Did CBD Lead to a Death in New York?
Death after CBD use?: an evaluation of a case report
by Dr Linda Klumpers
In February 2020, New York doctors published a patient case report, suggesting that a CBD product caused the death of a 56-year old woman. (Yin et al., 2020) With cannabis having the image of being a relatively harmless plant that practically cannot be overdosed, and CBD being the more ‘innocent’ non-intoxicating cannabinoid, this case report hit the cannabis news like a bomb. What happened to this patient and what caused her death?
The case: The patient had a history of a herniated disc with chronic pain, high blood pressure, and coronary artery disease, and visited the emergency room (ER) for skin rash and ulceration. Although familiar with CBD products, one week prior to her visit, she had tried a new liposomal CBD extract spray by a company from Oklahoma. Upon her ER visit, doctors diagnosed her with a potentially lethal disorder of the skin and mucous membranes that is called Stevens-Johnson Syndrome (SJS), or toxic epidermal necrolysis (TEN) in a more severe disease form. Although initial treatment of the TEN went well, she ultimately passed away from a septic shock. The authors of the case report use mixed language throughout the report about the association between CBD and her TEN: the title sounds conclusive:“Commercial Cannabinoid Oil-Induced Stevens-Johnson Syndrome” but towards the end, confusingly, they described a possible association:”It is unclear if marijuana-derived/CBD products can induce SJS-TEN. However, our case suggests an association.”
The options: were the authors wrong about the potential role of CBD in TEN leading to the patient’s death? No, but let’s put this and some other options in a broader perspective.
- Medication. One of the medicines that the patient had been taking for at least five years, meloxicam, is known to be able to cause SJS-TEN. (NIH, 2020) Realizing that meloxicam could have triggered TEN in the patient, it is, however, suspicious that this happened after years of her taking the medication and not earlier.
- CBD-Drug Interaction. One option, given by the authors, is that meloxicam’s concentration in the blood increased significantly due to an interaction with CBD (see CBD Metabolism article for more information). Meloxicam and CBD are both metabolized by the enzyme CYP2C9. (Schmid et al., 1995; Jiang et al., 2011; Yamaori et al., 2012) Although the patient in our case study used CBD for a longer time, she recently switched to a different formulation with an unknown dosing regimen. This could have caused the CBD concentrations in her body to go up, but we don’t know this for sure, as no information has been published about this, and possibly never even measured.
- Pre-existing conditions. SJS-TEN can also occur after a pre-existing bacterial infection or illness. Although we would like to assume that this was not applicable, we are not sure, because this option would need to be confirmed or denied by the authors.
- Other compounds. The article stated that ”The complete chemical analysis from the patient’s commercial CBD oil was not performed.” Without knowing what the patient administered exactly, it is impossible to draw conclusions about CBD being the (indirect) cause of the patient’s death.
- Unknown causes. As stated by the National Institutes of Health:“In many cases, no definitive trigger for an individual's SJS/TEN is ever discovered.” (Genetics Home Reference, 2020) This statement can be applied to our case: although we can make assumptions about what happened, there is no proof and we don’t know what exactly happened.
In conclusion: Did CBD trigger TEN leading to the patient’s death? We have no proof to confirm or deny this statement.
But if CBD was indeed involved in this patient’s death, what would this mean for me? In case that the CBD product was indeed involved in the patient’s death, it doesn’t mean that all CBD products are dangerous for everyone. Firstly, it is important to get products from a trustworthy source that is able to show you certificates of analysis. Secondly, always consult your healthcare professional before starting or changing your CBD product or dose: they will be able to inform you about CBD-drug interactions as well as other potential safety measures. We will be speaking more about this in the future posts.
- This year, a patient case report was studied after the patient’s death, which followed their changing to a new CBD product
- The authors of the case study state in their paper title that there is a relationship between CBD and the patient’s death, but in their conclusion, they state that the relationship is unclear
- From the case study, there is a lack of information needed to understand whether CBD played a role in this patient’s death
- It is important to get your CBD products from a trustworthy source that is able to show you certificates of analysis
We are now working with our friends at Cannify to bring you more information on important topics. Cannify researches and educates about cannabis. It is the first company to match patients and products with science. Cannify's founder Dr. Linda Klumpers earned a Ph.D. in Clinical Pharmacology of cannabis and has been studying cannabis for over a decade. Cannify educates an audience that includes patients, healthcare providers, and university students, and is actively involved in various cannabis-related research projects.
- Genetics Home Reference, National Institutes of Health, 2020, https://ghr.nlm.nih.gov/condition/stevens-johnson-syndrome-toxic-epidermal-necrolysis
- Grayson, Leslie, Brannon Vines, Kate Nichol, and Jerzy P. Szaflarski. "An interaction between warfarin and cannabidiol, a case report." Epilepsy & behavior case reports 9 (2018): 10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5789126/
- Jiang, Rongrong, Satoshi Yamaori, Shuso Takeda, Ikuo Yamamoto, and Kazuhito Watanabe. "Identification of cytochrome P450 enzymes responsible for metabolism of cannabidiol by human liver microsomes." Life sciences 89, no. 5-6 (2011): 165-170. https://realmofcaring.org/wp-content/uploads/2019/10/Identification-of-cytochrome-P450-enzymes-responsible-for-metabolism-of-cannabidiol-by-human-liver-microsomes.pdf
- NIH, 2020 Stevens-Johnson syndrome/toxic epidermal necrolysis
- Schmid, Jochen, Ulrich Busch, Gunther Heinzel, Gerhard Bozler, Siegfrid Kaschke, and Michael Kummer. "Pharmacokinetics and metabolic pattern after intravenous infusion and oral administration to healthy subjects." Drug metabolism and Disposition 23, no. 11 (1995): 1206-1213. https://www.ncbi.nlm.nih.gov/pubmed/8591720
- Yamaori, Satoshi, Kyoko Koeda, Mika Kushihara, Yui Hada, Ikuo Yamamoto, and Kazuhito Watanabe. "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 (2011): 1112080289-1112080289.
- Yin, Han Y., Nicholas Hadjokas, Kanish Mirchia, Robert Swan, and Samuel Alpert. "Commercial cannabinoid oil-induced Stevens-Johnson syndrome." Case reports in ophthalmological medicine 2020 (2020). https://www.hindawi.com/journals/criopm/2020/6760272/