Paradoxical Patterns of Sinusoidal Obstruction Syndrome-Like Liver Injury in Aged Female CD-1 Mice Triggered by Cannabidiol-Rich Cannabis Extract and Acetaminophen Co-Administration

Laura E Ewing, Mitchell R McGill, Eric U Yee, Charles M Quick, Charles M Skinner, Stefanie Kennon-McGill, Melissa Clemens, Joel H Vazquez, Sandra S McCullough, D Keith Williams, Kristy R Kutanzi, Larry A Walker, Mahmoud A ElSohly, Laura P James, Bill J Gurley, Igor Koturbash, Laura E Ewing, Mitchell R McGill, Eric U Yee, Charles M Quick, Charles M Skinner, Stefanie Kennon-McGill, Melissa Clemens, Joel H Vazquez, Sandra S McCullough, D Keith Williams, Kristy R Kutanzi, Larry A Walker, Mahmoud A ElSohly, Laura P James, Bill J Gurley, Igor Koturbash

Abstract

The goal of this study was to investigate the potential for a cannabidiol-rich cannabis extract (CRCE) to interact with the most common over-the-counter drug and the major known cause of drug-induced liver injury-acetaminophen (APAP)-in aged female CD-1 mice. Gavaging mice with 116 mg/kg of cannabidiol (CBD) [mouse equivalent dose (MED) of 10 mg/kg of CBD] in CRCE delivered with sesame oil for three consecutive days followed by intraperitoneally (i.p.) acetaminophen (APAP) administration (400 mg/kg) on day 4 resulted in overt toxicity with 37.5% mortality. No mortality was observed in mice treated with 290 mg/kg of CBD+APAP (MED of 25 mg/kg of CBD) or APAP alone. Following CRCE/APAP co-administration, microscopic examination revealed a sinusoidal obstruction syndrome-like liver injury-the severity of which correlated with the degree of alterations in physiological and clinical biochemistry end points. Mechanistically, glutathione depletion and oxidative stress were observed between the APAP-only and co-administration groups, but co-administration resulted in much greater activation of c-Jun N-terminal kinase (JNK). Strikingly, these effects were not observed in mice gavaged with 290 mg/kg CBD in CRCE followed by APAP administration. These findings highlight the potential for CBD/drug interactions, and reveal an interesting paradoxical effect of CBD/APAP-induced hepatotoxicity.

Keywords: acetaminophen; cannabidiol; liver injury; natural products; phytochemical; sinusoidal obstruction syndrome.

Conflict of interest statement

Quick serves as a scientific consultant for Allergan. James is a co-owner of Acetaminophen Toxicity Diagnostics, LLC. No conflicts of interest are declared by the other authors.

Figures

Figure 1
Figure 1
Co-administration of cannabidiol-rich cannabis extract (CRCE) and APAP results in sinusoid obstructive syndrome-like histomorphological alterations in the livers of aged female CD-1 mice. H&E stained liver sections from (A) vehicle-gavaged mice (sesame oil), (B) 116 mg/kg CBD, (C) 290 mg/kg CBD, (D) APAP (400 mg/kg), (E) 116 mg/kg CBD+APAP, (F) 290 mg/kg CBD+APAP. Black brackets indicate areas of clear cell changes (D), yellow brackets (E) and arrows (F) indicate areas of sinusoidal dilation with vascular congestion, and blue arrows (E) indicate areas of hepatic plate atrophy. CRCE—cannabidiol-rich cannabis extract; APAP—acetaminophen. Magnification: X10.
Figure 2
Figure 2
Effects of CRCE/APAP co-administration on commonly assessed clinical chemistry parameters for liver injury. Blood was collected at the time of sacrifice, and the serum was subsequently separated and removed for analysis. Veh (n = 7); Veh + APAP (n = 7); 116 mg/kg CBD (n = 7); 116 mg/kg CBD+APAP (n = 5); 290 mg/kg CBD (n = 7); 290 mg/kg CBD + APAP (n = 6). Data are presented as mean ± SEM (* p < 0.05). ALT: alanine aminotransferase; AST: aspartate aminotransferase; ALP: alkaline phosphatase; GGT: gamma-glutamyl transferase.
Figure 3
Figure 3
Effects of CRCE/APAP co-administration on intrahepatic expression of cytochrome P450s and UDP-glucuronosyltransferases. Livers were collected 5 h after APAP administration and gene expression was measured using the quantitative real-time (qRT) PCR. Veh (n = 7); Veh + APAP (n = 7); 116 mg/kg CBD (n = 7); 116 mg/kg CBD + APAP (n = 7); 290 mg/kg CBD (n = 8); 290 mg/kg CBD + APAP (n = 8). Data presented as mean ± SEM fold changed from vehicle (* p < 0.05; ** p < 0.01; *** p < 0.001; and **** p < 0.0001). The following genes were changed significantly with either CBD or APAP, but the two-way ANOVA did not yield any significant comparisons: Cyp2d22 (APAP, p = 0.0016), Ugt1a1 (CBD, p = 0.0186; APAP, p = 0.0255), Ugt1a6 (CBD, p = 0.0222), and Ugt1a9 (APAP, p = 0.0026).
Figure 4
Figure 4
Mechanisms of CRCE/APAP-induced liver injury. (A) APAP-Cys protein adducts; levels of (B) GSH, and (C) GSSG/GSH; (D) mRNA levels of Gclm as measured by quantitative real-time (qRT) PCR; E) protein levels of Jnk and pJNK as measured by Western blot; and F) representative blot. Veh (n = 7); Veh + APAP (n = 7); 116 mg/kg CBD (n = 7); 116 mg/kg CBD + APAP (n = 7); 290 mg/kg CBD (n = 8); 290 mg/kg CBD + APAP (n = 8). Data presented as mean ± SEM fold changed from vehicle (* p < 0.05; ** p < 0.01; and **** p < 0.0001). GSSG levels were significantly affected by APAP (p = 0.0151), but there are no significant comparisons.

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