What is the treatment for marijuana-induced liver failure?

Treatment of Marijuana-Induced Liver Failure

For marijuana-induced liver failure, the recommended treatment is immediate discontinuation of marijuana use, supportive care, and molecular adsorbent recirculation system (MARS) therapy while evaluating for liver transplantation. 1

Initial Management

1. Discontinue marijuana exposure immediately

   • Complete cessation of all cannabis products including CBD oil 2
   • For patients using CBD medically, doses should be kept below 300 mg/day if continuation is necessary 2

2. Supportive care measures

   • Fluid resuscitation with crystalloids as first choice 3
   • Norepinephrine for refractory hypotension 3
   • N-acetylcysteine therapy regardless of etiology (improves morbidity and mortality) 3
   • Maintain serum sodium between 140-145 mmol/L 3
   • Monitor blood glucose every 2 hours 3
   • Tracheal intubation for progressive hepatic encephalopathy (Glasgow <8) 3

3. Laboratory and diagnostic workup

   • Liver function tests including ALT, AST, ALP, GGT, bilirubin (total and direct) 3
   • Coagulation studies (PT/INR, Factor V) 3
   • Arterial blood gas and lactate level 3
   • Arterial ammonia 3
   • Abdominal Doppler ultrasound to exclude chronic liver disease and verify vessel permeability 3
   • Echocardiography to rule out cardiac causes 3

Specific Interventions

1. Molecular Adsorbent Recirculation System (MARS)

   • MARS therapy has been shown to be effective and safe in patients with fulminant hepatic failure following marijuana intoxication 1
   • Should be initiated early in the course of treatment

2. Management of complications

   • Hepatic encephalopathy: Frequent monitoring, minimize sedation depth, avoid benzodiazepines and psychotropic drugs 3
   • Renal failure: Renal replacement therapy according to specific recommendations 3
   • Coagulopathy: Restrict clotting factors administration unless active bleeding 3
   • Infection prevention: Empirical broad-spectrum antibiotics for worsening hepatic encephalopathy or signs of SIRS 3

3. Liver transplantation evaluation

   • Early contact with transplant unit 3
   • Patients should be placed on transplant list while other therapies are being administered 3
   • Note: History of marijuana use is no longer considered an absolute contraindication to liver transplantation in many centers 3

What to Avoid

1. Do not administer:

   • Benzodiazepines and psychotropic drugs (including metoclopramide) 3
   • Lactulose or rifaximin to lower ammonia levels 3
   • Nephrotoxic drugs, including NSAIDs 3

2. Do not routinely correct coagulation unless active bleeding is present 3

Monitoring and Follow-up

1. Liver function tests:

   • Initial monitoring 2-3 times per week 3
   • Continue monitoring until normalization even after drug discontinuation 2

2. Clinical monitoring:

   • Observe for signs of hepatic decompensation (ascites, encephalopathy) 3
   • Monitor for recovery or progression to guide further management decisions

Special Considerations

• Cannabinoids have shown both hepatoprotective and hepatotoxic effects in different contexts 4, 5
• CBD doses below 300 mg/day have not been reported to cause hepatotoxicity in adults 2
• Gamma-glutamyl transpeptidase (GGT) may be a sensitive marker for liver enzyme elevations in this context 2

This approach prioritizes the most effective interventions for marijuana-induced liver failure while addressing potential complications and providing a clear pathway to recovery or transplantation if needed.