg, 30 mg, 20 mg, 10 mg or 9 mg, 8 mg, 7 mg, 6 mg, 5 mg, 4 mg, 3 mg, 2 mg, 1 mg or less.

In numerous embodiments the high dose forms of the oral compositions can comprise a total amount of THC and CBD of up to about 240 mg, 220 mg, 200 mg, 180 mg, 160 mg, 140 mg, 120 mg, 100 mg, 80 mg, 60 mg 180 mg, 120 mg, 60 mg, 50 mg, and the low dose forms - up to about 50 mg, 40 mg, 30 mg, 20 mg, 10 mg and less, or up to about 10 mg, 9 mg, 8 mg, 7 mg, 6 mg, 5 mg, 4 mg, 3 mg, 2 mg or less of both actives.

In certain embodiments the low dose forms of the compositions can comprise 48 mg, 36 mg, 24 mg, 12 mg of both actives.

In yet other embodiments the composition of the invention can comprise THC and CBD in the range of about 10-15 mg or about 2-3 mg as high and low dose forms respectively. Applicability of this type of composition has been presently exemplified.

It should be noted that the compositions in the form of transdermal patches can comprise a significantly higher amount of actives.

It should be further appreciated that in numerous embodiments the compositions of the invention can comprise one or more additional therapeutic agents. In this context the term Therapeutic agent' encompasses a broad range of drugs routinely used in patients under MHD, including but not limited to: blood pressure tables (anti-hypertensives such as atenolol, amlodipine, doxazosin, and ramipril, losartan and similar), diuretics (furosemide, bumetanide), blood-thinning medications (aspirin, clopidogrel, dipyridamole, warfarin), phosphate binders, alfa-calcidole or cinacalcet (for leveling parathyroid hormone), erythropoietin stimulating agent (for reducing anaemia), iron, tinzaparin (to prevent clotting in dialysis machine), antimicrobial lock (for hemodialysis lines), and other medications (many times including, sodium bicarbonate, allopurinol for gout, quinine sulphate for muscle cramps, pain killers and additional over-the-counter medications).

In numerous embodiments the compositions of the invention constitute a combination therapy for use in a method of treating and/or maintenance of a patient subjected to MHD with regard to the treatment of treating PEW and improvement of nutritional status and appetite. The term 'combination therapy' encompasses herein a situation wherein a composition of the invention is formulated apart and is administered in succession or simultaneously with another therapeutic agent, and also a situation wherein the composition is formulated together with at last one additional therapeutic agent.

In certain embodiments the compositions of the invention can be applied as monotherapies for the improvement of PEW and nutritional status in patients with a milder CKD.

It is another important aspect of the invention to provide methods for treating PEW and/or improving nutritional status in patients subjected to MHD by applying one or more of the previously described compositions, i.e., the cannabis-based compositions with a particular content of THC and CBD, including oral compositions, compositions incorporated into transdermal delivery systems, and others.

In numerous embodiments said improving of nutritional status further comprises an increased appetite.

As has been presently demonstrated, in numerous embodiments the methods of the invention can comprise administering to the patient a therapeutically effective amount of a cannabis-based composition comprising THC and CBD in approximately equal proportions (about 1:1), for example compositions derived from the strains Midnight and Mango.

In other embodiments, however, the methods of the invention can comprise administering to the patient a therapeutically effective amount of a cannabis-based composition enriched in CBD comprising THC:CBD ratio of about 1:4 up to 1:20 (w/w), respectively, exemplified by compositions derived from the strain Avidekel.

Thus in the broadest sense, the methods of the invention can apply cannabis-based compositions comprising THC:CBD ratios of at least about 1:1 and further 1:2, 1:3, 1:4, 1:5, 1:6, 1:7, 1:8, 1:9, 1: 10, 1:11, 1:12, 1:13, 1:14, 1:15, 1:16, 1:17, 1:18, 1:19 or 1:20 (w/w), respectively. The terms Therapeutic dose' or 'therapeutically effective dose', which herein are interchangeable, relate to doses of compositions and dosage forms of the invention producing an improvement or treatment of PEW and/or nutritional status in a given patient. The terms 'treating' and 'improving' with respect to nutritional status and PEW are interchangeable.

Various methods of measuring an improvement or change in PEW, appetite and nutritional status have been presently exemplified (Example 1-D). Under improvement is meant a change in at least one criteria of PEW or a marker of nutritional status, and also a reduction of up to 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 100% or more according to relevant clinical score.

An extended panel of markers of PEW and nutritional status has been included in the presently described clinical trial, some of them as explained below are not obvious and have not been previously tested in the context of MHD and/or in relation to PEW.

(i) Biochemical markers of nutritional status

Plasma albumin: Low plasma albumin correlates with body protein stores. Due to its long half-life and large hepatic reserve, it is a relatively advanced manifestation of malnutrition. In some patients under MHD plasma albumin remains low despite supplementation via dialysis.

Transferrin level: Low transferrin level was linked to co-morbidity in patients under MHD and CAPD (continuous ambulatory peritoneal dialysis).

Plasma cholesterol: Low plasma cholesterol is characteristic of patients under MHD and is considered a significant predictor of mortality in this group.

Plasma creatinine: Lower plasma creatinine was closely related to mortality in dialysis patients. Creatinine is produced by a non-enzymatic creatine metabolism in skeletal muscle, and serves for the assessment of lean body mass.

Total Lymphocyte count (TLC): TLC was significantly associated with morbidity and mortality in dialysis patients.

Serum uric acid: This marker correlates with most surrogates of body composition, muscle function, inflammation, and health-related quality of life in patients under MHD, and was also related to hospitalizations and risk of CVD death in this group.

Serum insulin-like growth factor-l (IGF-l): Low serum IGF-l correlates with protein intake, markers of mineral and bone metabolism and survival, also inflammation and all-cause mortality in this population. (ii) Biochemical markers of inflammatory response

Circulating interleukin-6 (IL-6): High circulating IL-6 and its soluble receptor (sIL- 6R) are characteristic of ESKD and dialysis patients. Up-regulated IL-6 was also related to decreased renal function and retention of uremic solutes, volume overload/CHF, persistent infections, oxidative stress, increased visceral fat mass, and other factors related to dialysis (bio-incompatibility, non-sterile dialysate, back-filtration).

C -reactive protein (CRP): High CRP is a marker of inflammation linked to mortality and CVD in dialysis patients.

Tumor necrosis factor alfa (TNFα): High serum TNFα was associated with anorexia and poor nutritional status. TNFα impacts on both pro- and anti-inflammatory mediators, including effects on lipid metabolism, coagulation, insulin resistance and endothelial dysfunction.

(iii) Appetite-regulating peptides measurement

Plasma ghrelin: Low plasma ghrelin and its acylated form (AG) were associated with mortality, especially in connection with inflammation and other weight-regulating hormones. Presumably, it is the most significant factor contributing to food and energy homeostasis. Plasma ghrelin herein refers to the stomach-derived, 28-amino acid, orexigenic peptide, and also to the two major forms, including an acylated ghrelin (AG) and des-acyl ghrelin (DAG).

Serum leptin: High serum leptin levels are characteristic of patients with renal failure. Leptin has a bimodal function, it down-regulates NPY (a stimulator of food intake), and up- regulates a-MSH (alpha-melanocyte- stimulating hormone - an inhibitor of food intake). Unlike in the general population, leptin was not related to perceived appetite and food intake in dialysis patients. Leptin herein refers to a 16-kDa protein produced by adipocytes.

Serum obestatin: The role of serum obestatin in dialysis patients is still undecided. High serum obestatin is characteristic of ESKD patients, but more recently its lower levels were associated with mortality in patients under dialysis. Obestatin herein refers to an anorexogenic gut hormone, and specifically to the active form of a 23-amino-acid peptide derived from the C terminal portion of the preproghrelin precursor.

Serum neuropeptide Y (NPY) Low serum NPY was associated with anorexia. NPY is involved in drinking and eating control and in intestinal motility and secretion. It is the most potent orexigen in the pathogenesis of obesity.

In numerous embodiments the methods of the invention comprise measuring at least one marker selected from one or more of the above groups (i) to (iii), i.e., biochemical markers of nutritional status, biochemical markers of inflammatory response or appetite- regulating peptides. Implementation of these markers in the methods of the invention is illustrated in Example D-1.

It should be appreciated that the methods of the invention are specifically adapted for patients under MHD, in terms of administration routes, schedule of administrations and coordination with dialysis.

In numerous embodiments the proposed methods involve an oral administration or sublingual administering of the cannabis-based compositions of the invention.

In certain embodiments said administering comprises 1 to 3 administrations per day.

In further embodiments the methods can involve single oral or sublingual administration per day. This type of methods have been presently exemplified.

Yet in other embodiments the methods can also involve multiple daily administrations.

In numerous embodiments the methods of the invention can be applied pre- or post dialysis, as exemplified in Example 1-E2.

In certain embodiments, the methods of the invention can be applied while fasting.

Yet in other embodiments the method can be applied with meals or snacks.

It should be further appreciated that in certain embodiments the methods of the invention can involve transdermal administration. Transdermal compositions and dosage forms of the invention will be described in detail below. In this context it should be noted that transdermal route usually involves a prolonged administration over a course of l-3h, 3-6h, 6- l2h, l2-24h or more.

Of particular interest are methods wherein the administering of the cannabis-based compositions is performed by means of a transdermal patch.

It should be appreciated that the methods of the invention are versatile and can involve oral and transdermal administrations at the same time or in succession in the same patient, depending on patient's preferences and advise of the treating physician.

Thus from yet another point of view the invention can be articulated as a method for treating PEW and/or improving nutritional status in a patient subjected to MHD, said method comprises:

(a) administering to the patient a composition, an oral dosage form, a transdermal patch of the invention or a combination thereof, and

(b) measuring one or more markers of nutritional status in said patient to determine effectiveness of treatment. Measuring markers of nutritional status and determining an improvement or change in PEW, appetite and nutritional status have been explained in detail above. Feasibility of such methods, including all the implied measurements and estimations, has been exemplified in the presently described clinical trial (Example 1 and Tables 3-4).

In numerous embodiments of said methods the oral forms or the transdermal patch can be administered alone under specific regimens (daily or nocturnal) pre- or post-dialysis.

In other embodiments, the oral forms and the patch can be administered in combination simultaneously or in succession under specific regimens (e.g. nocturnal patches) in connection with dialysis (e.g., pre-dialysis oral forms).

In numerous embodiments step (a) and (b) are repeated with the administration of increasing doses of the compositions or oral dosage forms, usually by 2-fold, and repeated measurements of marker(s) of nutritional status. Such repetitive titration methods have been exemplified (Example 1-C3).

In this connection the monitoring for adverse events (AE), including those related to cannabis, is of crucial importance. The side effects of cannabis overdose are referred to in Example 1-C2, whereby the above method can proceed unless the patient manifests at least symptom of a cannabis-related AE.

The precise procedure for monitoring for AE in MHD patients is described in Example 1-E4, whereby the above method can proceeds unless the patient manifests at least symptom of AE regardless of causal relationship with the drug.

In further embodiments said at least symptom of AE can be classified as a mild, moderate or severe.

It should be noted that in numerous embodiments the above method can further incorporate measuring at least one parameter indicative of dietary intake, appetite and/or health-related quality of life (QoL).

As the presently proposed methods implement all the previously described compositions and dosage forms, it is understood that in numerous embodiments the methods of the invention involve administering of the cannabis-based compositions comprising a content of THC or CBD of about up to 30%, 25%, 20%, 15%, 14%, 13%, 12%, 11%, 10%, 9%, 8%, 7%, 6%, 5%, 4%, 3%, 2%, 1% or <1% (w/w).

In certain embodiments the methods of the invention apply a therapeutically effective amount of THC or CBD in the range of about 30% to 10%, or 10% to 1% (w/w), as high and low therapeutic doses, respectively. In further embodiments the methods of the invention apply a therapeutically effective amount of THC or CBD in the range of about 14-16% or about 2-4% (w/w) as high and low therapeutic doses, respectively.

In terms of total amounts of actives, the methods of the invention can apply a therapeutically effective amount of THC and CBD up to about 1000 mg, 900 mg, 800 mg, 700 mg, 600 mg, 500 mg, 400 mg, 300 mg, 200 mg, 100 mg, 90 mg, 80 mg, 70 mg, 60 mg, 50 mg, 40 mg, 30 mg, 20 mg, 10 mg or 9 mg, 8 mg, 7 mg, 6 mg, 5 mg, 4 mg, 3 mg, 2 mg, 1 mg or less depending on the frequency or number of administrations.

In numerous embodiments the methods of the invention apply two types of therapeutically effective amounts of THC and CBD:

- a high therapeutic dose wherein both actives are administered in the amount of up to about 240 mg, 180 mg, 120 mg or 60 mg per administration; and

- a low therapeutic dose wherein both actives are administered in the amount of up to about 48 mg, 36 mg, 24 mg orl2 mg per administration.

In certain embodiments both actives are administered at the therapeutic amounts of about 10-15 mg per administration or about 2-3 mg per administration, as high and low therapeutic doses, respectively. This is particularly true for methods using oral or sublingual routes.

It should be noted that methods using transdermal patches can apply a much higher doses of actives with therapeutically effective doses of up to 300 mg, 400 mg, 500 mg, 600 mg, 700 mg, 800 mg, 900 mg, 1000 mg or more.

As has been noted a particularly useful type of compositions has been provided in the form of oil extracts of certain strains of cannabis. Extracts that are compatible with the presently proposed methods can be obtained from the strains Midnight, Mango and Avidekel

It should be further appreciated that in numerous embodiments the methods of the invention can be provided as combination therapies involving simultaneous administering or in succession at least one additional therapeutic agent for treating or maintenance of the patient subjected to MHD. Relevant therapeutic agents have been discussed above.

In yet another aspect, the invention provides an oral dosage form comprising oil extracts of certain cannabis plants with a particular content of THC/CBD for use in treating or preventing PEW and/or improving nutritional status and/or increasing appetite in patients under MHD. The applicable cannabis plants can be broadly characterized as having THC:CBD ratio of about 1:1, and also CBD enriched strains with THC CBD ratios of about 1:2, 1:3, 1:4, 1:5, 1:6, 1:7, 1:8, 1:9, 1: 10, 1:11, 1:12, 1:13, 1:14, 1:15, 1:16, 1:17, 1:18, 1:19 or 1:20 (w/w), respectively. Examples of such strains are provided with Midnight, Mango and Avidekel.

Applicability of dosage forms with THC:CBD ratio of about 1:1 for the improvement of PEW and/or nutritional status and appetite in patients under MHD has been presently demonstrated.

Of particular interest are the two forms designated herein as high and low dosage forms of the invention, comprising THC or CBD in the range of about 30% to 10%, or 10% to 1% (w/w), respectively.

In numerous embodiments the THC or CBD in these dosage forms is in the range of about 14-16% or about 2-4% (w/w), as high and low forms, respectively.

In further embodiments the high dosage forms of the invention can comprise a total amount of THC and CBD up to about 240 mg, 180 mg, 120 mg or 60 mg, and the low dosage forms - up to about 48 mg, 36 mg, 24 mg orl2 mg.

In certain embodiments the total amount of the THC and CBD in the dosage forms of the invention is in the range of about 10-15 mg or about 2-3 mg, for the high and low forms, respectively. These particular forms of the strain Midnight have been presently exemplified.

The term dosage form is used herein in the sense of a pharmaceutical drug product in the form in which it is marketed for use, in terms of specific active and inactive components (excipients), specific configuration (such as a capsule shell, for example), and particular dose (a unit dose).

Thus it should be understood that in numerous embodiments the dosage forms of the invention further comprise buffers and excipients and stabilizing agents.

In numerous embodiments the oral dosage forms of the invention can further comprise at least one additional therapeutic agent.

In numerous embodiments the dosage forms of the invention are provided in the form of drops, as in the present clinical trial.

It should be appreciated that the dosage forms of the invention can be further encapsulated into hard capsules, uncoated or coated with flavoring and coloring agents, to assist consumption and distinction from other drugs.

In certain embodiments the dosage forms of the invention can be provided in the form of collagen or gelatin pellets. As has been noted, of a particular interest is a form of a transdermal patch. The ter s ' transdermal patch ' or ' transdermal delivery system ' (these terms are interchangeable) herein refer to a variety of systems, including first-, second- and more recent third-generation delivery systems known to be particularly advantageous for lipophilic drugs such as cannabis and cannabinoids. The compositions and dosage forms of the invention can be incorporated into these systems using of known in the art technologies,.

First-generation transdermal delivery systems essentially refers to the configuration where the drug is stored in a reservoir enclosed on one side with an impermeable backing and on the other side - with an adhesive contacting to the skin. This term encompasses systems wherein the drug is dissolved in a liquid or gel-based reservoir, and also systems where the drug is incorporated into a solid polymer matrix, and also multilayer systems using impermeable, semi-permeable membranes, and systems using liquid chemical enhancers such as ethanol.

Another type of transdermal systems can employ second-generation delivery systems, i.e., those using chemical enhancers, non-cavitational ultrasound and iontophoresis.

The most recent type of transdermal delivery systems are third-generation delivery systems with targeted effects using microneedles, thermal ablation, microdermabrasion, electroporation and cavitational ultrasound.

Further, in numerous embodiments the dosage forms and compositions of the invention can be incorporated into delivery systems permitting controlled or suspended release of actives. These types of systems have been subject to intensive R&D, yielding advanced delivery systems with so-called 'smart' polymers and hydrogels to make systems that are triggered by changes in environmental factors, such as pFl, temperature, or glucose.

Ultimately, from yet another important aspect the invention provides use of extracts of certain cannabis-plants with a particular content of THC/CBD for the manufacture/ preparation of a medicament for treating PEW and/or improving nutritional status and/or appetite in a patient subjected to MF1D.

In numerous embodiments said use involves cannabis plants comprising THC and CBD in approximately equal proportions (about 1:1).

In certain embodiments said use can be achieved with cannabis strains such as Midnight or Mango.

In further embodiments said use is achieved with oil extracts of the cannabis strains.

As has been explained in detail, these types of strains and oil extracts can serve for producing an oral medicament or a transdermal medicaments, including transdermal patches. The terms approximately or about, these ter s herein are interchangeable, denote up to ± 10% deviation from a respective measurement, or 9%, 8%, 7%, 6%, 5% or less a deviation thereof.

The presently disclosed methods and experimental conditions should not be perceived as limiting, as they only serve illustrative purposes. In the same way, the terms and definitions are not intended to be limiting but are meant to describe specific embodiments, as the scope of the invention will be limited only by the appended claims and equivalents thereof.

EXAMPLE 1: Impact of cannabis oil of the invention on nutrition in MHD patients The following example demonstrates an impact of a cannabis oil of the invention on nutrition in MHD patients with PEW. The example describes a randomized, double-blind, placebo-controlled, parallel-group, pilot study using an extended array of clinical assessment measures and a careful monitoring strategy and design with primary objectives:

(i) To assess the safety and tolerability of cannabis oil after single and multiple oral doses in adult MHD patients; and

(ii) To investigate the effect of cannabis oil on the appetite in these patients.

Study secondary objectives (abbreviations are decoded in Annex A):

- To characterize the PK profile of cannabis oil (and its metabolites) after single and multiple oral doses;

- To establish clinical proof of cannabis oil treatment for the improvement of

nutritional scores (MIS, GNRI, OSND) in the study population;

- To establish clinical proof of cannabis oil treatment for the improvement of health- related QoL in the study population;

- To establish clinical proof of cannabis oil treatment for the improvement of muscle strength in the study population;

- To establish clinical proof of cannabis oil treatment for the improvement of

biochemical nutritional markers (albumin, transferrin, creatinine, cholesterol, uric acid, TLC, IGF-l) in the study population;

- To assess potential effects on the appetite -regulating peptides (ghrelin. Leptin,

obestatin, NPY);

- To assess potential effects on the inflammatory cytokines blood levels (CRP, IL-6, TNF-α);

- To assess potential effects on the BIA derived body composition parameters (lean body mass, fat mass, phase angle); A. STUDY ENDPOINTS

A.l Safety endpoints

Parameters monitored to assess cannabis oil safety:

- Adverse events,

- Change in physical examination,

- Change in routine hematology and blood chemistry,

- Change in coagulation tests.

A2. Pharmacokinetic endpoints

Parameters monitored in patients plasma for cannabis oil (and/or its metabolites^'):

- Maximum observed plasma concentration (C_rnax),

- Time of occurrence of Crnax (t_rnax),

- Terminal half-life (t_1/2),

- Area under plasma concentration-time curve from hour 0 to last sample with measurable plasma concentrations (AUC_last),

- Area under plasma concentration-time curve from hour 0 to infinity AUC_inf,

- Last measurable plasma concentration (C_last),

- Time to reach last measurable plasma concentration (t_last),

- Area under the plasma concentration-time curve over one dosing interval

- Concentration at the end of a dosing interval before the next dose administration (Ctrough).

A.3 Clinical endpoints

Primary endpoints

- Safety,

- Change in appetite assessed by the Visual Analogue Scale (VAS).

Secondary endpoints

- Change in nutritional status assessed by the Malnutrition-Inflammation Score (MIS), Geriatric Nutritional Risk Index (GNRI) and Objective Score of Nutrition on Dialysis (OSND),

- Change in Health Related Quality of Life (HRQoL) assessed by the following questionnaires: EQ-5D or SF-36 v.2,

- Change in daily energy intake,

- Change in daily protein intake,

- Change in serum albumin, - Change in serum uric acid,

- Change in lean body mass assessed by BIA,

- Change in handgrip strength,

- Change in fat mass as assessed by BIA,

- Change in normalized protein nitrogen appearance (nPNA) as calculated by urea

kinetic modeling,

- Change in CRP, IL-6 and TNF-α.

B. STUDY POPULATION

Admission criteria included adult patients with ESKD on 3-times weekly hemodialysis for at least three months prior to screening. Hemodialysis parameters included in all cases: vascular access 4-5h 3-4 times per week at a blood flow rate 250-300 mL/min; bicarbonate dialysate (30 mEq/L) at a dialysis solution flow rate of 500 mL/min; high flux dialyser membrane (biocompatible) with surface area of 1.8-2.2m²; efficiency assessed on the basis of delivered dose of dialysis (Kt/V_urea) using a single-pool urea kinetic model; protein equivalent of nitrogen appearance (nPNA) was calculated from serum urea levels using three-point method. Adverse events (AE) were monitored during the entire (according to ICD-9).

B.l Inclusion criteria

- Male or female, age > 18 years, on MHD hemodialysis treatment at least 3 months,

- Stable and adequate hemodialysis treatment three months prior to the study

- Patients with Malnutrition-Inflammation Score (MIS) > 6.

B.2 Exclusion criteria

- Previous or current use in cannabis or marijuana,

- Critical illness as defined by the need of respiratory or circulatory support,

- Known or suspected allergy to trial products,

- Females of childbearing potential who are pregnant, breast-feeding,

- Patients with active malignant disease or liver cirrhosis,

- Actively symptomatic gastrointestinal bleeding and inflammatory bowel disease,

- Patients on chronic treatment with steroids on (Prednisone) or immunosuppressants,

- Patients receiving the following: Astemizole, Cisapride, Pimozide or Terfenadine,

- Patients suffering from one of the following: acute vasculitis, severe systemic infection, severe heart failure, severe hepatic disease,

- Any condition judged by the investigator to interfere with the trial, - A significant history of alcohol, drug or solvent abuse,

- History of schizophrenia, affective disorder, anxiety disorder or mental incapacity.

B.3 Withdrawal/treatment pause criteria

- Renal transplantation scheduled,

- Switch to another type of dialysis,

- Pregnancy.

C. STUDY DRUG

C.l Investigational product

Midnight oil (investigational product) was made from resin-producing female inflorescences of the Midnight strain and olive oil. The Midnight strain typically contains THC (Δ⁹-THC ) and CBD in a ratio of approximately 1:1 (w/w). The product was analyzed and titrated with pure CBD and olive oil to produce high precision THC/CBD compositions. The low and high Midnight oils with THC/CBD content of 3% and 15%, respectively, were produced by dilutions in olive oil. Examples of such products are demonstrated in Tables 1-2 using quality control analysis by HPLC.

Table 1. Midnight oil 3% (1:1)

Table 2. Midnight oil 15% (1:1)

Each Midnight oil drop (approximately 0.04 ml ) contains about 1.2 mg CBD and 1.2 mg Δ⁹-THC for the 3% low-dose oil, and about 6 mg CBD and 6 mg Δ⁹-THC for the 15% high-dose oil.

During the titration period patients always started with the low-dose (3%) and continued titration until achieving noticeable improvement (see STUDY PROCEDURES) in absence of AE related to cannabis or other AE. A patient could switch to the high-dose (15%) oil only after reaching 20 drops of the low-dose form. Patients in the control group received a placebo oil containing olive oil and chlorophyll.

C.2 Side effects

Side effects of medical cannabis are relatively mild, and may include physiological effects such as dizziness, irregular heartbeat, weakness, lower blood pressure and blood sugar, red and irritated eyes, tiredness, lack of coordination, lack of balance and dryness in mucous membranes; and/or cognitive side effects such as short-term memory impairment, distortions in the perception of time and space. These side effects usually dissipate with continuous use. For people that are pre-disposed cannabis can cause a temporary psychotic attack, anxiety, delusions, or hallucinations. C.3 Dose and mode of administration

Titration period: this stage at which each patient attempts to find his/her ideal dose can last for up to 6 weeks and during this time the impact of the treatment on the disease’s symptoms is not as good as when the dose is balanced between maximum impact on the symptoms and minimal side effects.

Initial and maximum dose: The initial dose is one drop of oil under the tongue three times a day (morning, noon and evening) for three days and then two drops, three times a day, for three more days, and so forth. The dose is increased gradually for each patient depending on the effect of the cannabis oil and tolerability of each patient. The subjects continue titration until AE* is experienced or after reaching the maximum dosage of 20 drops of the low-dose form (3% oil) or 4 drops of the high-dose form (15% oil) per administration. If AE occurs, a patient is tapered down one level to a pre-adverse reaction dose.

The first 6 weeks of the titration phase are followed by 10 weeks of relatively stable treatment phase with maximal dose (with no AE) to complete 16 weeks of treatment.

C.4 Prior and concomitant therapy

Drug interactions: The cannabis oil is added to the patient's treatment regime. Cannabis usually works well in combination with other drugs. Four drugs should be avoided: Astemizole, Cisapride, Pimozide, Terfenadine, due to drug interaction.

D. STUDY PROCEDURES

D.l Appetite assessment:

VAS questionnaire in this particular version was developed to assess positive and negative ratings (Flint A, et al. Int J Obes Relat Metab Disord 2000; 24:38-48) of hunger, satiety, fullness, prospective food consumption, desire to eat fatty, salty, etc., (Annex B), and palatability of the test meal (Annex C).

The Simplified Nutritional Appetite Questionnaire (SNAP) was developed to assess appetite and predict weight loss (Wilson MM, et al. Am J Clin Nutr 2005; 82:1074-81 ; Salmean YA, et al. BMC Res Notes 2013; 6:510). SNAQ consists of four questions with scores in a range of 4-20 points, with lower scores related to weight loss (Annex D).

D.2 Health-related quality of life (QoL) assessment

Short Form 36 quality of life (QoL) scoring system is a version of the health-related QoL scoring system. It is a self-administered questionnaire and was widely used and validated in MHD patients (Kalantar-Zadeh K, et al. J Am Soc Nephrol 2001 ; 12:2797-806). The 8 scales of SF36 are categorized into 2 dimensions: physical health and mental health. EQ-5D is a measure of health status according to EQ-5D descriptive system and EQ visual analogue scale (EQ VAS). The EQ-5D comprises five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression, with 3 levels in each dimension. Health status as assessed by the EQ-5D was found as predictive of all-cause mortality in MHD patients (Sexton DJ, et al. Hemodial Int 2016; May 15. doi: 10.111 l/hdi.12415).

D.3 Dietary intake assessment

Continuous 3-day dietary histories (including a dialysis day, a weekend day and a non dialysis day) were obtained from study participants (self-reported in a food diary). A dietary record included information on the type of foods and beverages, timing, methods of food preparations, missed meals, amount consumed in restaurants and the amount of consumed convenience and processed foods. The dietary energy and protein intake was calculated and normalized for ideal body weight according to the European Best Practice Guidelines (Fouque D, et al. Nephrol Dial Transplant 2007; 22 Suppl 2:ii45-87). The ideal weight was calculated differently for men and women using the Lorentz equations. Dietary intake has been calculated using DOS-based program 'MANA' (http://www.sph.uth. edu.tmc:8052/hnc/software/soft.htm adapted for analysis of food intake records in the Israeli population). Dietary protein intake was estimated by calculating normalized protein nitrogen appearance (nPNA) from the patient’s urea generation rate by using urea kinetics modeling (Depner TA and Daugirdas JT. J Am Soc Nephrol. 1996; 7: 780-5), with single-pool model urea kinetics to estimate the nPNA.

D.4 Biochemical markers of nutritional status

- Plasma albumin was measured using the standard bromocresol green (BCG) method.

- Plasma transferrin, cholesterol, creatinine, uric acid, and TLC are routine measurements using an automatic analyzer.

- Serum IGF-l was measured by radioimmunoassay.

D.5 Biochemical markers of inflammatory response

- Plasma IL-6 was measured by a commercially available photometric ELISA kit.

- Serum C-reactive protein was measured by a turbidimetric immunoassay.

- TNF-α levels were measured in plasma using commercially available ELISA kit.

D.6 Appetite-regulating peptides measurement

Acyl-ghrelin and des-acyl ghrelin, leptin, obestatin and NPY were measured in plasma using commercially available ELISA kits. D.7 Anthropometric measurements

The anthropometric measures included: BMI, mid arm circumference (MAC), triceps skinfold thickness (TSF), and calculated mid arm muscle circumference (MAMC) estimated mid arm circumference (cm) - 0.314 x TSF (mm) (Blumenkrantz MJ, et al. Am J Clin Nutr 1980; 33: 1567-85). All measurements were done post-dialysis (dry weight). Assessments of anthropometry were related to long-term outcomes in end-stage renal disease (Stosovic M, et al. Nephrol Dial Transplant 2011 ; 26: 1367-74). Changes in both MAC and skinfold thickness were associated with all-cause mortality and hospitalization.

D.8 Handgrip strength

Handgrip strength (HGS) cab be evaluated in both the dominant and non-dominant arms using the Harpenden Handgrip Dynamometer). HGS is a useful tool for systematic assessment of muscle mass related to nutritional status and prognosis in patients on MHD (Leal VO, et al. Nephrol Dial Transplant 2011; 26: 1354-60). HGS was repeated three times. D.9 Bioelectrical impedance analysis (BIA)

Body composition was determined by body impedance analysis (BIA). Impedance is low in lean tissue, where intracellular fluid and electrolytes are primarily contained, but high in fat tissue where fluid contain are very low. Impedance is proportional to body water content (TBW). Lean body mass is calculated from the estimates of TBW. Fat mass is calculated as the difference between body weight and lean body mass . In this study, BIA has been performed at approximately 30 min post-dialysis. The multi-frequency technique (using 3 frequencies: 5, 50 and 100 kHz) was used to estimate TBW, extracellular water (ECW), fat mass (FM) and lean body mass (LBM), using NutriPlus software, version 5.1.

D.10 Scoring systems for nutritional assessment

Malnutrition-inflammation score (MIS) is a comprehensive scoring system with significant associations with prospective hospitalization and mortality, and also measures of nutrition, inflammation and anemia in MHD patients (Kalantar-Zadeh K, et al. Am J Kidney Dis 2001; 38: 1251-63; Kalantar-Zadeh K, et al. Nephrol Dial Transplant 2004; 19: 1507-19). In brief, MIS consists of four sections (nutritional history, physical examination, BMI, and laboratory values) and 10 components with 4 levels of severity from 0 (normal) to 3 (very severe). The sum of all 10 components results in an overall score ranging from 0 (normal) to 30 (severely malnourished). PEW defined by a MIS score of >6 (Yamada K, et al. Am J Clin Nutr 2008; 87: 106-13.). Geriatric Nutritional Risk Index (GNRI ) in this study was modified to improve the efficiency and rationalization of nutritional assessment. Faced with the difficulty in identifying the usual body weight of elderly patients, the usual body weight was replaced with ideal body weight in the NRI (Nutritional Risk Index) formula (Bouillanne O, et al. Am J Clin Nutr 2005; 82:777- 83). Ideal body weight was calculated according to the Lorentz formula and Chumlea et al (Chumlea WC, et al. J Am Geriatr Soc 1985; 33:116-20). GNRI was calculated as GNRI = [1.489 x albumin (g/L)] + [41.7 x (weight/ideal body weight)].

Objective Score of Nutrition on Dialysis (OSND) was created by combining the change in end-dialysis dry weight (overall change in past 3-6 months) with anthropometric measurements (BMI, skinfold thickness and midarm circumference) and three laboratory tests (serum albumin, transferrin and total cholesterol) (Beberashvili I, et al. Nephrol Dial Transplant 2010; 25:2662-71). The original OSND has 7 components, each categorized into three malnutrition risk categories (normal, moderate and low), wherein a lower score reflects a more severe degree of malnutrition.

Weight change was determined as the change in edema-free body weight obtained after hemodialysis over the course of 6 months. The lowest score 1 is given if weight loss is 10% or greater. Score 2 indicates weight loss that is between 5% and 10% of dry weight. Score 4 is given for weight loss less than 5% of body weight, or any increase in body weight.

Body mass index (BMI) was also grouped into three categories: BMI less than 17 kg/m2 is scored as 1, BMI between 17 kg/m2 and 19.9 kg/m2 is scored as 2 and normal BMI (≥20kg/m2) is scored as 4.

Triceps skinfold thickness (TSF) is scored 1 if it is less than 9.9mm for males and 13.1mm for females. A score of 2 is given if TSF is 10.0-12.4 mm for males and 13.2- 16.4 mm for females; and score 4 is given if TSF above 12.5 mm for males and 16.5 mm for females.

Midarm circumference (MAC) is scored 1 if it is less than 20.1 cm for males and 18.5 cm for females; 2, if MAC is 20.2-25.2 cm for males and 18.6-23.1 cm for females; and 4, if MAC is above 25.3 cm for males and 23.2 cm for females.

The OSND includes three laboratory values. Flypoalbuminemia less than 3.0 g/dL is scored as 0, serum albumin 3.1-3.4 g/dL is scored as 3 and normoalbuminemia (serum albumin above 3.5 g/dL) is scored as 6.

Serum total cholesterol level is scored 0 when it is less than 150 mg/dL; 3, if serum cholesterol is 150-200 mg/dL; and 6 if serum cholesterol is above 200 mg/dL. For hemodialysis patients also treated with statins, a cholesterol level less than !30mg/dL (instead of 150 mg/dL) is scored as 0; cholesterol 130-180 mg/dL is scored as 3 in such patients and cholesterol level above 180 mg/dL is scored as 6.

In this study, serum albumin and cholesterol levels were scored by the 0, 3, 6 system instead of the 1, 2, 4 system (used for the other indicators). This gives albumin and cholesterol levels greater weight, corresponding to their profound impact on outcome of hemodialysis patients.

Serum transferrin is scored 1 when its level is less than 120 mg/dL; 2, if serum transferrin is 120-149 mg/dL; and 4, if serum transferrin is above 150 mg/dL.

The sum of all seven components ranges from 32 (normal) to 5 (severely malnourished).

D.ll Residual renal function measurement

Residual Renal Function (RRF) was estimated by calculating GFR expressed in mL/min/l.73 m² (Annex E). In brief, the GFR was estimated as the mean of urea and creatinine clearance using urine collections made over the entire interdialytic period (48 hours, starting with empty bladder at the start of one dialysis session and ending at the start of the next). The mean blood urea and creatinine plasma concentrations during the collection period were estimated as the mean of the post-FID concentration immediately after dialysis (the study used the slow flow/stop pump sampling technique). In this study, at the completion of hemodialysis the dialysate flow was turned off and the ultrafiltration rate (UFR) was decreased to 50 mL/h, the transmembrane pressure (TMP)/UFR was set to the lowest value or set to zero. Further, the blood flow was decreased to 50 to 100 mL/min for 15 seconds. The mean blood urea and creatinine concentrations during the collection period were estimated as the mean of the post-HD concentration immediately after dialysis (after rebound correction) and the pre-HD value immediately before the following dialysis. RRF were calculated according to the formula recommended by European Best Practice Guidelines for Hemodialysis (European Best Practice Guidelines for Haemodialysis. Nephrol Dial Transplant 2002; 17, Suppl 7:7-9).

E. STUDY SCHEDULE

The study were designed to reveal (i) the PK behavior of the cannabis oil and (ii) its treatment effects and/or potential hazards in MHD patients. To that end the study included the following milestones: E.l Screening visit (VO)

Patients were reviewed for inclusion and exclusion criteria, physical examination (including weight, height), vital signs measurement (including body temperature, seated pre dialysis heart rate and blood pressure), residual renal function measurement, demographic information has been also obtained.

E.2 PK part

Cannabis oil was administered in two subsequent time points (herein 'Periods 1 and 2'). During Period 1, at pre-dose patients was evaluated for a number of clinical parameters, also including PK measurements and monitoring of adverse events (AE) (see Table 3). On dosing day 1 (Dl), the cannabis oil was administered at pre-dialysis after an overnight fast of at least 8 hours. After drug administration, patients were re-evaluated with regard to the same parameters at several time-point. On days 2 and 3 (D2 and D3), 24h and 48h after drug administration, respectively, patients were re-evaluated (pre-dialysis) with regard to the same. Period 1 was followed by a washout period (7 days) to allow for complete elimination of cannabis.

Upon returning for Period 2, subjects received Dl consisting of a single, 1 drop oral dose of cannabis oil 1.0 ± 0.2 h with pre- and post-dose PK sampling. The drug was administered at post-dialysis after an overnight fast of at least 8 h. Patients were consistently evaluated for a number of parameters, including PK and AE (see Table 3). The same evaluations (pre-dialysis) were repeated on D2 and D3, 24h and 48h. Period 2 was also followed by a washout period.

These steps were repeated for all escalating doses of cannabis.

On the basis of findings in the PK part it was decided whether to use of single or multiple dose(s) in the treatment part of the study, also the appetite and nutritional status study part.

E.3 Appetite and nutritional evaluation part

The participants in this part consented to additional tests, including biochemical and nutritional parameters (see Table 3). Randomization visit (VI) was the baseline value for the trial, wherein patients were randomly assigned to receive cannabis oil/ placebo. All patients started with a fixed dose decided in the PK part of the study. The study drug was administered after an overnight fast of at least 8 hours, administered orally with meals or snacks. Patients wer re-evaluated (pre-dialysis) at VI and at subsequent follow up visits (V2, V3 and V4) with respect to clinical parameters (e.g., physical examination, vital signs, ECG, AE), handgrip strength, and further hematological, biochemical and nutritional markers (e.g., albumin, creatinine, cholesterol, transferring, uric acid, TLC, IGF-l, inflammatory biomarkers (CRP, IL-6, TNF-α), appetite-regulating peptides (ghrelin, leptin, obestatin, NPY), and VAS and SNAQ questionnaires for appetite assessment, SF-36 v2 and EQ-5D questionnaires for HRQoL assessment, spKt/Vurea, nPNA have been calculated from blood urea. Additional assessments (post-dialysis) included BIA (within 30 min), nutritional scores (MIS, GNRI, OSND), and drug compliance.

Additional considerations included screen failure assessed on VO (patients who do not meet all the inclusion and exclusion criteria), concomitant medications and activities assessed on VI (prescribed renal diet and medications throughout the study), study drug discontinuation at any time point (upon patient request, concurrent illness or medical event, pregnancy). Special attention has been given to the assessment of AE.

E.4 Adverse events (AE)

The assessment related to any reaction, side effect, or other undesirable event that occurs in conjunction with drug use, including any illness, sign, symptom or clinically significant laboratory test abnormality or worsened during the course of the clinical trial, regardless of causal relationship to the drug. AEs were recorded at every visit after screening (VI to V4 and follow up VI -V2). Severity of AE was determined by a patient or a physician as a qualitative assessment using the following scale:

1 = Mild (discomfort noticed, but no disruption of normal daily activity.)

2 = Moderate (discomfort sufficient to reduce or affect normal daily activity.)

3 = Severe (incapacitating, with inability to work or to perform normal daily activity.)

A drug-related AE is the one meeting at least 3 of the following criteria: (1) following a reasonable temporal sequence from administration of the drug; (2) following a known pattern of response to the drug; (3) could not be reasonably explained by the known characteristics of the patient’s clinical state, environmental or toxic factors, or other modes of therapy administered; (4) decreases on cessation of treatment or reduction in dose.

AEs were further classified to non-serious or serious (SAEs). An SAE is one that meets any one of the following criteria: results in death; is a life-threatening experience; requires or prolongs inpatient hospitalization (>24 h); causes persistent or significant disability/incapacity.A patient experiencing one or more SAEs were monitored for 60 days after drug discontinuation of the or until AE was determined as no longer significant.

Study schedule relating to above milestones, as well as the sequence and timing of various measurements, is summarized in Table 3 below. Table 3 Study schedule

F. STATISTICAL PLAN

F.l Sample size rationale

At least 50 subjects were screened to give at least 30 subjects randomized (15 cannabis, 15 placebo), and treated for 3 months. Data have been analyzed using SPSS V 17.0.

F.2 Efficacy analysis

Categorical data was recorded using absolute and relative frequencies (n and %). Continuous data was presented using descriptive statistics (n, mean, standard deviation [SD], minimum and maximum, or median and interquartile range when appropriate. The homogeneity of the treatment groups regarding demographic and baseline characteristics were also assessed. An ANCOVA was applied to changes from baseline to end of treatment taking treatment arm and baseline level into account. The overall test for effect was performed as a two-sided F test with 5% significance. Both treatment groups were compared in the baseline adjusted ANCOVA, and pair-wise t tests - using the Tukey method to adjust for multiple comparisons. The primary efficacy analysis included all randomi ed patients (full analysis set) and was performed according to intention-to-treat principle.

F.3 Safety Analysis

Adverse events were evaluated with a Cochran-Mantel-Haenszel χ² test for the proportion of patients with the event to test for treatment difference. The intention-to-treat analysis set included all patients who are treated with at least one dose of trial product, the results were presented as change with 95% confidence intervals. In general, model assumptions were checked descriptively using box plots and normal quantile-quantile plots. F.4 PK Analysis

Single and multiple-dose PK parameters were derived from the plasma concentration time. A compartmental or non-compartmental PK method were used to analyze the plasma concentrations of cannabis and its metabolites. Individual and mean plasma concentrations at each time point were presented by listings and descriptive summary statistics for each dose group/food condition. Time profile plots of each dose group/food condition, arithmetic and logarithmic means (+SEM) at each time measurement were for plasma data. All PK parameters were presented by individual listings and summary statistics for each dose group/food condition. Box-plots were performed by dose group/food condition for PK parameters. The dose proportionality of PK plasma parameters Cmax and AUC were evaluated using Power model. Log-transformed PK parameters were included in the linear mixed effects model including dose as a fixed effect. Dose proportionality was analyzed using the estimated slope parameter of the linear model. Table 4 below summarizes the main steps in the study.

Table 4 Protocol synopsis

ANNEX A. List of abbreviations

3V Third Ventricle

AgRP Agouti-related Peptide

AIDS Acquired Immune-deficiency Syndrome

ALT Alanine Aminotransferase

ANCOVA Analysis of Co-variance

ANOVA Analysis of Variance

ARC Arcuate Nucleus

AST Aspartate Amino Transferase

Area under the plasma concentration-time curve from time 0 to the time of last quantifiable concentration

AUC_inf Area Under the plasma concentration-time Curve from hour O to infinity

AUC_last Area Under the plasma concentration-time Curve from hour 0 to last sample with measurable plasma concentrations

BIA Bioelectric Impedance Analysis

CART Cocaine- and Amphetamine-Regulated Transcript

C_average Average plasma concentration at steady state

CBD Cannabidiol

CKD Chronic Kidney Disease

CL/F Apparent total body Clearance

C_last Last measurable plasma concentration

C_min Minimum observed plasma concentration

CNS Central Nervous System

CRH Corticotropin-releasing Hormone

C_rnax Maximum observed plasma concentration

CRP C-reactive Protein

C_trough Concentration at the end of a dosing interval before the next dose administration

EC Endocannabinoid

EQ-5D EuroQol five dimensions questionnaire

ESKD End Stage Kidney Disease

GNRI Geriatric Nutritional Risk Index

Hcrt Hypocretin

HD Hemodialysis

HRQoL Health Related Quality of Life

IGF-l Insulin-like Growth Factor- 1

IL-6 Interleukin-6

LH Lateral Hypothalamus

MA Megestrol Acetate

MCH Melanine-concentrating Hormone

MHD Maintenance Hemodialysis

MIS Malnutrition-inflammation Score nPNA normalized Protein Nitrogen Appearance

NPY Neuropeptide Y

NTS Nucleus of the Tractus Solitarius

NYHA New York Heart Association

OSND Objective Score of Nutrition on Dialysis

PEW Protein Energy Wasting

PK Pharmacokinetics

POMC Pro-opiomelanocortin

PTF% Peak-trough fluctuation

PVN Paraventricular Nucleus

QoL Quality of Life

Accumulation ratio of AUCo-t

R_acc C_rnax Accumulation ratio of Cmax

SF-36, v.2 Short Form 36, version 2

SNAQ Simplified Nutritional Appetite Questionnaire t_1/2 Apparent ter inal elimination half-life THC T etrahydrocannabinol

t_last Time to last measurable plasma concentration

TLC Total Lymphocyte Count

TNF-α Tumor Necrosis Factor- a

t_rnax Time to reach Cmax (time at peak plasma level)

VAS Visual Analogue Scale

V_z/F Apparent volume of distribution

λ_z Apparent terminal elimination rate constant

ANNEX B. VAS Questionnaire

ANNEX C. Payability

ANNEX D. Simplified nutritional appetite questionnaire (SNAQ)

Administration Instructions: Ask the subject to complete the questionnaire by circling the correct answers and then tally the results based upon the following numerical scale: a=l, b=2, c=3, d=4, e=5. The sum of the scores for the individual items constitutes the SNAQ score. SNAQ score < 14 indicates significant risk of at least 5% weight loss within six months.

>

i

*

ANNEX E. Calculation of GFR from interdialytic urine collections

t - time in minutes between dialyses.

PreUrea, PreCreatspre - dialysis urea and creatinine concentrations in blood sample at the end of collection.

PostUrea, PostCre - post-dialysis urea and creatinine concentrations in blood sample at beginning of collection.

Uvol - urine collection volume in millilitres.

Uurea, Ucreat - urea and creatinine concentrations.

SA - surface area.

Claims

1. A cannabis-based composition comprising tetrahydrocannabinol (THC) and cannabidiol (CBD) in approximately equal proportions for use in treating protein-energy- wasting (PEW) and improving nutritional status in a patient subjected to maintenance hemodialysis (MHD).

2. The composition of claim 1, wherein said improving of nutritional status further comprises an increased appetite.

3. The composition of claim 1 or 2 comprising THC or CBD in the range of about 30% to 10%, or 10% to 1% (w/w).

4. The composition of claim 3 comprising THC or CBD in the range of about 14-16% or about 2-4% (w/w).

5. The composition of any one of claims 1-4 in a form of an oil extract of a cannabis plant.

6. The composition of claim 5, wherein said cannabis plant is selected from at least one strain herein designated as Midnight or Mango

7. The composition of any one of claims 1-6 being adapted for oral or sublingual administration.

8. The composition of any one of claims 1-6, being adapted for transdermal administration.

9. The composition of any one of the preceding claims, further comprising at least one additional therapeutic agent.

10. The composition of claim 7 comprising THC and CBD in the range of about 10-15 mg or about 2-3 mg.

11. The composition of claim 7 comprising THC and CBD of up to about 240 mg, 180 mg, 120 mg or 60 mg, or up to about 48 mg, 36 mg, 24 mg or 12 mg.

12. The composition of any one of the preceding claims for use as a combination therapy in a method of treating or maintenance of the patient subjected to MHD, said combination therapy comprising administering the composition simultaneously or in succession with at least one additional therapeutic agent.

13. A method for treating PEW and improving nutritional status in a MHD patient, the method comprises administering to a patient a therapeutically effective amount of a cannabis- based composition comprising THC and CBD in approximately equal proportions.

14. The method of claim 13, wherein said improving of nutritional status further comprises an increased appetite.

15. The method of claim 13 or 14, wherein said administering is oral or sublingual administering.

16. The method of claim 15, wherein the administering comprising 1 to 3 administrations per day.

17. The method of claim 15 or 16, wherein the administering is carried out pre- or post dialysis.

18. The method of any one of claims 15-17, the administering is carried out with meals or snacks.

19. The method of claim 13 or 14, wherein the administering is transdermal administering.

20. The method of claim 19, wherein the administering is by a transdermal patch.

21. The method of any one of claims 13-18, wherein the therapeutically effective amount of the THC or CBD in the composition is in the range of about 30% to 10%, or 10% to 1% (w/w).

22. The method of claim 21, wherein the therapeutically effective amount of the THC or CBD in the composition is in the range of about 14-16% or about 2-4% (w/w).

23. The method of claim 21 or 22, wherein the therapeutically effective amount of the THC and CBD in the composition is up to about 240 mg, 180 mg, 120 mg or 60 mg per administration, or up to about 48 mg, 36 mg, 24 mg or 12 mg per administration.

24. The method of claim 21 or 22, wherein the therapeutically effective amount of the THC and CBD in the composition is in the range of about 10-15 mg per administration or about 2-3 mg per administration.

25. The method of any one of claims 13-24, wherein the composition is in a form of an oil extract of a cannabis plant.

26. The method of claim 25, said cannabis plant is selected from at least one strain herein designated as Midnight or Mango.

27. The method of any one of claims 14-26 as a combination therapy for treating and/or maintenance of the patient subjected to MHD, the combination therapy further comprising administering to the patient simultaneously or in succession at least one additional therapeutic agent.

28. An oral dosage form comprising an oil extract of a cannabis plant comprising THC and CBD in approximately equal proportions for use in treating or preventing PEW and improving nutritional status or increasing appetite in a MHD patient.

29. The oral dosage form of claim 28, wherein the cannabis plant is selected from at least one strain herein designated as Midnight or Mango.

30. The oral dosage form of claim 28 or 29 comprising THC or CBD in the range of about 30% to 10%, or 10% to 1% (w/w).

31. The oral dosage form of claim 30 , wherein the THC or CBD is in the range of about 14-16% or about 2-4% (w/w).

32. The oral dosage form of claim 30 or 31, wherein the total amount of THC and CBD is up to about 240 mg, 180 mg, 120 mg or 60 mg, or up to about 48 mg, 36 mg, 24 mg or 12 mg.

33. The oral dosage form of claim 30 or 31, wherein the total amount of the THC and CBD is in the range of about 10-15 mg or about 2-3 mg.

34. The oral dosage form of any one of claims 28-33 further comprising at least one additional therapeutic agent.

35. A transdermal patch comprising an extract of a cannabis plant comprising THC and CBD in approximately equal proportions for use in treating or preventing PEW and improving nutritional status or increasing appetite in a MHD patient.

36. The transdermal patch of claim 35, wherein the cannabis plant is selected from at least one strain herein designated as Midnight or Mango.

37. The transdermal patch of claim 35 or 36 comprising THC or CBD in the range of about 30% to 10% or 10 to 1% (w/w).

38. The transdermal patch of claim 37, wherein the THC or CBD is in the range of about 14-16% or about 2-4% (w/w).

39. The transdermal patch of any one of claims 35-38 further comprising at least one additional therapeutic agent.

40. A method for treating PEW and improving nutritional status in a MHD patient, said method comprises

(a) administering to the patient at least one of a composition of any one of claims 1-12, an oral dosage form of any one of claims 28-34, a transdermal patch of any one of claims 35-39, and

(b) measuring at least one marker of nutritional status in said MHD patient to thereby determine effectiveness of treatment.

41. The method of claim 40, wherein the administering is daily administering.

42. The method of claim 40 or 41, wherein the administering is carried out pre- or post dialysis.

43. Use of an extract of a cannabis- plant for the manufacture/ preparation of a medicament for treating PEW and improving nutritional status in a MHD patient, said cannabis comprises THC and CBD in approximately equal proportions.

44. Use according to claim 43, wherein the cannabis plant is selected from at least one strain herein designated as Midnight or Mango.

45. Use according to claim 43 or 44 wherein the extract of a cannabis plant is an oil extract.

46. Use according to any one of claims 43-45, the medicament being an oral medicament or a transdermal patch.