Meloxicam And CBD Oil Interaction

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Cannabidiol and Non-Steroidal Anti-Inflammatory Drug Interactions: A Case of Drug-Induced Aseptic Meningitis It can’t be emphasized enough that patients must be honest with their doctors about their cannabis use, particularly if CBD is involved, given its modulating effects on various CYP enzymes. A case report suggests that CBD oil contributed to someone's death. Some scientists—and the weed industry—aren’t so sure.

Meloxicam And CBD Oil Interaction

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Journal of Neurology Research, ISSN 1923-2845 print, 1923-2853 online, Open Access
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Volume 10, Number 4, August 2020, pages 132-135

Cannabidiol and Non-Steroidal Anti-Inflammatory Drug Interactions: A Case of Drug-Induced Aseptic Meningitis

Mallory Emig a, b , Jafar Kafaie a , Samantha Ong a , Xujia Li a

a Saint Louis University Hospital, Saint Louis, MO, USA
b Corresponding Author: Mallory Emig, Saint Louis University Hospital, Saint Louis, MO 63110, USA

Manuscript submitted May 8, 2020, accepted June 5, 2020, published online June 20, 2020
Short title: Cannabidiol and NSAIDs
doi: https://doi.org/10.14740/jnr598

Abstract ▴Top

Cannabidiol (CBD) and other marijuana derivatives are being more widely used in the medical community by people in an attempt to alleviate a variety of symptoms. While these products have shown promise in their analgesic properties, little is known about the potential pharmacological interactions of these and other drugs. We present a case of a 57-year-old Caucasian woman who presented with altered mental status, ataxia, left-sided numbness, and slurred speech. An extensive workup was completed and found to be largely unremarkable, though a thorough history revealed that her symptoms were likely caused by concurrent use of CBD and non-steroidal anti-inflammatory drugs (NSAIDs) resulting in drug-induced aseptic meningitis. The benign nature of CBD makes it a promising avenue for pain relief. Physicians and patients should be informed about the potential drug-drug interactions of CBD and other medications.

Keywords: Cannabidiol; NSAIDs; Drug-induced aseptic meningitis

Introduction ▴Top

Cannabidiol (CBD) is a phytocannabinoid that is derived from Cannabis sativa and Cannabis indica that has become more frequently used for its medicinal qualities. The consumer market of CBD-infused products is continuously growing, although its therapeutic benefits are still under question by the US Food and Drug Administration (FDA) [ 1 ]. Due to its low tetrahydrocannabinol (THC) concentration, CBD oils and other derivatives provide medicinal benefits without the psychoactive effects of recreational marijuana, one of the most commonly used illicit drugs in the USA [ 2 ]. CBD is generally used for the side effects of chemotherapy, pain, anxiety, and other neurological and psychiatric illnesses, including but not limited to post-traumatic stress disorder, seizures, and Tourette’s syndrome [ 3 ]. Generally, in the medical community, CBD is considered a low-risk drug and has been used for decades for its neuroprotective effects. However, CBD’s actions throughout the body are not fully understood and there are many side effects that should be considered before prescribing to patients.

CBD extracts usually contain no or very low amounts of THC, which is the component in marijuana that induces the euphoric psychoactive effect. However, CBD still has side effects including diarrhea, nausea, irritability, and weight/appetite changes that should not be ignored [ 4 ]. More importantly, because CBD interacts with common biological targets implicated in drug metabolism and excretion, it increases the likelihood of drug-drug interactions (DDIs) with commonly prescribed and over-the-counter medications such as non-steroidal anti-inflammatory drugs (NSAIDs), antimicrobials, and antiepileptics [ 5 ]. The mean half-life of CBD is 2 -5 days, so the drug can cause effects even if the patient stopped using before any symptoms of DDIs present [ 6 ]. As CBD is implicated as both a subject and a cause of DDIs, physicians and patients should be made aware of potential safety concerns with CBD use.

The adverse drug effects and DDIs of CBD are based on its pharmacologic targets and pharmacodynamic qualities related to metabolism, absorption, and elimination. Molecular targets of CBD include a wide variety of receptors and channels, and its metabolites can act on a multitude of cytochrome P450 (CYP) enzymes. In particular, CYP enzymes are responsible for the metabolism of NSAIDs, one of the most widely used drugs worldwide. In the USA alone, more than 30 billion doses of NSAIDs are consumed and more than 70 million prescriptions are written for NSAIDs [ 7 ]. These drugs (e.g. ibuprofen, diclofenac, ketoprofen, naproxen, flurbiprofen, meloxicam, piroxicam, and tenoxicam) are metabolized by two enzymes of the CYP superfamily, mainly the CYP2C8 and CYP2C9 [ 8 ]. CBD decreases the activity of both CYP2C8 and CYP2C9 in vitro [ 9 , 10 ]. Because the activity of CBD on the enzymes in vivo has not been established, clinical data is needed to fully understand the DDIs between CBD and NSAIDs. Physicians should strongly consider DDIs when the use of CBD is reported in concurrence with the use of commonly prescribed medications such as NSAIDs.

Although studies have shown the various adverse effects of CBD on different organ systems, clinical data demonstrating the negative consequences of CBD DDIs are minimal. One prior clinical study by Geffrey et al presented DDIs between CBD and clobazam, supporting the fact that concomitant use of CBD with other medications should be monitored carefully [ 11 ]. In fact, though CBD has shown promising results in treating a variety of symptoms, its effects on different processes throughout the body remain poorly understood and therefore should be treated/recommended with caution. The current case study offers further evidence that DDIs between CBD and common medications such as NSAIDs can lead to unforeseen and potentially severe nervous system pathology such as aseptic meningitis.

Case Report ▴Top

Our patient is a 57-year-old woman with a medical history significant for occasional headaches, thyroid nodules, a Warthin’s tumor of the left parotid gland resected in 2009, coronary artery disease, hypertension, thyroid nodules, rheumatoid arthritis and a 40-pack-year smoking history, who presented with altered mental status, ataxia, left sided numbness, and slurred speech.

She initially presented to an outside facility with the above symptoms for 9 days. She underwent routine testing including magnetic resonance imaging (MRI) of her brain without contrast which was unremarkable. She was discharged home after 2 days. Two days after being discharged, she returned to the facility with agitation, aggressive behavior, and staring spells along with ongoing altered mental status and ataxia. She was somnolent and complained of headaches. She had no fever and routine labs were again unremarkable. She underwent a lumbar puncture (LP) and extensive lab testing, the results of which were largely non-specific. Urinalysis and toxicology were negative. There were no metabolic or vitamin abnormalities. Thyroid studies were significant for a thyroid stimulating hormone (TSH) of 0.18. Inflammatory markers were not elevated. Autoimmune panels were within normal limits. Human immunodeficiency virus (HIV) and rapid plasma reagent (RPR) for syphilis were non-reactive. Cerebrospinal fluid (CSF) analysis revealed a white blood cell (WBC) count of 180, 96% lymphocytes, red blood cell (RBC) count of 5, glucose 62, protein 280, and cytology and flow cytometry were negative. Comprehensive cultures were sent and were all negative. MRI total spine was done and MRI brain with and without contrast was repeated, this time showing diffuse leptomeningeal enhancement. Routine electroencephalogram (EEG) was unremarkable. She was transferred to our hospital for further evaluation.

Upon arrival at our facility, she was awake and alert without agitation. A detailed history was taken, which noted worsening of her intermittent headaches starting in April 2019. At that time, she began to use CBD oil for her rheumatoid arthritis along with her prescribed NSAIDs. Around that time, her headaches became more frequent and more painful, leading her to increased NSAID use. Over the next few months, she experienced persistent headaches and developed gait difficulties. The memory issues and confusion were the newest symptoms she experienced, leading to her wandering the streets around the neighborhood lost and confused. Upon further questioning, she recalled having episodes of subjective fevers and night sweats as well as unintentional weight loss of 25 LBS. Review of systems was otherwise negative.

She reported a family history of thyroid disease as well as rheumatoid arthritis. She denied a recent history of travel, dietary changes, and knowledge of any exposure to toxins. Neurological exam was non-focal and was significant for decreased orientation (only oriented to self and place), fatigue, and mild weakness. Palpation of the thyroid revealed an enlarged goiter. She had diffuse bruising of her extremities. No rashes were noted.

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Over the next 24 h, the patient’s headaches worsened and she again became aggressive and agitated. She was started on hydrocodone-acetaminophen for headaches. She underwent thyroid ultrasound which showed a large multinodular thyroid as well as a second LP. LP showed protein 182, WBC 238 w/93% lymphocyte, glucose 60, and flow cytometry and cytology were pending but eventually were unremarkable. Infectious labs were all negative. Encephalopathy, encephalitis, and paraneoplastic panels were sent out to Mayo clinic. The patient continued to have episodes of agitation and aggression, particularly at night, eventually requiring scheduled quetiapine. In the mornings, she had a poor recollection of the events that occurred overnight.

Due to high concern for an underlying malignancy, she underwent a whole-body positron emission tomography-computed tomography (PET-CT) which was significant for “intense fluorodeoxyglucose (FDG) uptake in the right parotid gland with subsegmental and tonsillar lymph nodes demonstrating increased FDG avidity concerning for malignancy”. Hematology was consulted for the significant PET findings. They recommended a biopsy of the parotid gland. Due to her negative infectious workup and lack of fever, the patient was not started on antibiotics. An ear, nose, and throat (ENT) specialist was consulted for fine needle aspiration (FNA) of the right parietal mass which showed recurrence of a Warthin’s tumor.

After discussion with the patient and family about the unclear etiology of her presentation, she denied leptomeningeal biopsy and the decision was made to trial a dose of intravenous (IV) steroids. She was started on IV methylprednisolone 500 mg twice a day (BID) for 3 days. She was given intravenous immunoglobulin (IVIG) 2 g/kg in 2 days after receiving solu-medrol for 3 days. The patient reported significant improvement in her headaches and cognition. She was able to be discharged home under the care of her family.

Encephalitis, encephalopathy, and paraneoplastic panels resulted in no abnormalities. She was seen in a follow-up clinic 1 month after being discharged and reported that she felt completely back to her baseline which was confirmed by family members. She underwent a follow-up MRI which showed no leptomeningeal enhancement or signal abnormality and no other findings.

Discussion ▴Top

The patient’s presentation and complicated medical history led to a concern for a wide range of etiologies. Malignancy was high on the differential given her smoking history and B symptoms. Metabolic disorders were also considered though it was difficult to pursue this differential with a lack of abnormal lab findings. Careful history taking helped support the possibility of medication-induced encephalitis given that her headaches worsened with an increase in the use of her NSAIDs and subsequent administration of topical CBD. Infection was considered, but the patient was never febrile while in the hospital and she did not improve with antibiotics. Extensive infectious labs were sent with no significant results, helping us rule out this possibility. Because of all the negative lab findings, a diagnosis of drug-induced aseptic meningitis was highly considered.

The current case study found that the concomitant use of CBD with meloxicam could have precipitated drug-induced aseptic meningitis (DIAM). DIAM is a rarer cause of meningitis that is associated with NSAID use [ 12 ]. The symptoms of DIAM are similar to those that are found in cases of meningoencephalitis, including fever, headache, altered mental status, arthralgia, and myalgia [ 13 ]. The diagnosis of DIAM is a diagnosis of exclusion and is made by ruling out other possible causes of meningitis. The fact that all the laboratory tests, in this case, were negative for malignancy, infections, and autoimmunity and she returned to her baseline with complete resolution of the brain MRI findings, supporting the likelihood that our patient’s aseptic meningitis was caused primarily by the use of medications. The pathogenesis of DIAM can be attributed to two proposed mechanisms, one being direct meningeal irritation by the drug and the other being a hypersensitivity reaction to the drug [ 14 ].

Although there are no published clinical cases about meloxicam specifically inducing aseptic meningitis, NSAIDs have been shown to be related to this pathology [ 12 ]. Therefore, it is possible that meloxicam can have similar effects as other NSAIDs that have been shown to cause DIAM. Meloxicam is primarily metabolized to a 5’-hydroxymethyl metabolite by CYP2C9 (major) and CYP3A4 (minor) [ 15 ]. As stated before, CBD decreases the activity of CYP2C9 in vitro. It is possible that the inhibitory effect of CBD on CYP2C9 led to a higher concentration of meloxicam, which led to the DIAM. Given the increasing popularity of CBD, it is important for both physicians and patients to be aware of possible DDIs of these substances and the symptoms that may result.

Acknowledgments

None to declare.

Financial Disclosure

None to declare.

Conflict of Interest

None to declare.

Informed Consent

Consent to write and publish the case was obtained from the patient.

Author Contributions

ME provided the body of the case report and summarized the case as well as contributing to the discussion, revising the final draft, and submitting the final paper for review. JK revised the final draft and provided expertise on the clinical importance of the case. SO and XL drafted the Introduction and Discussion and compiled and reformatted the references section.

Data Availability

The authors declare that data supporting the findings of this study are available within the article.

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  2. Results from the 2015 national survey on drug use and health: detailed tables. 2015. Accessed on March 14, 2020. https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015.pdf.
  3. Tzadok M, Uliel-Siboni S, Linder I, Kramer U, Epstein O, Menascu S, Nissenkorn A, et al. CBD-enriched medical cannabis for intractable pediatric epilepsy: The current Israeli experience. Seizure. 2016;35:41-44.
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  4. Iffland K, Grotenhermen F. An update on safety and side effects of cannabidiol: a review of clinical data and relevant animal studies. Cannabis Cannabinoid Res. 2017;2(1):139-154.
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  5. Brown JD, Winterstein AG. Potential adverse drug events and drug-drug interactions with medical and consumer Cannabidiol (CBD) use. J Clin Med. 2019;8(7):989.
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  6. Consroe P, Kennedy K, Schram K. Assay of plasma cannabidiol by capillary gas chromatography/ion trap mass spectroscopy following high-dose repeated daily oral administration in humans. Pharmacol Biochem Behav. 1991;40(3):517-522.
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  7. Medscape [Internet]. 1994-2020. cited on May 3, 2020. Nonsteroidal Anti-inflammatory Drug (NSAID) Toxicity; [about 2 screens]. Available from: March 13, 2020. https://emedicine.medscape.com/article/816117-overview.
  8. Jaja C, Bowman L, Wells L, Patel N, Xu H, Lyon M, Kutlar A. Preemptive genotyping of CYP2C8 and CYP2C9 allelic variants involved in NSAIDs metabolism for sickle cell disease pain management. Clin Transl Sci. 2015;8(4):272-280.
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  9. Yamaori S, Koeda K, Kushihara M, Hada Y, Yamamoto I, Watanabe K. Comparison in the in vitro inhibitory effects of major phytocannabinoids and polycyclic aromatic hydrocarbons contained in marijuana smoke on cytochrome P450 2C9 activity. Drug Metab Pharmacokinet. 2012;27(3):294-300.
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  10. Highlights of prescribing information. 2018. Accessed on March 29, 2020. https://www.epidiolex.com/sites/default/files/EPIDIOLEX_Full_Prescribing_Information.pdf.
  11. Geffrey AL, Pollack SF, Bruno PL, Thiele EA. Drug-drug interaction between clobazam and cannabidiol in children with refractory epilepsy. Epilepsia. 2015;56(8):1246-1251.
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  12. O’Brien WM, Bagby GF. Rare adverse reactions to nonsteroidal antiinflammatory drugs. J Rheumatol. 1985;12(1):13-20.
  13. Tattevin P, Revest M, Lavoue S. Meningites et meningoencephalitesaseptiques. Reanimation. 2008;17(7):639-650.
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  14. Jolles S, Sewell WA, Leighton C. Drug-induced aseptic meningitis: diagnosis and management. Drug Saf. 2000;22(3):215-226.
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  15. Schmid J, Busch U, Heinzel G, Bozler G, Kaschke S, Kummer M. Pharmacokinetics and metabolic pattern after intravenous infusion and oral administration to healthy subjects. Drug Metab Dispos. 1995;23(11):1206-1213.


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Did CBD Kill This Woman?

On February 20, 2020, the journal Case Reports in Ophthalmogical Medicine published an article about a 56-year-old woman who died two days after ingesting a sublingual CBD tincture in addition to a cocktail of drugs prescribed to manage her pre-existing conditions. 1

Sensationalized accounts of this report quickly circulated online, which misrepresented the incident as the “first death caused by CBD .”

The actual report, entitled “Commercial Cannabinoid Oil-Induced Stevens-Johnson Syndrome,” does not validate this alarming claim. That, however, won’t stop CBD cynics and drug war diehards from brandishing this case report as proof that cannabidiol is a dangerous substance.

Written by a team of researchers affiliated with the SUNY Upstate Medical University in Syracuse, New York, the case report describes a 56-year-old woman with “a medical history of herniated disc with chronic pain, hypertension, and coronary artery disease.” She had been taking three pharmaceuticals – famotidine, lisinopril-hydrochlorothiazide, and meloxicam – under a doctor’s supervision to treat her ailments.

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In an effort to improve her health, the unidentified woman also had been using various CBD products for five years without ill effect. But a week after switching to a new CBD product called “Natural Native,” she was admitted to her local emergency room with a hideous rash and skin ulcers. She was diagnosed with Stevens-Johnson syndrome, which is usually triggered by a bad reaction to medications, causing skin tissue to die and detach. The mucous membranes of the eyes, mouth, and/or genitals are also adversely affected. 2

She ultimately died of septic shock while hospitalized.

What are Liposomes & What Is Their Role in This?

The case report notes the patient had previously used commercial CBD products “without side effects or associated allergic reactions [which] suggests involvement of other ingredients in this non- FDA -regulated product as the causative agent.”

What other ingredients may have been involved?

Shortly before she died, she had started taking a CBD tincture that utilized a liposomal delivery method. 3 This may have been a key factor in her untimely demise.

Liposomes, composed of natural or synthetic lipid bilayers, are small spherical vesicles that can be used in product formulation as a means of enhancing the bioavailability of the active ingredient(s). Employed as a vehicle for administering drugs and nutraceuticals, this type of delivery system can facilitate a 10 to 100-fold increase in bioavailability depending on the compound in question. Sounds impressive, but that’s not always a good thing.

It’s worth noting that the pharmaceutical cocktail prescribed by her doctor included meloxicam, a non-steroidal anti-inflammatory drug, which reduces inflammatory pain by inhibiting COX enzymes that produce compounds, known as prostaglandins, that regulate the body’s inflammatory response.

When the liposomal CBD product was administered in conjunction with meloxicam and two other pharmaceuticals, the combination proved to be fatal.

Mechanisms at Play—It’s Not Just the CBD

How and why did this fatality occur?

Similar to grapefruit juice, CBD can cause drug-drug interactions due to its inhibitory or inductive actions on cytochrome P450 enzymes ( CYP s). In particular, CBD inhibits both CYP2C9 and CYP3A4 , the latter of which is responsible for metabolizing nearly 30 percent of prescribed pharmaceutical drugs. 4-8 Significantly, the aforementioned meloxicam is also metabolized by CYP2C9 and CYP3A4 . 9

Unfortunately, this information was not included in the case report, which also neglected to indicate that grapeseed oil was one of the components of the CBD -infused liposomal formulation consumed by the patient. Grapeseed oil contains retinoids, which are Vitamin A derivatives that have many important functions throughout the body, including roles in vision, regulation of cell proliferation and differentiation, growth of bone tissue, immune function, and activation of tumor suppressor genes. 10 But these compounds must be carefully dosed to avoid potential toxicity.

Product manufacturers should be cognizant of the chemical make-up of all the ingredients in their formulations, especially when using delivery methods designed to enhance bioavailabiity. Liposomal delivery likely enhanced not only the level of CBD in the patient but also the level of retinoid compounds found in the grapeseed oil. This, in turn, could lead to enhanced inhibition of CYP3A4 and CYP2C9 , which would slow the metabolism of the meloxicam, further elevating its levels in the blood. Enhanced retinoid delivery likely exacerbated the situation by triggering the Stevens-Johnson syndrome.

Furthermore, the case report notes “complete chemical analysis from the patient’s commercial CBD oil was not performed.” Additionally, a certificate of analysis was not avilable on the website purveying this product, and we don’t know the dose of CBD that was administered or if other contaminants were also present.

To summarize: The problematic interaction between CBD , meloxicam, and retinoids was heightened due to the liposomal delivery of retinoid-containing grapeseed oil.

A Cautionary Tale

CBD skeptics and click-bait confabulators on the internet jumped to the conclusion that cannabidiol caused this woman’s death. But those who read the case report know that the actual cause of death was septic shock. While CBD ’s inhibitory activity on CYP enzymes may have contributed to this, the chance combination of all these factors is what ultimately led to the woman’s death.

Let this be a lesson for CBD consumers, product formulators, and physicians alike – be careful!

Although cannabis is still federally illegal, it is essential that health professionals be well informed about potentially catastrophic drug-drug interactions. And it can’t be emphasized enough that patients must be honest with their doctors about their cannabis use, particularly if CBD is involved, given its modulating effects on various CYP enzymes.

Education and honest discourse are paramount if we are to prevent more tragedies such as this from occurring in the future.

The diagram above depicts the proposed interaction between CBD , meloxicam, and retinoids. This interaction would be heightened due to the liposomal delivery of retinoid containing grapeseed oil. Source: Mawson AR , Eriator I, Karre S. Stevens-Johnson syndrome and toxic epidermal necrolysis ( SJS / TEN ): could retinoids play a causative role?. Med Sci Monit. 2015;21:133–143. Published 2015 Jan 12. doi:10.12659/ MSM .891043.”

The diagram above depicts the proposed interaction between CBD , meloxicam, and retinoids. This interaction would be heightened due to the liposomal delivery of retinoid containing grapeseed oil. Source: Mawson AR , Eriator I, Karre S. Stevens-Johnson syndrome and toxic epidermal necrolysis ( SJS / TEN ): could retinoids play a causative role?. Med Sci Monit. 2015;21:133–143. Published 2015 Jan 12. doi:10.12659/ MSM .891043.”

Footnotes

  1. Yin, Han Yang & Hadjokas, Nicholas & Mirchia, Kanish & Swan, Robert & Alpert, Samuel. (2020). Commercial Cannabinoid Oil-Induced Stevens-Johnson Syndrome. Case Reports in Ophthalmological Medicine. 2020. 1-5. 10.1155/2020/6760272.
  2. Dodiuk-gad RP , Chung WH , Valeyrie-allanore L, Shear NH . Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: An Update. Am J Clin Dermatol. 2015;16(6):475-93.
  3. Enhanced CBD Oil Extract Spray https://www.exspose.com/index.php?route=product/product&product_id=58 A… 3/9/20
  4. Zanger UM , Schwab M. Cytochrome P450 enzymes in drug metabolism: regulation of gene expression, enzyme activities, and impact of genetic variation. Pharmacol Ther. 2013;138(1):103-41.
  5. Michiru Nagao, Yukako Nakano, Masataka Tajima, Erika Sugiyama, Vilasinee Hirunpanich Sato, Makoto Inada, and Hitoshi Sato.Cannabis and Cannabinoid Research.ahead of print http://doi.org/10.1089/can.2019.0098
  6. Yamaori S, Ebisawa J, Okushima Y, Yamamoto I, Watanabe K. Potent inhibition of human cytochrome P450 3A isoforms by cannabidiol: role of phenolic hydroxyl groups in the resorcinol moiety. Life Sci. 2011;88(15-16):730-6.
  7. World Health Organization Expert Committee on Drug Dependence. Cannabidiol ( CBD ) Pre-review Report Agenda Item 5.2 and Peer Review. World Health Organization: Geneva, Switzerland, 2017. Google Scholar
  8. Yamaori, S., Koeda, K., Kushihara, M., Hada, Y., Yamamoto, I., & Watanabe, K. (2012). Comparison in the In Vitro Inhibitory Effects of Major Phytocannabinoids and Polycyclic Aromatic Hydrocarbons Contained in Marijuana Smoke on Cytochrome P450 2C9 Activity. Drug Metabolism and Pharmacokinetics, 27(3), 294–300. doi:10.2133/dmpk.dmpk-11-rg-107
  9. Ludwig E, Schmid J, Beschke K, Ebner T. Activation of human cytochrome P-450 3A4 -catalyzed meloxicam 5’-methylhydroxylation by quinidine and hydroquinidine in vitro. J Pharmacol Exp Ther. 1999;290(1):1-8.
  10. Garavaglia J, Markoski MM , Oliveira A, Marcadenti A. Grape Seed Oil Compounds: Biological and Chemical Actions for Health. Nutr Metab Insights. 2016;9:59-64.
  11. Mawson AR , Eriator I, Karre S. Stevens-Johnson syndrome and toxic epidermal necrolysis ( SJS / TEN ): could retinoids play a causative role?. Med Sci Monit. 2015;21:133–143. Published 2015 Jan 12. doi:10.12659/ MSM .891043.

Kyle Boyar is a cannabis scientist with a background in neurobiology, microbiology, and analytical chemistry. He is currently employed as the Director of Product Science at Tagleaf. Additionally, he also serves as the Vice Chair and Scholarship Committee Chair for the American Chemical Society’s Cannabis Chemistry Subdivision ( CANN ).

Copyright, Project CBD . May not be reprinted without permission.

The Bizarre Case of a Death Allegedly Caused by CBD Oil

A case report suggests that CBD oil contributed to someone’s death. Some scientists—and the weed industry—aren’t so sure.

Two days after trying a new CBD oil extract to treat her chronic pain, a 56-year-old woman developed an awful rash.

Her primary care physician prescribed antihistamines and prednisone, a common steroid used to treat inflammation. She went home. The rash got worse. From a local emergency room, she went to a hospital burn unit. There, the rash went out of control.

Angry red lesions broke out over 30 percent of her body, including her eyes and groin. Skin peeled from her arms and back. Doctors administered more antibiotics, more anti-inflammatory steroids. They didn’t work. After a month of suffering, she was dead from septic shock, the final result of a rare and extremely serious allergic reaction called Stevens-Johnson Syndrome (SJS), according to an account published February in Case Reports in Ophthalmological Medicine.

Companies Making CBD Gummies, Vapes, and Lube Got Millions In Bailout Loans

Described by the Mayo Clinic as both “rare and unpredictable,” Stevens-Johnson Syndrome is typically triggered by “a medication, an infection or both.” According to the British NHS, among the “medicines that most commonly cause” the affliction is the “oxicam” family of anti-inflammatory drugs. The woman had been taking meloxicam for arthritis, but that’s not what killed her, according to the case report, written by a group of eye doctors from SUNY Upstate Medical University in Syracuse, New York. She had already been on meloxicam without any reported complications, after all.

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What set off the fatal allergic reaction, they claim, was the product she had tried. It was a new brand of cannabidiol (CBD) oil she was taking for back pain; she had previously taken other CBD brands without issue. Though the new CBD oil she used was not tested for impurities, either some unknown ingredient in the oil or some reaction triggered by the CBD was the most likely cause of the allergic reaction and subsequent death, the doctors wrote, published under the title “Commercial Cannabis Oil–Induced Stevens-Johnson Syndrome.”

If true, the news that a cannabis product killed someone would amount to the upending of a longstanding claim from weed legalization advocates that the drug is so safe no one has ever died from it. And this wasn’t a case of high-THC cannabis allegedly causing psychosis—it was a possible reaction to CBD oil, an increasingly popular and widely available wellness product in the United States.

Physicians and medical professionals with expertise in cannabis consulted by VICE were divided on the merits of the medical journal article. But though they argued over the value of the case study and what (if anything) it means, one common theme emerged: it’s still the Wild West days for CBD, a drug that is still poorly studied, poorly understood and—with products of wildly varying potency and purity available online in all 50 states, at gas stations and novelty shops and corner bodegas—almost entirely unregulated.

News of the “first death caused by CBD” made ripples in the weed world and on social media. Project CBD, a cannabidiol advocacy organization, published a rebuttal that criticized “CBD skeptics and click-bait confabulators” rushing to blame a cannabis product, while raising the possibility that the oil could have reacted with the woman’s medications to fatal effect.

Peter Grinspoon is a physician on staff at Massachusetts General Hospital in Boston and a professor at Harvard Medical School who frequently blogs about cannabis and other drugs on Harvard’s website (his father is Lester Grinspoon, the Harvard psychiatrist who authored Marihuana Reconsidered, one of the bibles of cannabis-policy reform, in the 1960s). Grinspoon was skeptical that the death had much to do with CBD.

“It’s unlikely that this is the first case in 5,000 years of a cannabinoid causing Stevens-Johnson Syndrome (SJS), but it is certainly possible,” he said.

Grinspoon allowed that CBD could have inhibited liver enzymes metabolizing the meloxicam, raising its potency and lowering the body’s defenses, thus triggering the allergic reaction. It’s possible that the CBD, the meloxicam and the other pharmaceuticals the woman was taking could have set off a sort of perfect storm.

But since the SUNY ophthalmologists did not analyze the CBD oil—and offered up theoretical adulterants as a cause, apparently without knowing whether they were in the CBD product or not—“they have no idea, really, what this patient consumed, and it seems sort of intellectually reckless to pin the death on CBD,” Grinspoon said.

“Researchers are always eager to try to be the first ones to tie a death to a cannabinoid as this gets you in the news,” he added.

Some experts were even more dismissive of the case study. “I think the paper is shite,” Jeffrey Hergenrather, a physician and former president of the Society of Cannabis Clinicians, wrote in an email. “Regarding CBD and the association with SJS, I’ve never heard of such a thing.”

The case report did not address what possible contaminant in the offending CBD oil might have been and what it might have done. Nor did it state the size and frequency of the CBD dose taken or any of the patient’s genetic factors that might have been an equal or greater risk factor for Stevens-Johnson Syndrome, he said. Instead, the authors went straight to the CBD—and that, he pointed out, is a classic tell of anti-cannabis bias. “As usual it is easy to publish a case report implicating harm with a cannabis product,” he said. “Cannabis is an easy target for assertions of harm.”

Other researchers similarly pointed to gaps in the knowledge.

“I don’t remember seeing any other case reports associated with cannabidiol, but that being said, we don’t know what else was in the cannabidiol products that might be associated with this type of disorder,” said Ziva Cooper, a pharmacologist and the research director at the University of California, Los Angeles’s Cannabis Research Initiative.

Side effects of drugs like meloxicam are known because “thousands of people” using it “have been tracked. And this has not been the case with cannabidiol,” she said.

How to Get Into Weed While You’re Self-Isolating

The case report notes that the “new liposomal CBD extract spray” came from Natural Native, a CBD company based in Oklahoma. Last November, the company received a warning letter from the Food and Drug Administration. On Facebook and on its website, Natural Native broke several FDA rules for marketing CBD water, marketing CBD products intended for infants and otherwise making scientific claims that suggested CBD was a drug that could help with health conditions ranging from acne to chronic pain to cancer. (CBD is a “drug” in the taxonomical sense, but in the legal sense, a drug needs FDA approval to be marketed as such.)

In this, the company is hardly unique. Making unsubstantiated claims about CBD’s medical benefits or marketing CBD products as medicines or food products in violation of FDA rules is unscrupulous, but also happens often enough that it’s almost become a cannabis industry standard.

In interviews with VICE, Danny Bannister, one of Natural Native’s owners, did not deny crossing the line with the FDA. But nonetheless, he said, the case report could baselessly damage his business. He has been trying, to no avail, to get the title of the paper changed.

Bannister first heard about the case report in late February, when one of his competitors emailed the story to a retail client of his. The title, Bannister pointed out, is “Commercial Cannabis Oil-Induced Stevens-Johnson Syndrome,” which sounds conclusive. Only toward the end of the report’s discussion section do the authors admit that it’s still “unclear if marijuana-derived/CBD products can induce” SJS, and that it’s a subject that requires more study as well as general clinical awareness.

“He should take that assertive assumption out of the title,” Bannister said. “Even turning it into a question. It would be that simple.”

Bannister said he’s been unable to get a response from either the SUNY Upstate doctors who wrote the case study or the editors at Case Reports in Ophthalmological Medicine. (The report’s authors also did not respond to repeated requests for comment from VICE.)

Underlying all this is a lot of uncertainty, and the stark truth that CBD is widely available, poorly understood, and also poorly regulated. Under former FDA Commissioner Scott Gottlieb, the Trump Administration seemed interested in getting a stronger handle on CBD regulation. But Gottlieb stepped down last year, and with COVID-19 seizing the attention of both the agency and the public, the nature of the industry seems unlikely to change anytime soon.

It’s true that a woman did die after taking CBD oil, but that doesn’t mean that CBD killed her. CBD is safe for the vast majority of people, but that doesn’t mean it’s safe for everyone. We simply don’t know enough about how CBD interacts with other drugs.

“Drugs kill people all the time. The safety profile of CBD is pretty good, but it is a drug,” said Michael Backes, a Southern California cannabis consultant and author of Cannabis Pharmacy, one of the leading compendiums of the plant’s medical and scientific effects. “There may be a person out there who takes a particular preparation of CBD, and it could kill them. That could happen.”

Follow Chris Roberts on Twitter.

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