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Case Presentation
A 48-year-old woman presented with a history of anxiety and depression, pain, insomnia, constipation, and focal nodular hyperplasia (benign tumors of the liver). She was looking to reduce her medications for these conditions and to improve her overall health. She had been prescribed the following medications: venlafaxine (Effexor), progestin (Norethindrone), Tylenol PM for sleep, plus Advil and Tylenol, as needed for pain.

Some clients prefer the ease of taking a daily soft gel, but oral CBD (edibles and soft gels) has a greater likelihood of interacting with some pharmaceutical medications. Ingested CBD undergoes first-pass metabolism by the liver, utilizing the Cytochrome P-450 (CYP450) enzyme system.3 If another medication requiring this enzyme system for metabolism is taken at the same time as the CBD, it could affect the blood levels of that medication. For some drugs this may not be an issue, but for medications with a narrow therapeutic window, it’s necessary to proceed with caution. Some blood thinners and antiarryhthmics utilize the CYP450 enzyme system and fall into this category. A general rule is that medications contraindicated with grapefruit could potentially be affected by ingested CBD.4

References

5. de Mello Schier AR, de Oliveira Ribeiro NP, Coutinho DS, et al. Antidepressant-like and anxiolytic-like effects of cannabidiol: a chemical compound of cannabis sativa. CNS Neurol Disord Drug Targets. 2014;13(6):953-960.

Patients suffering from pain, anxiety, depression, insomnia, migraines, autoimmune and inflammatory disorders, and other conditions are increasingly turning to medical cannabis and CBD for relief.1 Many are dissatisfied with the side effects of traditional pharmaceuticals for these conditions and are searching for a more holistic approach to managing their health.

Because I’ve seen dramatic results in hundreds of clients in my practice—in particular for anxiety, pain, and insomnia—with little to no side effects, I urge health care professionals to consider CBD and cannabis as viable adjuncts to treatment.

In our latest question and answer, the pharmacist discusses whether or not CBD (cannabidiol) interacts with trazodone or Effexor (venlafaxine).

Even then, we don’t know much about CBD in general. We do know that CBD can inhibit certain metabolizing enzymes, a common characteristic of many drug interactions. However, there are many studies that theorize that while CBD does inhibit metabolizing enzymes, it takes extraordinarily large doses to do so and the inhibition is not to a significant extent for most individuals.

Anna asked

CBD has recently has exploded in popularity, with many different products available over the counter. With this, it is important to consider potential drug interactions with prescription medication, such as Effexor and trazodone.

Hello, could you tell me if I can take CBD oil (the bottle contains 500mg pure CBD, one drop contains 1,25 mg) and vitamins/supplements (C,K,B6,B12,B3,magnesium) with these medications: – Effexor 150 mg prolonged release (in the morning)- Trittico (trazodone) 75 mg prolonged release (in the evening)I’m afraid of potential interactions.

The amounts of CBD used in studies range greatly (from 1 mg to over 600 mg), but there is preliminary positive evidence for a variety of indications, including:

People considering or taking CBD products should always mention their use to their doctor, particularly if they are taking other medications or have underlying medical conditions, such as liver disease, kidney disease, epilepsy, heart issues, a weakened immune system, or are on medications that can weaken the immune system (such as cancer medications). A pharmacist is a great resource to help you learn about a potential interaction with a supplement, an herbal product (many of which have their own drug interactions), or an over-the-counter or prescription medication. Don’t assume that just because something is natural, it is safe and trying it won’t hurt. It very well might.

The researchers further warned that while the list may be used as a starting point to identify potential drug interactions with marijuana or CBD oil, plant-derived cannabinoid products may deliver highly variable cannabinoid concentrations (unlike the FDA-regulated prescription cannabinoid medications previously mentioned), and may contain many other compounds that can increase the risk of unintended drug interactions.

While generally considered safe, CBD may cause drowsiness, lightheadedness, nausea, diarrhea, dry mouth, and, in rare instances, damage to the liver. Taking CBD with other medications that have similar side effects may increase the risk of unwanted symptoms or toxicity. In other words, taking CBD at the same time with OTC or prescription medications and substances that cause sleepiness, such as opioids, benzodiazepines (such as Xanax or Ativan), antipsychotics, antidepressants, antihistamines (such as Benadryl), or alcohol may lead to increased sleepiness, fatigue, and possibly accidental falls and accidents when driving. Increased sedation and tiredness may also happen when using certain herbal supplements, such as kava, melatonin, and St. John’s wort. Taking CBD with stimulants (such as Adderall) may lead to decreased appetite, while taking it with the diabetes drug metformin or certain heartburn drugs (such as Prilosec) may increase the risk of diarrhea.

The bottom line: Talk to your doctor or pharmacist if using or considering CBD

Many drugs are broken down by enzymes in the liver, and CBD may compete for or interfere with these enzymes, leading to too much or not enough of the drug in the body, called altered concentration. The altered concentration, in turn, may lead to the medication not working, or an increased risk of side effects. Such drug interactions are usually hard to predict but can cause unpleasant and sometimes serious problems.

Researchers from Penn State College of Medicine evaluated existing information on five prescription CBD and delta-9-tetrahydrocannabinol (THC) cannabinoid medications: antinausea medications used during cancer treatment (Marinol, Syndros, Cesamet); a medication used primarily for muscle spasms in multiple sclerosis (Sativex, which is not currently available in the US, but available in other countries); and an antiseizure medication (Epidiolex). Overall, the researchers identified 139 medications that may be affected by cannabinoids. This list was further narrowed to 57 medications, for which altered concentration can be dangerous. The list contains a variety of drugs from heart medications to antibiotics, although not all the drugs on the list may be affected by CBD-only products (some are only affected by THC). Potentially serious drug interactions with CBD included

CBD has the potential to interact with many other products, including over-the-counter medications, herbal products, and prescription medications. Some medications should never be taken with CBD; the use of other medications may need to be modified or reduced to prevent serious issues. The consequences of drug interactions also depend on many other factors, including the dose of CBD, the dose of another medication, and a person’s underlying health condition. Older adults are more susceptible to drug interactions because they often take multiple medications, and because of age-related physiological changes that affect how our bodies process medications.

Products containing cannabidiol (CBD) seem to be all the rage these days, promising relief from a wide range of maladies, from insomnia and hot flashes to chronic pain and seizures. Some of these claims have merit to them, while some of them are just hype. But it won’t hurt to try, right? Well, not so fast. CBD is a biologically active compound, and as such, it may also have unintended consequences. These include known side effects of CBD, but also unintended interactions with supplements, herbal products, and over-the-counter (OTC) and prescription medications.