When prescribing or purchasing CBD, in any form, it is very important that a medication profile be reviewed and checked for potential drug interactions. There are 2 major cyp450 enzymes that metabolize CBD; cyp3a4 (metabolizes most drugs) and cyp2d6. I recently had a client that came to me with a number of issues (after extensive interviews including a med profile which, at the time, only include something for sleep the primary ones being a compromised immune system which presented as a chronic EBV viral infection, spleen issues, chronic sore throat, swollen lymph nodes etc. and, more importantly, chronic gut issues which included ongoing stomach ulcers, SIBO (syndrome of inappropriate bacterial overgrowth-out of balance gut bacteria, gut inflammation, potential parasite and a 20 pound weight loss over a 3 month period. These issues were supported by a stool test and a nutritional test. I proceeded to treat the immune issues with LDN, colostrum, vitamin d and high dose vitamin C. I started to treat the gut issues with high dose probiotics, digestive enzymes and GI microbix and oregano for the potential parasites. I started CBD oil for both the gut and immune issues. Shortly afterwards I got a call from the client telling me that she was presenting with, initially, severe sweating of her hands (palmar hyperhydrosis) along with extreme fatigue which only got progressively worse over the next week. At this point I thought she may have been experiencing a "herx" reaction to parasite/bacteria die off (even thought about testing her flor Lyme as this is the kind of Herx reaction one might see). I started her on acetyl-glutathione and zeolyte powder for the assumed toxins. She then called me to tell me that she remembered that just recently her psychiatrist put her on fluoxetine, an SSRI antidepressant, that when I looked at the side effects severe sweating, extreme fatigue etc. She then told me that shortly after starting this drug she had minor symptoms of sweating etc. When I looked for a potential drug interaction with the CBD it turned out she did in fact have an interaction with cyp2dr which was preventing the metabolism of the fluoxetine thus steadily increasing her blood levels. Fluoxetine when used routinely has a half life of up to 6 days. A few days before I told her about the drug interaction she went ahead and stopped the drug anyway after she read the side effects. I also suggested she stop the CBD for at least a week before starting again (waiting for the serum levels of the drug to go down. Since then her symptoms have steadily declined.
It is amazing to me that with all my education I had never heard about the endocannabinoid system. This goes also, for my nurse and physician colleagues. While it has been know about for quite some time I believe it has been ignored due to its association with THC/cannabis/marijuana. As I worked through the certification program (ICCT) it became obvious that its main role is homeostasis (balance) of all the systems in the body and works hard to accomplish this. However, at times it needs a bit of help, thus CBD, which comes from the hemp plant and THC which comes from the cannabis plant. I would like to share all the information from the certification program but it sits in a binder that is 5 inches thick. That said, I will share some of the highlights, focusing on CBD. Every module in the certification program notes numerous clinical articles thus evidence based. If anyone questions the routine use of CBD in the noted indications there is literature out there to support its use.
Extraction: The extraction process/CBD oil production should be organic, Non-GMO, pesticide-free hemp that is tested for contaminants (heavy metals, pesticides/fungicides and mycotoxins (fungus) and the producer needs to use a safe solvent and verified extraction process. While there are a few routinely used extraction processes (ethanol, butane, Super critical, Co2) The super critical Co2 is by far the best. So what does one look for when trying to decipher between products. First,is this a full hemp extract (containing phytocannabinoids-CBD being one (113 reported) phenolic compounds (10,000 structures) and terpenes (essential oils etc) of which there are 100 reported. the one most studies is limonene for those who are familiar with essential oils and is the final certificate of analysis available (tells what is actually in the product and how much including does it have 0.3% THC or less to be legal and is there a THC free option).. Second, what is the medium used in the product i.e. olive oil, MCT oil, Palm oil, coconut oil or hemp oil and lastly,what is the mg per dose and volume of the bottle.
How Does It Work: (gets a little complicated) There are 2 cannabinoid receptors everywhere in the body, CB1 and CB2. It is these 2 receptors that work within the systems of the body attempting to create balance when things are off. Of course, every system in the body, nervous, GI, endocrine, etc has their own specific receptors with chemicals/transmitters that attach to the receptor and trigger a response. CB1 and CB2 receptors are, as I said, everywhere. and like other receptors require a chemical to trigger a response. THC works directly with CB1 and CB2 (which gives it some of its unique medicinal indications versus CBD although a lot of overlap).while CBD works indirectly through 2 transmitters called ananamide (aside from a myriad of other clinical indications, plays a major role in how we feel emotionally) and 2-ag which then are metabolized through 2 enzymes called FAAH and MAGL (not worth spelling them out).which also play a significant role in how CBD works. As mentioned above, the extraction process is critical as all of the cannabinoids, terpenes and phenolic compounds work together (synergy) to create a positive clinical outcome.
How is it metabolized: Both CBD and THC are metabolized by 3 liver isoenzymes (When combined account for the majority of how drugs and other chemicals) CYP2C19, CYP3A4, and CYP2D6. Why is this important? What I have found is that folks are buying CBD oil and other CBD products without knowing all the facts. As mentioned above, most drugs are metabolized by the three isoenzymes. This can result in significant/serious drug interactions with CBD, and if someone is on a lot of drugs (or any), the potential for drug interactions should be discussed with their clinician (unfortunately most clinicians are ignorant of this fact).
Side effects: While there may be some minor side effects/gut related issues (not including drug interactions) A review of 132 original studies by Bergamaschi et al. describes the safety profile of CBD and high doses up to 1,500mg per day and chronic use have been repeatedly shown to be well tolerated by humans.
Indications: The list is huge and I continue to routinely find additional indications. Generally speaking, it has anti-inflammatory (autoimmunity), antioxidative, antiemetic, antipsychotic (bipolar for example), endocrine (thyroid/hashimotos-graves), sex hormones/fertility, etc.), emotional (depression/anxiety), gut and neuroprotective properties. As an example, migraine, fibromyalgia and irritable bowel syndrome are connected in their pathology with CBD playing a balancing act between the 3. When you look at the major cannabinoids (CBD, CBG, CBGA, CBC, CBCA, CBN and all the terpenes) and the role that the endocannabinoid system plays hard to find an indication that does not fit.
Dosing: Not going to go into a lot of detail here as dosing varies based on what one is trying to treat. However,it is important to know dosing ranges as CBD in any form is expensive. If any additional questions (drug interactions/dosing), as this blog is being read, can contact me via email (firstname.lastname@example.org) or phone (940-435-9655).