Meloxicam And CBD Oil Interaction

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CBD is broken down by the same enzyme as 75% of medications and drugs. Here is a list of the medications that interact with CBD and if it's safe to mix. Learn more about CBD interactions with drugs and how to stay safe when you use CBD for pain or other symptoms. 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.

CBD Drug Interaction List: Is it Safe to take CBD with your Medications?

CBD is phenomenally popular right now. It’s being used to treat pain, anxiety, epilepsy, psychosis, and even neurodegenerative diseases like Alzheimer’s and Parkinson’s. It’s been called a “wonder drug,” without irony, and it has essentially no known downsides. It is readily available and easy to take.

At the same time, it’s important to be aware that CBD can interact with some medications. Taking it at the same time as other drugs can affect CBD’s dosage and effects, and can even change how your body breaks it down.

This article is your guide to safely taking CBD alongside your other medications and supplements. First, it has a quick overview of how CBD interacts with other drugs in your body, and then it lists the most common drugs that interact with CBD, and which you should be careful about taking at the same time. If you want to skip ahead, you can find the list here.

The CYP450 Pathway

Once a drug enters your system, its molecules are circulated through your blood and interact with your cells and tissues, doing whatever it is they’re supposed to do. Painkillers reduce pain signals and can stop swelling, antidepressants interact with brain cells to change your brain chemistry, and so on.

Once they’ve done their work, your body needs to get rid of the drug molecules. Too much of any drug in your bloodstream is toxic, and can start to harm your body.

Your body uses all kinds of systems to get rid of drugs, and the most important of these are enzymes–chemicals that break down other chemicals. The largest set of enzymes are the cytochrome p-450 group (or CYP450), which are responsible for breaking down about 75% of the medications and recreational drugs that we take.

CBD and the CYP450 Pathway

CBD interacts with the CYP450 system in three ways. First, some of the enzymes in the system are responsible for breaking down CBD molecules, as they are for molecules of other drugs. That’s normal–nothing to worry about there.

Second, CBD can affect how CYP450 enzymes are produced by your liver, making it produce not enough of some enzymes or too much of others. This can stop your liver from processing some drugs, like the epilepsy medications clobazam and valproic acid.

Third, and most importantly, CBD can actually stop many of the CYP system’s enzymes from working properly. This is called “inhibition,” and it can cause problems if it prevents the enzymes from breaking down other drugs. Sometimes, the enzymes are responsible for activating other drugs instead, but the same problem comes up–if CBD stops the enzyme from working, then it doesn’t do its normal job, and the other drug won’t behave normally, which can have negative consequences.

For instance, there’s a group of antidepressants called selective-serotonin reuptake inhibitors, which include drugs like citalopram, norfluoxetine, and sertraline. Normally, an enzyme called CYP3A4 breaks down molecules of those drugs, making sure they don’t build up to unsafe levels that can damage cells or tissues. CBD inhibits CYP3A4, though, which means that taking CBD and sertraline at the same time could be dangerous. CYP3A4 wouldn’t break the sertraline down, and it would accumulate for far too long.

It’s worth noting that CBD isn’t the only thing that does this. The herbs St. John’s Wort and goldenseal can also stop CYP450 enzymes from working properly, as can grapefruit and starfruit juice, and even tobacco.

Drugs that Interact with CBD List

That brings us to our list. Remember, the general rule is that you need to be careful taking CBD at the same time as any drug or medication that gets processed by CYP450 enzymes. If you’re thinking about doing so, be sure to check with your doctor first.

Here are the most common of those drugs and medications. They include many painkillers, anti-inflammatories, antipsychotics, antidepressants, anticonvulsants, statins, opioids, and other groups.

Does CBD Interact or Interfere with Medication? What Arthritis Patients Must Know Now

CBD (cannabidiol) is seemingly everywhere, with oils, tinctures, pills, chocolates, gummy bears, and creams available all over the internet, at national drugstore chains, and perhaps at your local farmer’s market — even if you don’t live in a state where medical or recreational marijuana is legal.

CBD, a type of chemical known as a cannabinoid, is a mainingredient in hemp, one type of cannabis plant. Marijuana, another type of cannabis plant, also has some CBD but an abundance of THC (tetrahydrocannabinol), an intoxicating cannabinoid known for making users feel “stoned” or “high.” While CBD won’t get you high, it interacts with cannabinoid receptors in your body and may have effects that are sought by people with arthritis, such as pain relief, reduced inflammation, and improvements in sleep and anxiety.

According to CreakyJoints research presented at the 2019 Annual European Congress of Rheumatology meeting earlier this year, 52 percent of respondents reported having tried CBD for a medical reason. Of those who did, 93 percent said it helped. More than half said they wanted more information on CBD from their doctor, but 58 percent of those who told their doctors about their CBD use did not get the information on safety, effectiveness, and dosing they were looking for.

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One common concern among people with chronic illness who use CBD is whether CBD can interfere with prescription drugs you may take for arthritis or other conditions.

We put commonly asked questions to Nina M. Bemben, PharmD, BCPS, a specialist in drug interactions who is trying to educate other pharmacists about possible drug-drug interactions with CBD, as well as Rachna Patel, DO, a physician who does consultations about medical marijuana and CBD and sells her own line of CBD products.

What kind of drug interactions can happen with CBD?

A huge number of medications, including CBD, are broken down by the same large family of liver enzymes, called CYP450.

CBD inhibits some enzymes in this family. This makes them break down certain drugs more slowly, which could potentially increase side effects unless your doctor adjusts the dose. On the other hand, CBD induces other enzymes in this family, which speeds the breakdown of certain drugs so they may potentially be less effective unless the dose is increased.

As examples, you may experience increased side effects if CBD is used along with these drugs:

  • Antidepressants (such as fluoxetine, or Prozac)
  • Medications that can cause drowsiness (antipsychotics, benzodiazepines)
  • Macrolide antibiotics (erythromycin, clarithromycin)
  • Heart medications (some calcium channel blockers)

“There is still a lot of uncertainty about how CBD interacts with drug-metabolizing enzymes in the body. We know that there are some drug-metabolizing enzymes that are affected by CBD, some that are not, and many others where we just don’t have any information yet,” says Dr. Bemben.

What do we know for sure about CBD’s interactions with other drugs?

The most direct information comes from studies on the only FDA-approved CBD product, Epidiolex, which is used to treat rare forms of epilepsy. Epidiolex has been found to increase blood levels of the blood thinner warfarin about 30 percent, which raises the risk of bleeding. It also interacts with other medications used for epilepsy.

“The manufacturer of Epidiolex was asked by the FDA to conduct more drug-drug interaction studies, so we will learn more about CBD’s interactions with other drugs in the future,” says Dr. Bemben.

Can CBD interact with medications I take specifically for arthritis?

“Based on what we know now about the way CBD is metabolized, I would not expect significant drug-drug interactions with drugs commonly used in arthritis treatment, such as methotrexate, and most nonsteroidal anti-inflammatory drugs (NSAIDs). I would advise caution on one NSAID, diclofenac, because there isn’t information on how CBD affects — if at all — the enzyme that metabolizes it,” says Dr. Bemben.

Rheumatologists are always on the alert for liver problems that may result from arthritis medications, and that includes CBD as well as NSAIDs and methotrexate.

Are older people more at risk of CBD drug interactions?

Yes, for several reasons. “As we age, our livers and kidneys may be slower to eliminate drugs from the body. In addition, older patients and those with chronic health problems are more likely to be using multiple medications, so the risk for drug interactions increases,” says Dr. Bemben.

Dr. Patel worries in particular about any side effects or interactions that result in dizziness and may increase the risk of falls in the elderly. For example, using the antidepressant fluoxetine together with cannabis products can increase dizziness and drowsiness.

Are there some people who should stay away from CBD?

Hold off if you have known liver damage, says Dr. Patel. In a study done on mice published earlier this year, the dose of CBD used to protect against seizures was found to induce liver damage. According to other animal research, CBD may increase levels of liver enzymes, raising concerns about liver toxicity in patients taking methotrexate.

“We use other therapies that cause liver injury, like nonsteroidal anti-inflammatories (NSAIDs). If liver enzymes go up in someone on methotrexate, we would generally hold the drug other than methotrexate [for example, CBD or an NSAID] to see if the enzyme levels normalize,” says Michael Weinblatt, MD, professor of medicine at Harvard Medical School in Boston.

People who take Epidiolex for epilepsy are more likely to develop abnormal liver enzymes, as well as sleepiness and other symptoms, if they are also using valproic acid to control seizures.

“This is important for people with arthritis to know because valproic acid is sometimes used for pain that isn’t controlled by other medications,” says Dr. Patel.

If I stick with a CBD cream, does that reduce the risk of drug interactions?

Probably, since little if any of a topical product is likely to be absorbed into your system. “Unfortunately, we just don’t have good information about how much of a topical CBD product gets absorbed. This can be influenced by the inactive ingredients in the product, where on the body it’s applied, and whether you apply a bandage over the area after applying it,” says Dr. Bemben.

While topical CBD products may not be absorbed deeply enough to raise concerns about drug interactions, that also means they may not be as effective for arthritis pain. “If you just have one joint hurting and it’s close to the surface, using a topical would be appropriate. It’s not as likely to help a hip or other deep joint,” says Dr. Patel.

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Which health professionals need to know I’m trying CBD?

Tell your rheumatologist and anyone else who prescribes medication for you. If you need surgery, an anesthesiologist may choose a different dose or type of anesthesia if you’re using CBD.

“If you fill all of your medications at the same pharmacy, your pharmacist will be able to assess for drug interactions for all of them, regardless of who prescribed them. You should still let the pharmacist know about over-the-counter medications, herbs, and supplements — including CBD — that you don’t get through the pharmacy. It is important to bring the CBD product to your doctor and pharmacist so they can check the amount of CBD and other ingredients it contains,” says Dr. Bemben.

“While patients may be wary of stigma surrounding CBD products, I believe most health care providers understand this is a growing area and one strategy patients are trying in hopes of getting relief,” she says.

Is there an online source I can use to figure out which of my medications might interact with CBD?

Online databases are available to help health professionals evaluate potential drug-drug interactions, at a price. “Freely available resources tend to be less reliable, and this highlights the importance of discussing all your medications, including CBD, with your doctor and pharmacist,” says Dr. Bemben.

One source available to patients is drugs.com, where you can plug in either cannabidiol (which will give you the FDA-approved oral product Epidiolex) or cannabis (which will give you both THC and CBD) and check for possible interactions with other medications you take.

Has anyone had a life-threatening drug interaction with CBD?

“There haven’t been reports of serious drug-drug interactions with over-the-counter CBD products. However, these products are relatively new and it typically takes time for reports to be published. We have very little information about over-the-counter CBD products and how they may interact with other drugs,” says Dr. Bemben.

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.

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.

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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.

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