TREATMENT OF FRAGILE X SYNDROME WITH CANNABIDIOL

Abstract

The present technology refers to a method for treating one or more symptoms of Completely Methylated Fragile X Syndrome (Fmet) in a subject that includes administering an effective amount of cannabidiol to the subject so as to treat one or more symptoms of Fragile X Syndrome.

Description

TREATMENT OF FRAGILE X SYNDROME WITH CANNABIDIOL Cross-reference to related applications This application claims benefit from and priority to U.S. Provisional Application No. 63 / 045,664, filed June 29, 2020, entitled "Treatment of Fragile X Syndrome with Cannabidiol," the contents of which are incorporated herein by reference in their entirety. Field of invention The present description refers to methods for treating one or more behavioral symptoms of fragile X syndrome in a subject who has complete methylation of the FMR1 gene (Fmet) by administering an effective amount of cannabidiol (CBD) to the subject. Background of the invention Cannabinoids are a class of chemical compounds found in the Cannabis plant. The two main cannabinoids in cannabis are cannabidiol, or CBD, and tetrahydrocannabinol, or THC. CBD lacks the psychoactive effects of THC. Studies have shown that CBD can be used to treat conditions such as epilepsy, arthritis, and cancer. Fragile X syndrome (FXS) is the most common inherited intellectual disability in males and a significant cause of intellectual disability in females. It is caused by a mutation in the Fragile X 1 (FMR1) gene, located on the X chromosome, and leads to dysregulation of the endocannabinoid system, including reductions in endogenous cannabinoids (2-AG and anandamide [AEA]). The disorder negatively affects synaptic function, plasticity, and neuronal connections, resulting in a spectrum of intellectual disabilities, social anxiety, and memory problems. In the United States, there are approximately 71,000 individuals with FXS. Behavioral problems are often the most significant concern reported by parents, and high levels of stress and depression, along with low levels of parental quality of life, are commonly associated with elevated problem behaviors in children. Wheeler A, Raspa M, Bann C, Bishop E, Hassl D, Sacco H, Bailey DB. 2014. Anxiety, attention problems, hyperactivity, and the Aberrant Behavior Checklist in fragile X syndrome. Am J Med Genet Parí A 164A:141-155, 141. As a result, reducing behavioral problems is a primary focus of ongoing clinical trials testing the efficacy of new medications for FXS. Wheeler pp. 41-142. The Anxiety, Depression, and Mood Scale (ADAMS) is an instrument used by clinicians, doctors, and researchers to assess anxiety, depression, and mood levels in patients with intellectual disabilities, including FXS. ADAMS consists of questions grouped into five subscales: (i) general anxiety, (ii) social avoidance, (iii) compulsive behavior, (iv) manic / hyperactive behavior, and (v) depressed mood. Each question is answered by a clinician / doctor on a four-point scale ranging from 0 (no problem) to 3 (severe problem). In addition to the subscale scores, ADAMS produces a total score. The original Aberrant Behavior Checklist (ABC) was designed to assess behavioral concerns in adults within institutional settings (Wheeler, p. 142). Since then, the original ABC has been adapted to address non-institutionalized patients and specifically to address FXS (Id.). The Aberrant Behavior Checklist – FXS Specific Scale (ABC-FXS) is used by clinicians, doctors, and researchers to access certain behaviors in patients with FXS. The ABC-FXS scale has six subscales, including (i) irritability, (ii) hyperactivity, (iii) socially unresponsive / lethargic, (iv) social avoidance, (v) stereotypy, and (vi) inappropriate speech. Similar to the ADAMS, the ABC-FXS scale is a four-point Likert-type scale ranging from 0 (not a problem) to 3 (the problem is severe). Brief description of the invention This description relates to a method for treating one or more behavioral symptoms of fragile X syndrome in a subject who has complete methylation of the FMR1 gene, the method. The method includes the transdermal administration of an effective amount of cannabidiol (CBD) to the subject. In some modalities, one or more symptoms are a behavioral symptom of Fragile X syndrome. In some modalities, the behavioral symptom is social avoidance. In some modalities, treatment includes improvement in the Clinical Global Impression-1 (CGI-1). In some formulations, CBD is (-)-CBD. The effective amount of CBD can range from approximately 50 mg to approximately 500 mg daily. In some formulations, the effective amount of CBD starts at approximately 50 mg daily and is adjusted up to approximately 500 mg daily. The effective amount of CBD can start at approximately 50 mg daily and is adjusted up to approximately 250 mg daily. In some formulations, the effective amount of CBD starts at 250 mg daily. The effective amount of CBD can also start at 500 mg daily. In some formulations, the 500 mg daily dose is administered to patients weighing over 35 kg. CBD can be administered in a single daily dose or in two daily doses. In some formulations, the effective amount of CBD can be 390 mg in divided targeted doses. In some formulations, the total daily dose of CBD is 250 mg. In some formulations, the total daily dose of CBD is 500 mg. In some formulations, the total daily dose of CBD is either 250 mg or 500 mg. Dosage, in some formulations, is based on weight. In some formulations, CBD is administered in a single daily dose. In some formulations, CBD is administered in two targeted doses. CBD can be formulated as a gel or an oil. In some formulations, CBD is formulated as a gel, for example, a permeation-enhanced gel. The gel can contain between 1% (w / w) and 7.5% (w / w) CBD. In some formulations, the gel contains 4.2% (w / w) CBD. ML / t / ZUZÓ / U I4 1 υυ In some forms, the gel contains 7.5% (weight / weight) of CBD. In some forms, the transdermal preparation may be a cream, balm, or ointment. CBD can be administered via a bandage, pad, or patch. CBD can be administered transdermally in the upper arm and shoulder. In some formulations, CBD is administered transdermally in the thigh or back. In some formulations, CBD is administered transdermally by application to the arm. CBD can be synthetic. CBD can be purified. CBD can be botanically derived. In some forms, CBD is not botanically derived. Transdermal administration of an effective amount of cannabidiol (CBD) may reduce the intensity of at least one adverse event or side effect compared to oral CBD administration. At least one adverse event or side effect may be a gastrointestinal (GI) adverse event. At least one adverse event or side effect may be related to liver function. In some formulations, at least one adverse event is drowsiness. In some formulations, the frequency and intensity of drowsiness are reduced as an adverse event. In some formulations, the psychoactive effects are reduced or eliminated. Detailed description of the invention As used herein, the term treat or treatment refers to mitigating, improving, removing, or alleviating at least one symptom (such as a behavioral symptom) of a condition, disease, or disorder in a subject, such as a human being, or the improvement of a verifiable measurement associated with a condition, disease, or disorder. As used herein, the term clinical efficacy refers to the ability to produce a desired effect in humans as shown through a clinical trial by the Food and Drug Administration (FDA) or any foreign counterpart. As used herein, the term cannabidiol or CBD refers to cannabidiol; cannabidiol prodrugs; pharmaceutically acceptable derivatives of cannabidiol, including pharmaceutically acceptable salts of cannabidiol; cannabidiol prodrugs; and cannabidiol derivatives. CBD includes 2-[3-methyl-6-(1-methylethenyl)-2-cyclohexen-1-yl-5-pentyl-1,3-benzenediol], as well as pharmaceutically acceptable salts, solvates, metabolites (e.g., cutaneous metabolites), and metabolic precursors thereof. The synthesis of CBD is described, for example, in Petilka et al., Helv. Chim. Acta, 52:1102 (1969) and in Mechoulam et al., J. Am. Chem. Soc., 87:3273 (1965), which are incorporated in this document as a reference. As used in the present invention, the term "transdermal administration" refers to the contact of CBD with the skin of the patient or subject under conditions effective for the CBD to penetrate the skin. Fragile X syndrome Fragile X syndrome is a rare genetic developmental disability that is the leading cause FXS is a well-known inherited intellectual disability and autism spectrum disorder, affecting 1 in 3,600 to 4,000 males and 1 in 4,000 to 6,000 females. It is the most common inherited intellectual disability in males and a major cause of intellectual disability in females, and the leading genetic cause of autism spectrum disorder (ASD). The disorder negatively affects synaptic function, plasticity, and neuronal connections, resulting in a spectrum of intellectual disabilities and behavioral symptoms, such as social avoidance and irritability. In the United States, there are approximately 71,000 people with FXS, about 60% of whom have complete methylation of the FMR1 gene. FXS is caused by a mutation in FMR1, a gene that modulates several systems, including important effects on the endocannabinoid system and, most critically, encodes a protein called FMRP. This protein helps regulate the production of other proteins and plays a role in the development of synapses, which are critical for transmitting nerve impulses, and in regulating synaptic plasticity. The FMR1 mutation manifests as multiple repetitions of a DNA segment known as the CGG triplet repeat. In most neurotypical people, the FMR1 gene correctly codes for the FMRP protein. In neurotypical individuals, CGG repeats are present, but these repeats occur only between 5 and 40 times. As a result, FMRP is produced at levels that allow for control over behaviors such as social avoidance and anxiety.In individuals with FXS, the CGG segment is repeated more than 200 times and, in most cases, renders the FMR1 gene non-functional. However, FMR1 gene methylation also plays a role in determining gene function. At methylation levels above 90%, considered complete methylation, the FMR1 gene is silenced, thus preventing the production of FMRP, and resulting in the dysregulation of systems and processes expected to be affected by FMRP. Patients with FXS can be classified as mosaic or non-mosaic. Mosaicism has been described as the coexistence of the full mutation and the pre-mutation CGG, which is repeated in adjacent cells throughout the body. Patients with mosaic FXS may still produce some level of FMRP because the FMR1 gene has not been completely silenced in all cells of the body. The amount of FMRP produced is generally modulated by methylation of the FMR1 gene. With methylation greater than 90% (considered complete methylation), the FMR1 gene is considered completely silenced. People with a genetically confirmed full fragile X mutation and full methylation of their FMR1 gene are generally the most severely affected by the disorder. The present description refers to a method for treating one or more behavioral symptoms of fully methylated fragile X syndrome (Fmet) in a subject by transdermally administering an effective amount of cannabidiol (CBD) to the subject, where one or more behavioral symptoms of fragile X syndrome are treated in the subject. Clinical and preclinical data support the potential of CBD in the treatment of epilepsy, arthritis, cancer, and Fragile X syndrome. Therapeutic drugs have been developed using innovative transdermal technologies to enable the sustained and controlled delivery of therapeutic levels of CBD. Transdermal delivery of cannabinoids (e.g., CBD) has advantages over oral dosing because it allows the drug to be absorbed through the skin directly into the bloodstream. This bypasses first-pass hepatic metabolism, potentially enabling lower dosage levels of active pharmaceutical ingredients with increased bioavailability and an improved safety profile.Transdermal administration also bypasses the gastrointestinal tract, decreasing the likelihood of gastrointestinal-related adverse events and the potential degradation of CBD by gastric acid into THC, which can be associated with unwanted psychoactive effects. Furthermore, transdermal CBD administration reduces the intensity and frequency of drowsiness, a common adverse event associated with oral CBD dosages. Transdermal CBD administration can also avoid adverse events related to liver function, which are typically associated with oral CBD dosages. In some formulations, transdermal administration of an effective amount of CBD reduces the intensity of at least one adverse event by approximately 15% to approximately 95% compared to oral CBD administration. CBD can be in gel form and can be pharmaceutically produced as a transparent, permeation-enhanced gel designed to provide controlled transdermal drug delivery with one or two daily doses. CBD gel can contain between 1% (w / w) and 7.5% (w / w) CBD. For example, a CBD gel might contain 4.2% (w / w) or 7.5% (w / w) CBD. The CBD gel can be applied topically by the patient or caregiver to the upper arm and shoulder, back, thigh, or any combination thereof. CBD gel may include diluents and carriers, as well as other conventional excipients such as wetting agents, preservatives, and suspending and dispersing agents. CBD gel may include a solubilizing agent, a permeation enhancer, a solubilizer, an antioxidant, a bulking agent, a thickening agent, and / or a pH modifier. The composition of CBD gel may be, for example: a. cannabidiol present in an amount of approximately 0.1% to approximately 20% (w / w) of the composition; b. a lower alcohol having between 1 and 6 carbon atoms present in an amount of approximately 15% to approximately 95% (w / w) of the composition; c. a first penetration enhancer present in an amount of approximately 0.1% to approximately 20% (w / w) of the composition; and d. water in an amount sufficient to make the composition 100% (w / w). Other formulations of CBD gel can be found in International Publication No. WO 2010 / 127033, the full contents of which are incorporated herein by reference. EXAMPLES Example 1: Treatment of FXS with CBD A total of 20 patients (mean age = 10.8, SD = 4.0) were enrolled in a 12-week study. Eighteen patients (14 men, 4 women) aged 6 to 17 years (mean = 11.2, SD = 3.96) with Fragile X syndrome, as confirmed by molecular documentation of the full FMR1 mutation, completed the open-label FAB-C study through week 12. CBD gel was added to other administered medications. The first six weeks of the study were designed for dose titration in patients. Dosage was initiated at 50 mg of CBD daily and could be increased to 250 mg of CBD daily. Weeks 7 through 12 of the study comprised the maintenance period, during which patients were treated at the dose established at week six, with a maximum of 250 mg of CBD daily. Upon completion of the study, patients could be enrolled in an open-label extension study for up to 12 months. The primary endpoint of the trial was the change in the total score on the Anxiety, Depression, and Mood Scale (ADAMS) from baseline to week 12. The ADAMS is a 28-item scale designed to assess general anxiety, social avoidance, compulsive behavior, manic / hyperactive behavior, and depressed mood. It has been validated in patients with FXS. The results for the primary outcome measure are summarized in Table 1, which details the mean (standard deviation) efficacy scale values ​​at baseline and at week 12 for the total ADAMS score. Table 1 Reference (n=18) Week 12 (n=18) Percentage Change from Reference (%; n=18) P-value* ADAMS: Total Scores 32.1 (14.36) 18.1 (8.32) -43.61 p<0.0001 * p-values ​​are presented for the comparison of the Week 12 value with the Reference value for the total score and each subscale, among those who completed the study (n=18). The ADAMS subscales are summarized in Table 2, detailing mean (standard deviation) effectiveness scales at baseline and week 12. Table 2 Reference (n=18) Week 12 (n=18) Percentage Change from Reference (%; n=18) P-value* ADAMS: Manic / Hyperactive Behavior Subscale 8.8 (3.99) 6.1 (3.29) -30.68 p=0.0003 ADAMS: Depressed Mood Subscale 2.9 (3.94) 2.0 (2.35) -31.03 p=0.1417 ADAMS: Social Avoidance Subscale 9.9 (5.18) 4.8 (2.07) -51.52 p=0.0002 ADAMS: General Anxiety Subscale 9.4 (4.35) 4.6 (3.35) -51.06 p<0.0001 ADAMS: Compulsive Behavioral Subscale 2.7 (2.40) 1.4 (1 -42) -48.15 p=0.0262 ML / t / ZUZÓ / U I4 1 υυ * The p-values ​​are presented for the comparison of the Week 12 value with the Reference value for the total score and each subscale, among those who completed the study (n=18). Compared to the total baseline score, patients treated with CBD transdermal gel showed a 44% reduction (p<0.0001) in the total ADAMS score. Furthermore, patients treated with CBD transdermal gel showed a statistically and clinically significant improvement compared to baseline on all but one of the ADAMS subscales (i.e., manic / hyperactive behavior, social avoidance, general anxiety, and compulsive behavior) at week 12. No significant change was observed for the ADAMS depressed mood subscale. Multiple secondary efficacy endpoints, including the Aberrant Behavior Checklist-Specific FXS (ABC-FXS), the Pediatric Anxiety Rating Scale (PARS-R), the Visual Analogue Scale (VAS) for Anxiety, Hyperactivity, and Temper Tantrums / Mood Lability, the Vineland Adaptive Behavior (VLD) III, and the Pediatric Quality of Life (PedsQL™). Both the PARS-R and Vineland scales are clinician-rated, while the other scales are caregiver-rated. The primary and secondary endpoints were assessed before and after 12 weeks of drug administration. The results of the secondary endpoints reinforce the findings demonstrated in the ADAMS trial. Consistent with the ADAMS findings, patients taking the CBD transdermal gel demonstrated statistically and clinically significant 12-week reductions in all ABC-FXS subscales (i.e., irritability, hyperactivity, socially insensitive / lethargic, social avoidance, stereotypy, and inappropriate speech) and in both PARS-R total score calculations (i.e., 5 and 7 points). Patients also showed significant improvement between baseline and Week 12 scores for all remaining scales, except for the PedsQL Physical Functioning, School Functioning, and Social Functioning subscales, as well as some VLD subscales (e.g., communication, daily living skills). Both the VLD and ADAMS are being administered in the Phase 2 extension of the trial. The ABC-FXS results are summarized in Table 3, detailing the mean values ​​(standard deviation) of the efficacy scales at baseline and week 12. Table 3 Reference (n=18) Week 12 (n=18) Percentage Change from Reference (%; n=18) P-value* ABC: Irritability 17.7 (12.68) 10.6 (11.03) -40.11 p=0.0096 ABC: Hyperactivity 13.7 (9.09) 9.8 (7.38) -28.47 p=0.0237 ABC: Socially Insensitive / Lethargy 9.2 (6.40) 4.1 (4.09) -55.43 p=0.0034 ABC: Social Avoidance 5.1 (3.46) 2.3 (2.22) -54.90 p=0.0005 ABC: Stereotypy 8.1 (5.91) 3.2 (3.07) -60.49 p=0.0006 ABC: Inappropriate Speech 5.9 (2.30) 3.5 (2.66) -40.68 p=0.0018 MA / t / ZUZÓ / U I4 1 υυ * The p-values ​​are presented for the comparison of the Week 12 value with the Reference, among those who completed the study (n=18). The PARS-R results are summarized in Table 4, which details the mean values ​​(standard deviation) of the efficacy scales at baseline and week 12. Table 4 Reference (n=18) Week 12 (n=18) Percentage Change from Reference (%; n=18) P* Value PARS-R - point 5 15.7 (3.88) 10.6 (3.43) -32.48 p=0.0006 PARS-R - point 7 21.3 (5.55) 14.4 (4.54) -32.39 p=0.0004 * p-values ​​are presented for comparison of the Week 12 value with the Reference value, among those who completed the study (n=18). The VAS results for Anxiety, Hyperactivity, and Temper Temper / Mood Lability are summarized in Table 5. Table 5 Reference (n=18) Week 12 (n=18) Percentage Change from Reference (%; n=18) P-value* VAS- Hyperactivity / Impulsivity 5.9 (2.43) 3.6 (2.49) -38.98 p=0.0002 VAS - Temper Temper / Mood Lability 4.7 (2.09) 3.2 (2-18) -31.91 p=0.0023 VAS - Anxiety 6.0 (2.05) 3.8 (1.93) -36.67 p=0.0005 * p-values ​​are presented for comparison of the Week 12 value with the Reference value, among those who completed the study (n=18). The PedsQL results are summarized in Table 6, which details the mean values ​​(standard deviation) of the efficacy scales at baseline and week 12. Table 6 MA / t / ZUZÓ / U I4 1 υυ Baseline (n=18) Week 12 (n=18) Percentage Change from Baseline (%; n=18) P-value* PedsQL: Total Scores 57.8 (18.78) 67.7 (18.27) 17.13 p=0.0100 PedsQL: Physical Functioning: 67.9 (27.36) 78.0 (22.39) 14.87 p=0.0606 PedsQL: Emotional Functioning 64.0 (20.72) 78.3 (16.63) 22.34 p=0.0394 PedsQL: Social Functioning 37.3 (24.70) 49.0 (24.35) 31.37 p=0.0717 PedsQL: School Functioning 55.7 (19.17) 59.1 (22.47) 6.10 p=0.3580 PedsQL: Psychosocial Health 52.4 (17.22) 62.2 (18.91) 18.70 p=0.0408 * p-values ​​are presented for comparison of the Week 12 value with the Reference value, among those who completed the study (n=18). The results of VLD III are summarized in Table 7, which details the mean values ​​(standard deviation) of the efficacy scales at baseline and week 12. Table 7 Reference (n=18) Week 12 (n=18) Percentage Change from Reference (%; n=18) P-value* VLD III: General Adaptive Behavior Composite 46.1 (16.29) 48.9 (16.49) 6.07 p=0.0472 VLD III: Communication 36.7 (18.52) 39.2 (20.34) 6.81 p=0.2968 VLD III: Receptive Communication 3.9 5.3 35.90 p=0.0752 (3.43) (4.34) VLD III: Communication - Expressive 3.3 (3.63) 3.7 (4.07) 12.12 p=0.5070 VLD III: Communication - Written 4.4 (3.81) 3.8 (3.64) -13.64 p=0.0293 VLD III: Daily Living Skills 52.7 (21.19) 54.6 (18.46) 3.61 p=0.3911 VLD III: Daily Living Skills - Personal 5.7 (4.26) 6.2 (4.33) 8.77 p=0.3374 VLD III: Daily Living Skills - Domestic 9.6 (3.42) 9.5 (3.09) -1.04 p=0.9395 VLD III: Daily Living Skills - Community 4.6 (3.09) 4.7 (2.93) 2.17 p=0.5636 VLD III: Socialization 45.9 (16.22) 50.9 (17.83) 10.89 p=0.0344 VLD III: Socialization Interpersonal Relationships 5.3 (3.51) 5.9 (3.64) 11.32 p=0.2937 VLD III: Socialization - Play and Leisure 3.4 (2.91) 4.5 (3.93) 32.35 p=0.0350 VLD III: Socialization - Coping Skills 6.6 (2.93) 7.8 (2.84) 18.18 p=0.0246 VLD III: Maladaptive Behavior - Internalizing 19.9 (1-71) 18.7 (1-79) -6.03 p=0.0486 VLD III: Maladaptive Behavior - Externalizing 18.7 (2.42) 17.2 (2.66) -8.02 p=0.0090. * p-values ​​are presented for comparison of the Week 12 value with the Reference value, among those who completed the study (n=18). Among the 18 patients who completed the 12-week treatment, the average improvement in general anxiety and depression (ADAMS Total Score) reached 44% (p<0.01), with particular benefit observed for the General Anxiety (51%; p<0.01) and Compulsive Behavior (48%; p<0.05) subscales. Furthermore, improvements in aberrant behavior, as measured by ABCfxs, ranged from 28% (Hyperactivity subscale; p<0.05) to 60% (Stereotypy subscale; p<0.01), with the Social Avoidance (p<0.01) and Social Unresponsiveness / Lethargy (p<0.01) subscales each improving by 55% during the treatment period. Beyond individual symptoms, quality of life improved by 17% (p=0.01). The trial successfully met its primary endpoint, achieving a 44% improvement (P<0.0001) in the total ADAMS score at week twelve compared to baseline. The trial also achieved clinically significant improvements across all ABC-FXS measures, which address key FXS symptoms, including irritability, hyperactivity, social unresponsiveness, social avoidance, stereotypy, and inappropriate speech. Following the 12-week open-label study, patients were eligible to participate in a 1-year open-label extension study. 72% (n=13) of the 18 patients who completed the initial 12-week study progressed to the extension. While the open-label extension is ongoing, some data have been collected up to week 38 (12 weeks in the initial study and up to 6 months in the extension). The results of the extension study demonstrate continued gains in both collected measures (ADAMS and ABCfxs). In fact, those who completed a week 38 visit (n=4) showed significant screening gains in overall anxiety and depression, and participants experienced an average improvement in their total ADAMS score of 74%.A similar improvement was observed for aberrant behavior, which ranged from 75% (Irritability subscale) to 96% (Social Avoidance subscale) and to 97% (Social Unresponsiveness / Lethargy subscale) in Week 38. The open-label extension is ongoing and data have been collected up to Week 51. The results are summarized in Table 8 (ABCfxs) and Table (ADAMS). Table 8 (ABCfxs) MA / J / Ul 4Ί Selection (reference score) N=12 Average Change for Week 12 Average Change for Week 38 (%) Average Change for Week 51 (%) P-values ​​for Week 51 Irritability 22.3 51.1 63.7 59.2 0.0007 Hyperactivity 16.6 36.7 48.2 40.4 0.0037 Social Unresponsiveness / Lethargy 10.8 65.7 83.3 72.2 0.0035 Social Avoidance 5.7 57.9 75.4 77.2 0.0013 Stereotypy 9.7 60.8 73.2 64.9 0.0012 Inappropriate Speech 6.2 56.5 66.1 56.5 <0.0001 Table 8 (ADAMS) Selection (reference score) N=12 Average Change for Week 12 (%) N=12 Average Change for Week 38 (%) N=12 Average Change for Week 51 (%) N=12 P-values ​​for Week 51 Manic / Hyperactivity 8.8 34.1 53.4 45.5 0.0014 Depressed Mood 3.2 43.8 62.5 59.4 0.0032 Social Avoidance 9.9 52.5 61.6 55.6 0.0004 General Anxiety 9.8 55.1 58.2 58.2 <0.0001 Compulsive Behavior 3.2 50.0 59.4 59.4 0.0213 Total Scores 33.3 48.6 59.2 54.4 <0.0001 ML / t / ZUZÓ / U I4 1 υυ The CBD gel was well tolerated, with excellent skin tolerability. One patient discontinued treatment due to worsening of pre-existing eczema. No other adverse events led to discontinuation, and no adverse events were considered serious. The most common adverse events were mild to moderate gastroenteritis (n=6) and upper respiratory tract infection (n=5). However, no patients experienced drug-related gastrointestinal events during the 12-week treatment period, and THC was not detected in plasma. The clinical trial results are significant for the many patients worldwide with FXS who currently have no approved treatment options for their symptoms. The data, particularly the improvements in anxiety, social avoidance, and irritability as measured by the ADAMS, ABCFXS, and PARS-R, are significant. The CBD gel was very well tolerated in children and adolescents with FXS. Example 2: Parent-Reported Patient Monograph This is the report on a 7-year-old boy who participated in the previous study and continued with an extension study, as reported by his caregiver. The caregiver's son has a full mutation of Fragile X syndrome. Prior to the trial, he was nonverbal, had a severe intellectual disability, a visual impairment, still required diapers, and had very severe gastrointestinal problems requiring tube feeding every two hours. Before the trial began, the boy never made eye contact, could rarely leave his house without severe emotional distress, did not initiate any form of communication, intensely disliked being touched, even by his parents, would not allow even family members to sit next to him, and would leave the room if anyone entered. Within the first two weeks of the trial, the patient began to make more eye contact, initiated physical contact with his family, for example, by holding his mother's hand, initiated emotional contact with his family, including seeking to be in the same room with his family, and exhibited an improved ability to leave the house, even to the extent that the family was able to take their first vacation together. After the initial trial ended and a few weeks into the extended trial, the caregiver noted another significant change in the patient. He began greeting his family, initiating and participating in more complex games, expressing preferences instead of simply rejecting all options, and recognizing the family pets. He also allowed his doctor to touch and hold him without distress. The patient began using body language (sign language) for the first time. He clearly communicated that he missed his mother and was eager to be held and hugged by her. The patient is reported to be happier, more relaxed, able to engage with the world in ways he couldn't before, and able to learn new skills he was previously unable to learn. His teachers, therapists, and aides have also noted the changes in the patient. Example 3: Treatment of the Completely Methylated (Fmet) FXS Subject with CBD A pivotal 14-week clinical study of cannabidiol (CBD) in children and adolescents with fragile X syndrome (CONNECT-FX) was conducted. The randomized, double-blind, placebo-controlled CONNECT-FX trial evaluated the efficacy and safety of Zygel CBD gel as a treatment for the behavioral symptoms of FXS. Two hundred forty-five (245) patients with Fragile X syndrome, confirmed with the full FMR1 gene mutation, were enrolled at 21 clinical sites in the United States, Australia, and New Zealand. All patients received placebo for the first two weeks (called a placebo trial, which is often used in neuropsychiatric clinical trials), and as a result, 33 patients were not randomized. The remaining 212 patients were included in the intention-to-treat (ITT) population (Zygel: n=110; placebo: n=102) and were randomized to receive either the trial drug or placebo for an additional 12 weeks. One patient did not receive study medication, so 211 patients were included in the safety analysis (Zygel: n=109; placebo: n=102). One patient did not have a post-reference efficacy measure, resulting in 210 patients in the full analysis set (Zygel: n=109; placebo: n=101). For the full efficacy analysis, 210 patients were included (Zygel: n=109; placebo: n=101). Zygel was administered at a weight-based dose of either 250 mg or 500 mg daily. The primary endpoint was the ABD-Cfxs social avoidance subscale. Secondary endpoints included the ABC-Cfxs irritability subscale, the ABC-Cfxs socially insensitive / lethargic subscale, and improvement in the Clinical Global Impression (CGI-I). The Clinical Global Impression Improvement Scale (CGI-I) is commonly used in clinical trials (Leigh et al. 2013) because it allows clinicians to use the caregiver's history and incorporate the score into a clinical rating for symptom severity. The CGI-I is a 7-point scale that requires clinicians to assess how much the patient's condition has improved or worsened relative to a baseline state at the start of the intervention, scoring it as follows: 1 – much improved; 2 – very improved; 3 – minimally improved; 4 – no change; 5 – minimally worse; 6 – much worse; or 7 – much, much worse. Information from both the clinician and the parent / caregiver history is incorporated into a clinical rating. Patients with FXS have a full mutation of the FMR1 gene and can be described as: (i) Non-mosaics (the patient has all cells with a full mutation of the FMR1 gene and all genes are fully methylated; note: methylation inactivates the FMR1 gene); (ii) size mosaicism (the patient has some cells with a full mutation of the FMR1 gene and some cells with a pre-mutation of the FMR1 gene and not all genes are methylated); and (iii) methylation mosaicism (all cells have a full mutation of the FMR1 gene but not all genes are methylated). Patients with >90% methylation are considered to have a fully methylated FMR1 gene and do not produce mRNA, and therefore do not produce FMR protein. The analysis was designed to explore the differences between two groups of patients—those with complete methylation and those without. Results ML / t / ZUZÓ / U I4 1 υυ Table 10 summarizes the results of CONNECT-FX in the full analysis population for key primary and secondary endpoints. Table 10: Complete Population Analysis Placebo Zygel N=101 N=109 Assessment Criteria Baseline Mean Week 12 Mean Change Baseline Mean Week 12 Mean Change Treatment Difference Treatment P-value ABC-Cfxs Social Avoidance Subscale 7.24 2.29 7.12 2.68 0.39 NS ABC-Cfxs Irritability Subscale 27.65 -4.14 28.49 5.88 1.74 NS ABC-Cfxs Socially Insensitive / Lethargy Subscale 12.82 -3.14 13.42 -3.50 0.36 NS CGI-I at Week 12 (Improved Much, Very Much) -15.9% -20.2% 1.33** NS NS = not statistically significant * A negative difference in treatment demonstrates that patients with Zygel improved compared to placebo “Odds Ratio Zygel did not achieve statistical significance versus placebo for the primary endpoint of improvement on the Social Avoidance subscale of the Aberrant Behavior Checklist Community FXS (ABC-CFXS). Zygel also did not demonstrate statistical significance versus placebo for the three key secondary endpoints, which were the change from baseline to the end of the treatment period in the ABC-CFXS Irritability subscale score, the ABC-CFXS Socially Insensitive / Lethargy subscale score, and the improvement in the Clinical Global Impression (CGI-I). An analysis of the most severely affected patients in the trial, as defined by patients with at least 90% methylation (complete methylation) of the affected FMR1 gene, demonstrated that patients receiving Zygel achieved statistical significance in the primary endpoint of improvement at 12 weeks of treatment on the ABC-Cfxs Social Avoidance subscale compared with placebo (p=0.020). This group comprised 80% of the patients enrolled in the CONNECT-FX study, and complete methylation is believed to occur in approximately 60% of the general FXS patient population. The terms Fragile X Syndrome in a subject with complete methylation of the impacted FMR1 gene refer to subjects with Fragile X Syndrome Fmet or FXS Fmet. Patients with genetically confirmed Fragile X mutation and complete methylation of their impacted FMR1 gene are generally the most severely affected by the disorder.Within the CONNECT-FX trial, this was corroborated by patients in the study reference analysis who had higher anxiety, lower IQ, lower adaptive function, and more severe autism compared to patients without a fully methylated FMR1 gene. One hundred and sixty-nine (169) patients met the criterion for complete methylation of the impacted FMR1 gene. One patient was not treated, and another had no post-reference efficacy measure, resulting in 167 patients (Zygel: n=91; placebo: n=76). Table 11 summarizes patient data for complete methylation (>90% methylation, Fmet) versus not fully methylated (<90% methylation, No-Fmet). Table 11: FXS Subpopulation of Complete Methylation (Fmet) Patients Full Data Set Fmet (>90%) No-Fmet (<90%) Full Analysis Set 210 167 42 Table 12 summarizes the results of CONNECT-FX in the analysis set of patients with complete methylation of the impacted FMR1 gene across key primary and secondary endpoints. Table 12: Complete Methylation (Fmet) Subpopulation Analysis Placebo N=76 Zygel N=91 Reference Criterion Week Reference Week Treatment Probability P-value of the assessment Mean 12 Mean 12 Difference Treatment Mean Mean Proportion Change Change ABC-Cfxs Social Avoidance Subscale 7.18 -1.99 7.12 -2.99 -1.0 0.020* ABC-Cfxs Irritability Subscale 28.0 -4.13 29.36 -6.43 -2.30 0.091 ABC-Cfxs Socially Insensitive / Lethargy Subscale 13.17 -2.74 13.30 -3.91 -1.17 0.135 CGI-I at Week 12 (Any Improvement) 35.7% 51.1% 1.88 0.056 *Statistically significant vs. placebo ML / t / ZUZÓ / U I4 1 υυ ** A negative difference in treatment demonstrates that patients with Zygel improved compared to placebo The mean improvement in the Social Avoidance subscale of the ABC-CFXS after twelve weeks of treatment was 40% for patients treated with Zygel and 21.1% for patients treated with placebo. The heterogeneity interaction test for the Social Avoidance subscale was statistically significant (p=0.002), meaning that the difference in treatment effects between subgroups was statistically significant. Security data Zygel was very well tolerated in CONNECT-FX, and the safety profile was consistent with previously published data from other Zygel clinical trials. No safety signals were identified. Approximately half (54%) of the 211 patients included in the safety population experienced a treatment-emergent adverse event (any event, whether unrelated or related to the study drug), all of which were mild or moderate. The frequency of treatment-emergent adverse events was similar between the treatment groups (58% of patients treated with Zygel, 50% of patients treated with placebo). No serious or severe adverse events were reported during the study. There were seven total psychiatric disorder TEAEs, five of which were in the placebo group. Only 15 (7%) patients experienced a treatment-related adverse event (20 events in total); 11 patients treated with Zygel experienced 14 treatment-related TEAEs, while four patients treated with placebo experienced six TEAEs. The most common treatment-related TEAE was application site pain (Zygel: 6.4%; placebo: 1.0%). Laboratory values ​​for chemistry and hematology were comparable between the placebo and Zygel treatment groups, and there were no clinically relevant abnormalities in either group. Specifically, there were no elevated liver function tests (LFTs) in the Zygel group, and two moderately elevated LFTs in the placebo group. This study identified a significant population of patients who appear to benefit substantially from treating their FXS behavioral symptoms with Zygel. Combined with the excellent tolerability observed in this trial, Zygel is believed to be an important therapeutic option for the most severely affected patients with Fragile X Syndrome.

Claims

1. A method for treating one or more symptoms of Fragile X syndrome in a subject having complete methylation of the FMR1 gene, the method comprising: transdermal administration of an effective amount of cannabidiol (CBD) to the subject.

2. The method according to any of the preceding claims, wherein one or more symptoms is a behavioral symptom of Fragile X syndrome.

3. The method according to claim 2, wherein the behavioral symptom is social avoidance.

4. The method according to any of the preceding claims, wherein the treatment includes improvement in the clinical overall impression (CGI-I).

5. The method according to any of the preceding claims, wherein the total daily dose of CBD is between approximately 50 mg and approximately 500 mg total daily.

6. The method according to any of the preceding claims, wherein the total daily dose of CBD is 250 mg.

7. The method according to any of claims 1 to 5, wherein the total daily dose of CBD is 500 mg.

8. The method according to any of the preceding claims, wherein the CBD is formulated as a gel.

9. The method according to any of claims 1 to 8, wherein the CBD is administered in a single daily dose.

10. The method according to any of claims 1 to 8, wherein the CBD is administered in two daily doses.

11. The method according to any of the preceding claims, wherein the CBD is administered transdermally in the subject's arm.

12. The method according to any of the preceding claims, wherein the CBD is a synthetic CBD.

13. The method according to any of claims 1 to 11, wherein the CBD is botanically derived.

14. The method according to any of the preceding claims, wherein transdermal administration of an effective amount of CBD reduces the intensity of at least one adverse event relative to oral administration of CBD.

15. The method according to any of the preceding claims, wherein at least one adverse event is selected from the group consisting of drowsiness, psychoactive effects, liver function, and adverse events related to the gastrointestinal tract.