Bad weed: synthetic cannabinoid–associated coagulopathy

Abstract

Recent multistate outbreaks of coagulopathy caused by brodifacoum-tainted synthetic cannabinoids or “fake weed” highlight the public health impact of long-acting anticoagulant rodenticides (LAARs). Patients presenting with this syndrome have had recent exposure to synthetic cannabinoids, evidence of isolated vitamin K antagonism with or without bleeding, and detectable levels of brodifacoum and other LAARs in circulation. This article will provide information on synthetic cannabinoids, LAARs, and coagulopathic manifestations arising from use of adulterated synthetic cannabinoids and their management.

Four cases of death involving the novel synthetic cannabinoid 5F-Cumyl-PEGACLONE

“…Recently, a painless macro-hematuria with altered coagulation was described in association with SC use, though no anticoagulant poisoning panel was performed [47]. Additionally, there were reports about products containing SCs allegedly laced with potent anticoagulant coumarin derivatives like brodifacoum and difenacoum [48,49]. In our case, to verify if the kidney bleedings could have been caused by such contaminants, the analysis of coumarin derivatives including super-warfarintype drugs was performed, but was found negative.…”

Superwarfarin (Long-Acting Anti-coagulant Rodenticides) Poisoning: from Pathophysiology to Laboratory-Guided Clinical Management

“…3,9,71 A major outbreak of synthetic cannabinoidassociated coagulopathy occurred in Illinois, US in 2018, with a total of over 300 persons being affected and a total of 7 deaths between March and October 2018. 9,13,16 In the case series by Kelkar et al, brodifacoum was identified as the culprit and was detected in all patients tested, whereas difenacoum, bromadiolone, and warfarin were additionally detected among the patients. 16 Limited experimental data suggests that there is no pharmacodynamics interaction between brodifacoum and synthetic cannabinoids, though pharmacokinetic interactions have not been ruled out.…”

“…[7][8][9][10] The significant morbidity and mortality from superwarfarin can be contrasted with the highly treatable nature of superwarfarin poisoning with factor replacement and vitamin K therapy, available in most parts of the world. 2,4,6,[11][12][13] The diagnosis of superwarfarin poisoning in patients without a clear history of exposure is difficult. Examples include victims of homicide attempts, 14,15 the unfortunate users of brodifacoum-laced synthetic cannabinoids in the recent Illinois outbreak, 9,16 and a substantial number of patients exposed to superwarfarins of yet uncertain origin in China and Hong Kong.…”

“…14,17,18 While detection of superwarfarins in serum confirms the poisoning, this service is not widely available in most parts of the world. 7,13,16 The aim of the present mini-review is therefore to raise the awareness of superwarfarin poisoning among clinicians, clinical biochemists and chemical pathologists, such that this highly treatable condition with significant potential for morbidity and mortality does not remain undiagnosed.…”

Adding more “spice” to the pot: A review of the chemistry and pharmacology of newly emerging heterocyclic synthetic cannabinoid receptor agonists

“…Importantly, the aforementioned adverse effects associated with SCRA use are not typically observed following cannabis consumption . Cases of coagulopathies following SCRA consumption in the United States have recently been linked to the presence of a potent vitamin K antagonist (brodifacoum [ 9 ]) in certain batches of SCRA‐containing products . At present, it remains unclear if this presence of 9 in certain batches of SCRA‐containing products is deliberate or accidental.…”