Purpose Increased cannabis use and recent drug approvals pose new challenges for avoiding drug interactions between cannabis products and conventional medications. This review aims to identify drug-metabolizing enzymes and drug transporters that are affected by concurrent cannabis use and, conversely, those co-prescribed medications that may alter the exposure to one or more cannabinoids. Methods A systematic literature search was conducted utilizing the Google Scholar search engine and MEDLINE (PubMed) database through March 2019. All articles describing in vitro or clinical studies of cannabis drug interaction potential were retrieved for review. Additional articles of interest were obtained through cross-referencing of published bibliographies. Findings After comparing the in vitro inhibition parameters to physiologically achievable cannabinoid concentrations, it was concluded that CYP2C9, CYP1A1/2, and CYP1B1 are likely to be inhibited by all 3 major cannabinoids Δ9-tetrahydrocannabinol (THC), cannabidiol (CBD), and cannabinol (CBN). The isoforms CYP2D6, CYP2C19, CYP2B6, and CYP2J2 are inhibited by THC and CBD. CYP3A4/5/7 is potentially inhibited by CBD. Δ9-Tetrahydrocannabinol also activates CYP2C9 and induces CYP1A1. For non-CYP drug-metabolizing enzymes, UGT1A9 is inhibited by CBD and CBN, whereas UGT2B7 is inhibited by CBD but activated by CBN. Carboxylesterase 1 (CES1) is potentially inhibited by THC and CBD. Clinical studies suggest inhibition of CYP2C19 by CBD, inhibition of CYP2C9 by various cannabis products, and induction of CYP1A2 through cannabis smoking. Evidence of CBD inhibition of UGTs and CES1 has been shown in some studies, but the data are limited at present. We did not identify any clinical studies suggesting an influence of cannabinoids on drug transporters, and in vitro results suggest that a clinical interaction is unlikely. Conclusions Medications that are prominent substrates for CYP2C19, CYP2C9, and CYP1A2 may be particularly at risk of altered disposition by concomitant use of cannabis or 1 or more of its constituents. Caution should also be given when coadministered drugs are metabolized by UGT or CES1, on which subject the information remains limited and further investigation is warranted. Conversely, conventional drugs with strong inhibitory or inductive effects on CYP3A4 are expected to affect CBD disposition.

Plant ash derived from fire plays an important role in nutrient balance and cycling in ecosystems. Factors that determine the composition and availability of ash nutrients include fire intensity (burn temperature and duration), plant species, habitat nutrient enrichment, and leaf type (live or dead leaf). We used laboratory simulation methods to evaluate temperature effects on nutrient composition and metals in the residual ash of sawgrass (Cladium jamaicense) and cattail (Typha domingensis), particularly on post-fire phosphorus (P) availability in plant ash. Live and dead leaf samples were collected from Water Conservation Area 2A in the northern Everglades along a soil P gradient, where prescribed fire may be used to accelerate recovery of this unique ecosystem. Significant decreases in total carbon and total nitrogen were detected with increasing fire temperature. Organic matter combustion was nearly complete at temperatures > or = 450 degrees C. HCl-extractable P (average, 50% of total P in the ash) and NH(4)Cl-extractable P (average, 33% of total P in the ash) were the predominant P fractions for laboratory-burned ash. Although a low-intensity fire could induce an elevation of P availability, an intense fire generally resulted in decreased water-soluble P. Significant differences in nutrient compositions were observed between species, habitat nutrient status, and leaf types. More labile inorganic P remained in sawgrass ash than in cattail ash; hence, sawgrass ash has a greater potential to release available P than cattail. Fire intensity affected plant ash nutrient composition, particularly P availability, and the effects varied with plant species and leaf type. Therefore, it is important to consider fire intensity and vegetation community when using a prescribed fire for ecosystem management.

The rapid increase of carbapenem resistance in Gram-negative bacteria has resurrected the importance of the polymyxin antibiotics. The recent discovery of plasmid-mediated polymyxin resistance (mcr-1) in carbapenem-resistant Enterobacteriaceae serves as an important indicator that the golden era of antibiotics is under serious threat. We assessed the bacterial killing of 15 different FDA-approved antibiotics alone and in combination with polymyxin B in time-killing experiments against Escherichia coli MCR1_NJ, the first reported isolate in the United States to coharbor mcr-1 and a New Delhi metallo-β-lactamase gene (blaNDM-5). The most promising regimens were advanced to the hollow-fiber infection model (HFIM), where human pharmacokinetics for polymyxin B, aztreonam, and amikacin were simulated over 240 h. Exposure to polymyxin B monotherapy was accompanied by MCR1_NJ regrowth but not resistance amplification (polymyxin B MIC from 0 to 240 h [MIC0h to MIC240h] of 4 mg/liter), whereas amikacin monotherapy caused regrowth and simultaneous resistance amplification (amikacin MIC0h of 4 mg/liter versus MIC240h of >64 mg/liter). No MCR1_NJ colonies were observed for any of the aztreonam-containing regimens after 72 h. However, HFIM cartridges for both aztreonam monotherapy and the polymyxin B-plus-aztreonam regimen were remarkably turbid, and the presence of long, filamentous MCR1_NJ cells was evident in scanning electron microscopy, suggestive of a nonreplicating persister (NRP) phenotype. In contrast, the 3-drug combination of polymyxin B, aztreonam, and amikacin provided complete eradication (>8-log10 CFU/ml reduction) with suppression of resistance and prevention of NRP formation. This is the first comprehensive pharmacokinetic/pharmacodynamic study to evaluate triple-drug combinations for polymyxin- and carbapenem-resistant E. coli coproducing MCR-1 and NDM-5 and will aid in the preparation for a so-called “postantibiotic” era.

The escalating use of medical cannabis and significant recreational use of cannabis in recent years has led to a higher potential for metabolic interactions between cannabis or one or more of its components and concurrently used medications. Although there have been a significant number of in vitro and in vivo assessments of the effects of cannabis on cytochrome P450 and UDP-glucuronosyltransferase enzyme systems, there is limited information regarding the effects of cannabis on the major hepatic esterase, carboxylesterase 1 (CES1). In this study, we investigated the in vitro inhibitory effects of the individual major cannabinoids and metabolites Δ9-tetrahydrocannabinol (THC), cannabidiol (CBD), cannabinol (CBN), 11-nor-THC-carboxylic acid, and 11-hydroxy-THC on CES1 activity. S9 fractions from human embryonic kidney 293 cells stably expressing CES1 were used in the assessment of cannabinoid inhibitory effects. THC, CBD, and CBN each exhibited substantial inhibitory potency, and were further studied to determine their mechanism of inhibition and kinetic parameters. The inhibition of CES1 by THC, CBD, and CBN was reversible and appears to proceed through a mixed competitivenoncompetitive mechanism. The inhibition constant (K i ) values for THC, CBD, and CBN inhibition were 0.541, 0.974, and 0.263 mM (0.170, 0.306, and 0.0817 mg/ml), respectively. Inhibition potency was increased when THC, CBD, and CBN were combined. Compared with the potential unbound plasma concentrations attainable clinically, the K i values suggest a potential for clinically significant inhibition of CES1 by THC and CBD. CBN, however, is expected to have a limited impact on CES1. Carefully designed clinical studies are warranted to establish the clinical significance of these in vitro findings.https://doi.org/10.1124/dmd.118.086074.ABBREVIATIONS: AUC, area under the plasma concentration-time curve; CBD, cannabidiol; CBN, cannabinol; CES1, carboxylesterase 1; DDI, drug-drug interaction; [I], inhibitor concentration; I max , maximal degree of inhibition; I max,u , maximal unbound plasma concentration of the inhibitor observed in clinical studies; K i , inhibition constant; LC-MS/MS, liquid chromatography tandem mass spectrometry; OC, oseltamivir carboxylate; 11-OH-THC, 11-hydroxy-Δ9-tetrahydrocannabinol; OST, oseltamivir phosphate; P450, cytochrome P450; R AUC , ratio of the area under plasma concentration-time curve of substrate with the presence of inhibitor over that without; R v , percentage ratio; THC, Δ9-tetrahydrocannabinol; THC-COOH, 11-nor-Δ9-tetrahydrocannabinol-carboxylic acid; UGT, UDP-glucuronosyltransferase.