Case 1E – AJ

and Cannabis Research

Group 5
Jessie Allison
Christina Carreau
Andrea Horta
Rachelle de Jong
Betty Rozendaal

Pharmacology BAS 206

January 23, 2007
 Case AJ

Medical history
• 43 yeo female
• Kidney transplant (3 years ago)
• DVP left calf (18 months ago)
• Protein C Deficiency (incr. risk of blood clots)
• Menopausal
• Drug complications, bruising and bleeding from
antithrombotic drugs
 Patient’s Medications
Medications Use
Cyclosporin immunosuppressant anti transplant rejection[i]

Mycophenolate mofetil Prevents organ transplant rejection reverses

ongoing acute infection
Prednisone In conjunction with other immunosuppressant
(corticosteroid) drugs i.e. Cyclosporine and MMF, to reduce
rejection of transplanted organs. [iii]
Glyburide controls hyperglycemia, used as an insulin
substitute[v]
Hydrochlorothiazide diuretic and anti-hypertensive[vii]

Warfarin anticoagulant
Aspirin thrombolytic
Gingko Incr. memory/vasodilator

Calcium Unknown, likely post menopausal bone loss

 Question 1

As an ND what are your initial considerations

in recommending natural therapies?
• Px on many allopathic drugs
• Understanding pharmacodynamics and
pharmacokinetics of natural herbs and drugs
• Risk of drug interactions, contraindications or
interference esp., anti rejection drugs
• Existing complications from allopathic drugs
• Need to co-manage with MD
 Question 2

Which medications are of most concern vis a

vis drug interactions in general?
• Drug/herb interactions
• Drug/drug interactions
• Increase bleeding time
• Increase blood pressure
• Risk of emboli
• Drug/herb additive or minimizing effects
• See table next slide
 Medication Interactions and Concerns
Medications Use Interactions/caution
Cyclosporin immunosuppressant anti transplant rejection[i] Warfarin, Prednisone (corticosteroids),
incr. serum concentration of cyclosporine.

Mycophenolate mofetil Prevents organ transplant rejection reverses Patients with evidence of bruising, bleeding
ongoing acute infection or infection must report it due to its
association with lymphoma.[ii]
Prednisone In conjunction with other immunosuppressant Adverse Effects: potential for pulmonary
(corticosteroid) drugs i.e. Cyclosporine and MMF, to reduce emboli[iv].
rejection of transplanted organs. [iii]
Glyburide controls hyperglycemia, used as an insulin Should not be given to patients with liver
substitute[v] disease or renal impairment.
Glyburide weakens the effects of Warfarin
(coumarin) derivatives.[vi]
Hydrochlorothiazide diuretic and anti-hypertensive[vii] Can decrease in GFR (similar to
cyclosporine).
Interactions with Prednisone may cause salt
and water retention (hypokalemia) . Could
potentially raise blood pressure.[viii]
Warfarin anticoagulant Risk of hemorrhages. Treatment highly
individualized and monitored.
Potential interactions:
Hydrochlorothiazide (diuretics),
Prednisone (corticosteroid),
immunosuppressives[ix]
Garlic and ginkgo may induce bleeding
events have anti-coagulant, anti-platelet
and/or fibrinolytic activity. Additive effects
to Warfarin’s anti-coagulative effect.[x]
 Medications cont’d

Medications Use Interactions/caution

Aspirin thrombolytic Additive blood thinning effect with other

drugs

Gingko Incr memory/vasodilator May have additive effect with antiplatlet

drugs

Calcium Unknown likely post menopausal bone loss May decrease drug absorption
 Question 3

Concerns with Gingko therapy and

Echinacea?

• Thiazide + Ginkgo therapy = < blood

pressure/hypertension (metabolic inhibition)
• Warfarin + Ginkgo = left parietal hemorrhage
(additive effect)
• ASA + Ginkgo = spontaneous hyphema (interior eye
hemorrhage)
• Echinacea + Ginkgo minimizes effects of
cylosporine + prednisone (anti rejection drugs)
 Question 4

Risk of additional Ginger, Garlic or Dong

Quai therapy?
Ginger
• Enhances effect of warfarin and other anticoagulants
• Reduced platelet aggregation (incr. bleeding time)
Garlic
• Antiplatlet/anti coagulant fibrinolytic enhanced effect on
warfarin
• Enhanced effect on glyburide (antihypoglycemic)
Don Quai
• Enhanced effect on warfarin
• Reduced platelet aggregation ( incr. bleeding time)
 Question 5

What additional education would be given to

the patient and what other actions would be
taken?
• Explain that herbs (although natural) and prescription and
non prescription drugs have potential to interact and
cause harm
• All medications and herbs must be disclosed to the
medical team for proper monitoring and follow up.
• Contact her MD to discuss patient’s concerns
• Provide list of anticoagulant/antiplatlet herbs to avoid i.e.
ginkgo, garlic, don quai while on blood thinning
medications
• Avoid echinacea or immune boosting herbs while on
immune suppressive drugs prednisone and cyclosporine
 Question 6

What are the recommendations for a patient taking garlic

for their heart prior, to surgery to avoid post operative
bleeding?
• Garlic is known to
– Reduce platelet aggregation and decrease clotting time
– Moderately reduce blood pressure
– Reduce cholesterol
• 2 g/day of garlic can lead to spontaneous spinal epidural
hematoma
Recommendations:
• Stop the use of garlic 1 week before surgery, do not
resume until risk of bleeding has ceased.
• Monitor use if in conjunction with other medications i.e.
ASA
 Cannabis Drug Profile
Cannabis Sativa
Indications:
• Treat pain (i.e. in cancer and AIDS), nausea,
suppression of spasms and convulsions (i.e. in
MS, cerebral palsy), loss of appetite, asthma, high
blood pressure, arthritis, laxative, recreation
• Constituents:
• Cannabinoids (15-20%)
• Delta-9-tetrahydrocannabinol (THC) (main
psychoactive ingredient)
 Physiological Action
Cannabinoids interact with neurotransmitters
and neuromodulators:
Actions:
• Analgesic
• Sedative
• Anti-inflammatory
• Hypotensive
• Anti-emetic
• Psychoactive (TCH)
 Pharmacokinetics
Absorption
• Inhalation: fast
• Oral: slow
• Rectal: lower and constant
• Transderma/sublingual: no clinical studies
Distribution
• THC concentrated in liver, kidney, heart, gut, lung, spleen, mammary glands, placenta,
adrenal cortex, pituitary and thyroid glands.
• 60% TCH bound to lipoproteins
Metabolism
• Complex
• Metabolized by liver
• Biotranformation by lung and intestines
• Isoenzyme P-450 activates TCH
Excretion
• 65 % through feces
• Plasma and urine half life : 3-4 days
• Clearing time is shorter for daily users (19-27 hrs) vs. inexperienced (50-57 hrs)
 Adverse Effects
• Controversial research
• Prolonged repetitive use similar to smoking
• Depression, anxiety, personality disturbances,
memory and learning disturbances in chronic users
• Exacerbates mental health issues
• Incr. anxiety, paranoia, loss of self control
• After effects: headache, dizziness, nausea,
vomiting
 Addictive Tendency and Therapy
Interactions
• Research suggests that a prolonged use of
cannabis may lead to dependency and a mild
withdrawal syndrome
Interactions
• Additive sedation effect with alcohol and
benzodiazepines
• Accelerated heart rate with amphetamines,
adrenaline, atropine, Beta blockers, diuretics,
tricyclic antidepressants
• THC
– Accelerates metabolism of theophyline
– Delay metabolism of antipyrine and barbiturates
 Contraindications
• Pregnancy
• Schizophrenia
• Prolonged use by smoking
• Operating a motor vehicle within 8 hours of use
• Self prescribing (to avoid dependence and
substance abuse)
 Thank You
•

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