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Update: 29.10.2020
CBD-drug interactions
Bioinformatics and chemoinformatics database of drugs and chemicals Drugbank.ca is the most reliable English-language tool as a source of up-to-date knowledge, information and data on drug-chemical interactions. There is also a section dedicated to cannabidiol.
We include a link for ease of reference: https://www.drugbank.ca/drugs/DB09061
Highlights from this article:
- Cannabinoids and cannabidiol CBD affects the rate of metabolism of pharmacological drugs metabolised by P450 family enzymes primarily, but not exclusively, in the liver
- The mechanism is identical to that of grapefruit, which should also not be consumed if you are taking certain drugs metabolised by P450 enzymes
- Drugs metabolised in e.g. the kidney should not interact with cannabinoids
I have already written quite a lot about the supplemental and therapeutic potential of CBD. It is very extensive. We know more and more about the mechanism of action of cannabidiol (CBD) and other cannabinoids. Side effects, although they may occur, fall into the category of mild and transitory. The benefits of use are increasingly well documented and the voices on the efficacy of CBD oil are increasing at an unprecedented rate.
What does this look like in the area of CBD-drug interactions?
Is CBD safe?
Let's start with the fundamental issue of answering the question "Is CBD safe?"
CBD has been found to be safe by the World Health Organisation. This is a fact.
The safety of CBD use is one of the primary factors that has led to a progressive relaxation of regulations related to both seed hemp-based formulations and the use of medical cannabis in many countries around the world. Recreational use of cannabis (it's a different variety of cannabis than seed hemp!) is also being liberalised, but this is a separate topic for a separate article.
The side effects of cannabinoids taken orally, e.g. CBD oil, are considered to be of low severity and boil down to the risk of nausea, diarrhoea, dry mouth, excessive drowsiness and temporarily reduced mood.
Before starting to use CBD oil, however, it is worth paying attention to the interactions of CBD with medication. I suggest consulting your doctor on this issue, and if he or she does not know the answer - which unfortunately still happens - then the only thing left is to rely on proven sources of knowledge and make the most informed decision possible on your own. It is also worth knowing doctors' opinions on CBD in oils and hemp.
Another important issue affecting the safety of cannabidiol is the use of CBD oils. You should always follow your doctor's advice or adopt the safest possible dosage model by starting with lower doses and only adjusting them up or down based on observation of your own body.
CBD-drug interactions - effects on drug metabolism
Every drug, in fact every substance you take regardless of what form it takes is metabolised by the body. EVERY SUBSTANCE. It doesn't matter if it is tomato juice, an evening beer, your favourite dumplings from your grandmother or a prescription pharmacological drug prescribed by your doctor.
The gut and liver play a special role in metabolic processes.
A certain "family" of enzymes called cytochromes P450 (CYP450) plays an important role in converting foreign substances into a form that allows them to be easily excreted from the body.
Some drugs and substances - including those that are quite natural, e.g. from grapefruit juice - can affect CYP450 enzymes. The effect is to speed up or slow down metabolism. This change can therefore affect the time it takes the body to metabolise drugs or supplements.
It is the CYP450 family of enzymes that is responsible for the cannabinoid metabolism including CBD. The CYP3A4 enzyme (a member of the CYP450 family of enzymes), with which CBD reacts, is primarily involved in this process.
Importantly, the enzyme CYP3A4 is involved in the metabolism of ca. 60% of drugs prescribed in clinical therapies. If this enzyme, and there is a limited supply of it in the body, 'gets busy' metabolising CBD, this could mean that other drugs delivered to the body will be metabolised more slowly.
A slower metabolism of a drug means a higher concentration of it in the body and thus there may be periodically more of it than needed. The periodic increase in the concentration of the drug in the body may amplify its effects including an increased risk of side effects of the drug.
Importantly, the order in which the substance is delivered is important. This means that if you take the drug first and use CBD oil later, the drug will have priority access to the CYP3A4 enzyme and thus the metabolism of CBD will be slower.
It is worth mentioning that the enzymatic breakdown time of CBD is approximately 6-8 hours. This is important information especially if you know the breakdown time of the substances in the pharmacological drug you are taking. You can then plan your use over the course of a day so as to minimise the risk of interaction.
CBD-drug interactions are therefore a topic that should not be underestimated. On the other hand, there is neither point nor need to demonise either. Selecting the right drugs, dosage is still possible although it requires some knowledge and effort.
Using CBD oil vs. pharmacological drugs - how to do it safely?
If you want to include the use of CBD oil, for example, as an adjunct to conventional treatment talk to your doctor about this. He or she may want to monitor the concentration levels of the medication you are taking at the same time as taking CBD. This is the safest course of action.
Do not interrupt your doctor's prescribed drug therapy unless he or she decides otherwise.
If you are determined to include CBD oil into your daily diet regardless of your doctor's opinion (or in the absence of such an opinion) make sure that you make this decision consciously after a thorough examination of the subject in terms of dosage. Particularly if you are using other medicines, it is important to stick to safe use rules.
One is that it is best to start with a smaller dose and adjust the amount over time (e.g. every 4-5 days). For more tips on this topic, see the article: CBD dosage.
As there are also medicines whose intake means you shouldn't/shouldn't use CBD oil, I write about the second rule later in the article 'CBD-drug interactions 2019/2020'.
Of the other important lessons you should take from this article is that if a drug is metabolised at sites other than cannabinoids, e.g. in the kidneys, then in principle there should be no risk of interaction.
Society of Cannabis Clinicians guidelines for co-administration of CBD with other pharmacological drugs:
The Society of Cannabis Clinicians recently reviewed a discussion of doctors using cannabinoids to treat patients. In the article, which you will find here two most interesting opinions on the use of CBD with medication have been published. They can certainly be useful for anyone considering including hemp oil supplementation in their diet when people are already using drugs metabolised by cytochromes P450.
- Patricia Frye, M.D., recommends that patients use CBD a minimum of one hour apart after taking pharmacological drugs. For drugs metabolised by P450 3A4 - including statins, warfarin, the anti-epileptic drugs clobazam and valproic acid, beta blockers, tricyclic antidepressants, MAO inhibitors (MAOIs) - she suggests increasing this interval to 2-3 hours. Testing The level of drug saturation suggests, among other things, the use of clobazam and chemotherapeutic agents.
- Jeff Helgenrather, M.D., on the other hand, draws attention to the risks of using high doses of CBD together with antiepileptic drugs metabolised by cytochrome P450. In such a situation, he recommends starting with low doses of CBD along with monitoring the blood levels of the pharmacological drugs used under the guidance of a doctor. In this way, an effective dosage of CBD can be determined relatively safely over time, minimising the risk of interactions.
CBD oil vs other medicines - CBD hemp oil vs other medicines
While scientists are working out the details of CBD's interaction with drugs there is a principle in addition to safe dosage that is worth following.
Well, CBD shows almost identical effects on drug metabolism as grapefruit. The difference lies primarily in the intensity of the effect. The mechanism of action of CBD is believed to be identical, but more potent.
It is therefore logical to conclude that if you should not reach for grapefruit (in any form) while taking certain medications, you should not take CBD either.
The drugs for which the service Drugs.com officially issued to warn against interaction with grapefruit include: alprazolam, amiodarone, atorvastatin, Carbamazepine, cilostazol, Clarithromycin, colchicine, dronedarone, erythromycin, felodipine, fentanyl, fexofenadine, indinavir, loratadine, losartan.
In turn, the service Medlineplus.gov indicates that CBD should not be combined with clobazam and valproic acidas they are metabolised in the liver and CBD can prolong their breakdown time, increase their concentration in the blood and therefore increase the risk of side effects.
In the case of other drugs, caution and careful, safe dosing combined with observation of the body's reaction and perhaps medical consultation of the analytically tested blood concentrations of certain substances should be used.
CBD oil vs tranquilizers
CBD shows properties silencing. The synonym for the word 'calming' is intentional, and is due to the bipolar nature of this natural chemical compound. CBD can have an energising and calming effect at the same time. How is this possible?
By maintaining the proper functioning of the endocannabinoid system, CBD indirectly influences the proper regulation of energy management processes in the body. It is with this property of CBD that the energising effect on humans is associated. On the other hand, a properly regulated organism behaves ... calmer, less reactive to external stimuli. CBD dosed as prescribed does not have the typically sedative effect associated with sedative drugs. Calm in this case does not mean sluggish, but rather relaxed.
As one of the best sources of CBD is a natural extract in the form of CBD full spectrum hemp oil, the impact of THC cannot be overlooked. This cannabinoid has sleeping and lethargic properties - you can feel lethargic afterwards. However, the amount of THC in Purehemp's CBD oils is traceable. The risk of inducing feelings of lethargy at the recommended dosage is almost zero. This trace amount of THC is even beneficial for the synergistic effect that is only characteristic of full spectrum cannabinoid preparations.
When faced with taking sedative medication, the use of CBD can enhance the effect of the medication. In theory, this means that by taking a natural full spectrum CBD preparation such as Purehemp's CBD oil, it is possible to reduce the dosage of sedative medication. Unfortunately, guidelines on this are not available due to the lack of research that would unequivocally answer this question.
Should I use CBD oil and tranquillisers? The safest thing to do is not to do this. However, if, as an adult, you want to try it or simply prefer a natural plant preparation to a pharmacological drug, you can make the decision yourself and start using CBD oil carefully according to the safe dosage rules.
CBD and anticoagulants
Research have shown that CBD and other plant cannabinoids can increase the effectiveness of drugs used for blood thinning (e.g. Warfarin) or whose use is associated with the risk of blood thinning.
By lowering the metabolic rate of these drugs, CBD raises their concentration in the blood and prolongs their presence in the body. This means that the use of CBD together with such drugs may increase the risk of bleeding, and it is therefore worthwhile for their co-use to be monitored by a doctor.
CBD and anti-epileptic drugs
The anti-epileptic/anti-epileptic properties of CBD are among the best studied. In terms of efficacy, mechanism of action and use of cannabidiol for this purpose, there is essentially no longer any debate.
Some problems arise in the area of CBD interaction with antiepileptic drugs. Quite old, dating back to 1992 the Lester Bronheim study indicated that low doses of CBD do not have antiepileptic properties, however, may still limit the availability of P450 enzymes, prolonging the action of pharmacological drugs such as clobazam or norclobazam. as a result, it may lead to an exacerbation of the symptoms of the disease.
With this in mind, in a situation where you are using these drugs it is better to dispense with CBD, and if you do, it is essential to consult your doctor before deciding to include it in your daily diet.
CBD and anti-cancer drugs
When CBD oil is used during chemotherapy, while taking anti-cancer drugs, the situation is similar to the interaction of CBD with anti-epileptic drugs.
In the treatment of cancer with chemotherapy, it is very important to precise dosage of anticancer drugs. Too low a dose can result in a lack of expected effectiveness, while too high a dose can lead to an increase in the already high toxicity.
Cancer drug therapies are composed based on standard models and statistical assumptions about their rate of metabolism in the human body. Introducing CBD into the equation can mean slowing down metabolism and raising chemotherapeutic concentrations to higher levels than assumed.
The fact is that CBD and other cannabinoids have shown efficacy in relieving pain associated with cancer and can slow down tumour growth. They also have a positive effect on improving the quality of life of cancer patients. The use of CBD, e.g. in the form of CBD oil, during chemotherapy should be taken into account by the doctor when planning the type and dose size of chemotherapeutics.
CBD and anti-rheumatic drugs
In this respect, the studies I found are among the clearest. They are so precise that I was able to reproduce a table of interactions of individual common anti-rheumatic drugs with individual drugs. The data come from a study conducted by researchers at Imperial College Healthcare NHS Trust in London.
Other common drugs commonly prescribed for rheumatism, whose metabolism occurs mainly in the kidneys, for example, should not interact with cannabinoids or CBD cannabidiol.
We are referring in particular to Baricitinib (Olumiant), Methotrexate, Hydroxychloroquine, Adalimumab (Humira), Abatacept (Orencia).
SUMMARY OF THE ARTICLE "CBD-drug interactions 2019/2020"
- CBD in that natural CBD taken from natural full spectrum hemp oil is considered safe and with a low risk of minor side effects
- CBD affects metabolism other substances including many pharmacological drugs
- The mechanism of this effect according to current knowledge is identical to that of grapefruit
- If the consumption of grapefruit is not recommended while taking a particular drug then so is the consumption of cannabinoids
- If the drug is metabolised e.g. in the kidneys then there should be no risk of interaction
- Cannabinoids of which CBD cannabidiol engages the activity of CYP450 family enzymes, in particular CYP3A4
- If the resources of the CYP3A4 enzyme or other enzymes of the CYP450 family are used at any given time to metabolise cannabinoids including CBD cannabidiol then there may not be enough of them to maintain the predicted rate of metabolism of pharmacological drugs
- This leads to slowing down the metabolism of other substances and drugsand this, in turn, can increase the concentration of these substances in the body
- Increased concentration, understood as a greater amount of the substances in question in the body over a certain period of time after they have been taken into the body than anticipated by the manufacturer and the doctor, may or may not increase the effectiveness of pharmacological drugs, but may also increase the risk of adverse side effects related to the drug
- The risk of interaction in each case should always be assessed by your doctor. Always consult your doctor before deciding to include CBD use in your case
The topic is not exhausted. I encourage you to keep an eye out for changes, additions and clarifications that are sure to follow. If you think this article is worth dividing up, singling out particular areas of interaction write to me!
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Please note that this article is for illustrative purposes and is an approximation of publicly available information. The information is not intended as advice. Before deciding to use CBD in your case, consult your doctor. If he or she provides an answer, always follow his or her advice. However, if he is unwilling or unable to answer your questions, which still happens, you can make the decision yourself at your own risk and responsibility.
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