What is ulcerative colitis?
Ulcerative colitis is a chronic, long-term illness that causes inflammation of the colon and rectum. Symptoms may include diarrhea, rectal bleeding, passage of mucus, and abdominal pain. It is characterized by periods of acute flares when people experience symptoms as well as periods of remission when symptoms stop.
What are cannabis and cannabinoids?
Cannabis is a widely used recreational drug that has multiple effects on the body via the endocannabinoid system. Cannabis contains multiple sub-ingredients called cannabinoids. Cannabis and cannabis oil containing specific cannabinoids can cause cognitive changes such as feelings of euphoria and altered sensory perception. However, some cannabinoids, such as cannabidiol, do not have a psychoactive effect. Cannabis and some cannabinoids have been shown to decrease inflammation in animal and laboratory models which suggests it may help people with ulcerative colitis. For example, cannabidiol is one such cannabinoid that has shown anti-inflammatory activity in mice.
What did the researchers investigate?
The researchers evaluated whether cannabis or cannabis oil (cannabidiol) was better than placebo (e.g. fake drug) for treating adults with active ulcerative colitis or ulcerative colitis that is in remission. The researchers searched the medical literature extensively up to 2 January 2018.
What did the researchers find?
Two studies including 92 adult participants with ulcerative colitis were included. Both studies assessed cannabis therapy in participants who had active ulcerative colitis. No studies that assessed cannabis therapy in participants with ulcerative colitis in remission were identified. One study (60 participants) compared 10 weeks of treatment with capsules containing cannabis oil with up to 4.7% D9-tetrahydrocannabinol (THC) to placebo in participants with mild to moderately active ulcerative colitis. The starting dose of cannabidiol was 50 mg twice daily which was increased, if tolerated, to a target of 250 mg twice daily. The other study (32 participants) compared 8 weeks of treatment with two cannabis cigarettes per day containing 0.5 g of cannabis, corresponding to 11.5 mg THC to placebo cigarettes in participants with ulcerative colitis who did not respond to conventional medical treatment.
The study comparing cannabis oil capsules to placebo found no difference in remission rates at 10 weeks. Twenty four (7/29) percent of cannabidiol participants achieved clinical remission compared to 26% (8/31) of placebo participants. The study also showed higher self reported quality of life scores in cannabis oil participants compared to placebo participants. More side-effects were observed in the cannabis oil participants compared to the placebo participants. These side effects were considered to be mild or moderate in severity. Common reported side effects include dizziness, disturbance in attention, headache, nausea and fatigue. No patients in the cannabis oil group had any serious side effects. Ten per cent (3/31) of the placebo group had a serious side effect. Serious side effects in the placebo group included worsening ulcerative colitis and one complicated pregnancy.
The second study comparing two cannabis cigarettes (23 mg THC/day) to placebo cigarettes showed lower disease activity index scores in the cannabis group compared to the placebo group. C-reactive protein and fecal calprotectin levels (both measures of inflammation in the body) were similar in both groups. No serious side effects were reported. This study did not report on remission rates.
The effects of cannabis and cannabis oil on ulcerative colitis are uncertain, thus no firm conclusions regarding the effectiveness and safety of cannabis or cannabis oil in adults with active ulcerative colitis can be drawn. There is no evidence for cannabis or cannabis oil use for maintenance of remission in ulcerative colitis. Further studies with a larger number of participants are required to assess the effects of cannabis in people with active and inactive ulcerative colitis. Different doses of cannabis and routes of administration should be investigated. Lastly, follow-up is needed to assess the long term safety outcomes of frequent cannabis use.
The effects of cannabis and cannabidiol on UC are uncertain, thus no firm conclusions regarding the efficacy and safety of cannabis or cannabidiol in adults with active UC can be drawn.There is no evidence for cannabis or cannabinoid use for maintenance of remission in UC. Further studies with a larger number of patients are required to assess the effects of cannabis in UC patients with active and quiescent disease. Different doses of cannabis and routes of administration should be investigated. Lastly, follow-up is needed to assess the long term safety outcomes of frequent cannabis use.
Cannabis and cannabinoids are often promoted as treatment for many illnesses and are widely used among patients with ulcerative colitis (UC). Few studies have evaluated the use of these agents in UC. Further, cannabis has potential for adverse events and the long-term consequences of cannabis and cannabinoid use in UC are unknown.
To assess the efficacy and safety of cannabis and cannabinoids for the treatment of patients with UC.
We searched MEDLINE, Embase, WHO ICTRP, AMED, PsychINFO, the Cochrane IBD Group Specialized Register, CENTRAL, ClinicalTrials.Gov and the European Clinical Trials Register from inception to 2 January 2018. Conference abstracts and references were searched to identify additional studies.
Randomized controlled trials (RCTs) comparing any form or dose of cannabis or its cannabinoid derivatives (natural or synthetic) to placebo or an active therapy for adults (> 18 years) with UC were included.
Two authors independently screened search results, extracted data and assessed bias using the Cochrane risk of bias tool. The primary outcomes were clinical remission and relapse (as defined by the primary studies). Secondary outcomes included clinical response, endoscopic remission, endoscopic response, histological response, quality of life, C-reactive protein (CRP) and fecal calprotectin measurements, symptom improvement, adverse events, serious adverse events, withdrawal due to adverse events, psychotropic adverse events, and cannabis dependence and withdrawal effects. We calculated the risk ratio (RR) and corresponding 95% confidence interval for dichotomous outcomes. For continuous outcomes, we calculated the mean difference (MD) and corresponding 95% CI. Data were pooled for analysis when the interventions, patient groups and outcomes were sufficiently similar (determined by consensus). Data were analyzed on an intention-to-treat basis. GRADE was used to evaluate the overall certainty of evidence.
Two RCTs (92 participants) met the inclusion criteria. One study (N = 60) compared 10 weeks of cannabidiol capsules with up to 4.7% D9-tetrahydrocannabinol (THC) with placebo capsules in participants with mild to moderate UC. The starting dose of cannabidiol was 50 mg twice daily increasing to 250 mg twice daily if tolerated. Another study (N = 32) compared 8 weeks of therapy with two cannabis cigarettes per day containing 0.5 g of cannabis, corresponding to 23 mg THC/day to placebo cigarettes in participants with UC who did not respond to conventional medical treatment. No studies were identified that assessed cannabis therapy in quiescent UC. The first study was rated as low risk of bias and the second study (published as an abstract) was rated as high risk of bias for blinding of participants and personnel. The studies were not pooled due to differences in the interventional drug.
The effect of cannabidiol capsules (100 mg to 500 mg daily) compared to placebo on clinical remission and response is uncertain. Clinical remission at 10 weeks was achieved by 24% (7/29) of the cannabidiol group compared to 26% (8/31) in the placebo group (RR 0.94, 95% CI 0.39 to 2.25; low certainty evidence). Clinical response at 10 weeks was achieved in 31% (9/29) of cannabidiol participants compared to 22% (7/31) of placebo patients (RR 1.37, 95% CI 0.59 to 3.21; low certainty evidence). Serum CRP levels were similar in both groups after 10 weeks of therapy. The mean CRP in the cannabidiol group was 9.428 mg/L compared to 7.638 mg/L in the placebo group (MD 1.79, 95% CI -5.67 to 9.25; moderate certainty evidence). There may be a clinically meaningful improvement in quality of life at 10 weeks, measured with the IBDQ scale (MD 17.4, 95% CI -3.45 to 38.25; moderate certainty evidence). Adverse events were more frequent in cannabidiol participants compared to placebo. One hundred per cent (29/29) of cannabidiol participants had an adverse event, compared to 77% (24/31) of placebo participants (RR 1.28, 95% CI 1.05 to1.56; moderate certainty evidence). However, these adverse events were considered to be mild or moderate in severity. Common adverse events included dizziness, disturbance in attention, headache, nausea and fatigue. None (0/29) of the cannabidiol participants had a serious adverse event compared to 10% (3/31) of placebo participants (RR 0.15, 95% CI 0.01 to 2.83; low certainty evidence). Serious adverse events in the placebo group included worsening of UC and one complicated pregnancy. These serious adverse events were thought to be unrelated to the study drug. More participants in the cannabidiol group withdrew due to an adverse event than placebo participants. Thirty-four per cent (10/29) of cannabidiol participants withdrew due to an adverse event compared to 16% (5/31) of placebo participants (RR 2.14, 95% CI 0.83 to 5.51; low certainty evidence). Withdrawls in the cannabidiol group were mostly due to dizziness. Withdrawals in the placebo group were due to worsening UC.
The effect of cannabis cigarettes (23 mg THC/day) compared to placebo on mean disease activity, CRP levels and mean fecal calprotectin levels is uncertain. After 8 weeks, the mean disease activity index score in cannabis participants was 4 compared with 8 in placebo participants (MD -4.00, 95% CI -5.98 to -2.02). After 8 weeks, the mean change in CRP levels was similar in both groups (MD -0.30, 95% CI -1.35 to 0.75; low certainty evidence). The mean fecal calprotectin level in cannabis participants was 115 mg/dl compared to 229 mg/dl in placebo participants (MD -114.00, 95% CI -246.01 to 18.01). No serious adverse events were observed. This study did not report on clinical remission, clinical response, quality of life, adverse events or withdrawal due to adverse events.
Cochrane What is ulcerative colitis? Ulcerative colitis is a chronic, long-term illness that causes inflammation of the colon and rectum. Symptoms may include diarrhea, rectal bleeding,
Can CBD Oil Help Inflammatory Bowel Disease (IBD)?
The Science: Can Cannabis and CBD Oil Treat Inflammatory Bowel Disease?
If you have inflammatory bowel disease, there’s a good chance you’ve considered using cannabis products or CBD oil to help manage your IBD – surveys from the last few years show that between 10-20% of people with Crohn’s Disease and Ulcerative Colitis use cannabis products to help manage their IBD symptoms . And now that both medical marijuana and legal, non-intoxicating cannabidiol (CBD) are becoming more widely accepted across the United States, those numbers are probably rising.
But if you suffer from IBD, every inflammatory flare-up could bring you one step closer to surgery – meaning it’s a good idea to do your research before making any changes to your routines. There are many studies underway on cannabis and hemp extracts for Crohn’s and ulcerative colitis, but what have scientists learned? Should you be using cannabidiol (CBD) alone or in combination with THC? Is it actually effective? And are there any risks involved?
If you’re already using cannabinoids (like THC and CBD) to manage inflammatory bowel disease – or if you’re merely flirting with the idea – there’s a bewildering amount of information to keep straight. We’ll explain the current research along with what it means for:
- Symptoms Management and Quality of Life
- Inflammation and Endoscopic Remission
- Future Outlook and Flare-Ups
Some Background First
If you suffer from IBD, it can feel extremely isolating… but you actually belong to an enormous and growing community of people who share your pain. The rise of inflammatory bowel disease over the last few decades is shocking — the diagnosis is rising on every continent while skyrocketing in developing countries. And for more than 1 in 100 American adults , this IBD diagnosis comes with high medical bills, a high likelihood of serious surgery, and an increased risk of mortality.
The hallmark trait of IBD — inflammation within the digestive tract — causes pain and suffering that is mostly invisible to the people around you. And one of the most frustrating things about IBD is that there’s no clear reason why you have it — or why it keeps flaring back up. Everything from your DNA to your diet, and from your daily habits to how you were raised, could have contributed to your current prognosis.
Whatever combination of genetics and environmental factors combined to trigger Crohn’s or ulcerative colitis, the end result is chronic gut inflammation that damages and weakens your digestive tract over time. Unfortunately, that damage comes with worsening symptoms, increased pain, and even increased risk of other diseases like colon cancer.
Hidden Roots = Difficult to Weed Out
Scientists struggle to develop safe and effective treatments for illnesses that can’t be traced to a clear root cause. If you’ve been diagnosed with Crohn’s or ulcerative colitis, you’re probably already aware that IBD is a chronic illness with no cure. The treatments offered by doctors — including aminosalicylates, corticosteroids, and risky surgical procedures — will at best merely hold the IBD in check. And they often come with a long list of serious side effects.
This is why so many people are seeking holistic approaches to deal with their recurrent illness – through diet and other lifestyle changes – and incorporating cannabinoids (like CBD and THC) into their treatment routine.
Many Levels of IBD Treatment
Although IBD symptoms are usually the first sign you’re experiencing a flare-up, they are just the end result of a long chain of events occurring within your body. And for the best possible outcome, you — along with the help of a medical professional — will want to treat IBD as far back along this chain as possible.
To begin with, if you are currently suffering, it’s important to relieve any symptoms that interfere with your life. Meanwhile, you should use every resource available to combat inflammation and achieve remission. And finally, even when your IBD is in remission, you need to stay vigilant by continuing an anti-inflammatory routine while tracking and avoiding triggers.
So where do cannabinoids fit in?
Cannabinoids to Treat IBD Symptoms — Some evidence
The prestigious National Academies of Sciences, Engineering and Medicine recently rated pain management as one of the most scientifically supported uses of cannabis. Many IBD patients agree with this conclusion: A large majority of surveyed IBD patients who use cannabis report that it helps relieve abdominal pain and cramps , while others find it helpful for combating nausea and diarrhea .
Cannabis study results (combo of THC, CBD and other cannabinoids): Surveys can be biased — in this case, we only learn about the experience of IBD patients who are already using cannabis for their symptoms. However, a number of studies have followed IBD patients who are newly prescribed cannabis as part of their treatment routine. A small study that compared inhaled cannabis to a placebo for 8 weeks found that 90% of cannabis users’ symptoms improved while only 40% of the controls saw an improvement.
One thing to keep in mind, though, is that although there’s good evidence that cannabis can help improve IBD symptoms, it might not help with the underlying inflammation. Here’s why.
CBD study results: To date, most of this research has been on cannabis products containing a combination of THC, CBD, and a full spectrum of other cannabinoids. However, THC is not legal in all states, and also comes with a notorious side effect – getting high – that not everyone enjoys. For these reasons, hemp-extract CBD products are being explored as an alternative to cannabis for treating IBD symptoms.
Pre-clinical evidence suggests that CBD provides pain relief by desensitizing TRPV1 channels on pain-perceiving nerves . And in addition to pain relief, CBD can improve “intestinal hypermotility” — aka diarrhea — when tested in rodents with inflamed guts. However, there have been few human clinical trials to date. One, which used a low oral dose (10mg daily) of purified CBD on Crohn’s Disease, reported that a low dose of CBD isolate was safe but ineffective at relieving Crohn’s symptoms. On the other hand, when scientists tested a higher dose (100-500mg daily) of full-spectrum CBD for Ulcerative Colitis, they reported a higher quality of life — although it did not impact remission.
An important distinction: Isolate vs full-spectrum : Why would these two CBD studies have different results? The most obvious answer is that 10mg may have been too low of a dose. However, another important distinction between these two studies is that the first study used CBD isolate — a single, purified molecule — which may be less effective than broad-spectrum extracts.
Indeed, full-spectrum hemp extracts contain a wide variety of beneficial molecules other than CBD, called the “ entourage ,” and studies typically have better results when the whole entourage is used together instead of CBD isolate. And for individuals struggling with colitis, the entourage molecule cannabigerol (CBG) might be even more effective than either THC or CBD. When purchasing CBD products, choose full-spectrum or broad-spectrum hemp extracts for full entourage benefits.
Cannabinoids for IBD Remission — Some preclinical but no clinical evidence
If you have IBD, always be aware that your physical symptoms might improve despite high levels of gut inflammation. To date, most human studies suggest that cannabinoids relieve IBD symptoms, but not intestinal inflammation . However, scientists are still actively investigating this topic.
A clue that cannabinoids could one day be used to fight intestinal inflammation comes from the current usefulness of medications (anti-TNFα drugs) that fight a notorious inflammatory molecule, Tumor Necrosis Factor. In preclinical studies using rodents and human biopsies, CBD combated gut inflammation by decreasing TNFα levels, as well as by turning on and off genes controlled by PPARγ .
Recently, a review of over 50 rodent studies concluded that two out of three studies found a positive effect of cannabinoids on colitis . In these experiments, scientists reported better results the earlier the cannabinoids were taken during an inflammatory episode.
However, until there’s clinical evidence that cannabinoids can improve intestinal inflammation, it’s safest to continue taking your prescription drugs to prevent progression of the disease. If you suffer from IBD and find major relief from cannabis or CBD oil, do not stop your meds without proper testing and approval from a medical professional.
Cannabinoids and IBD Flare-up Prevention — Unknown
Even in remission, low baseline levels of inflammation could escalate at the slightest trigger. In addition to prescription medications, the Mayo Clinic suggests stress-management and dietary changes as good practices to manage flare-ups, and even lists anti-inflammatory supplements like fish oil and turmeric as suitable complementary approaches.
CBD and THC are widely considered anti-inflammatory supplements, and CBD may have a role in managing some forms of anxiety . However, there is no current evidence that CBD or THC helps maintain remission for IBD.
Downsides and risks of cannabinoids for IBD:
THC’s cognitive effects – Most of the research to date has been with cannabis and cannabis extracts — which contain psychoactive THC in addition to a wide variety of other molecules. But for many people, being stoned all day is not a good option. If this describes you, choose high quality CBD products from reliable companies that use full-spectrum hemp extracts — that way you can stay sober while benefiting from the “ entourage effect. ”
Assuming you’re better because you feel better – Although research suggests that cannabis and CBD oil could help relieve IBD symptoms, there is no clinical evidence yet that they also stop intestinal inflammation. Nonetheless, many people use cannabis to decrease their dependence on prescription drugs. If you’re taking cannabinoids and feel great, do not take that as evidence that you can stop taking prescription medications without first consulting a medical professional.
Prescription drug interactions – Similar to grapefruits, CBD interferes with enzymes (cytochrome p450) that your body uses to metabolize certain pharmaceutical drugs. If you currently take prescription drugs — particularly any that come with a warning not to consume with grapefruits (ie warfarin, anti-epileptics, HIV antivirals, and chemotherapy) — we suggest speaking with a medical professional before incorporating CBD into your wellness routine.
Uncertainty if it should be considered an NSAID – CBD likely fights inflammation in multiple ways — and one of those ways is through inhibiting COX-2, an enzyme that produces inflammatory prostaglandins. Unfortunately, long-term NSAIDs (which also inhibit prostaglandins) are generally contraindicated for IBD because they can contribute to gastric ulcers.
Fortunately, s tudies indicate that cannabinoids are more likely to protect against aspirin-induced ulcers (through the endocannabinoid system ) than they are to create them, and data suggests that COX-2-selective drugs like CBD are safer compared to traditional NSAIDs because they don’t affect COX-1 digestive enzymes.
Consider different routes of application
There are many ways to take cannabis and CBD oil; orally, inhaled, rectally… and each route can affect how much enters your body and where the molecules go. If you’re unfamiliar with the many types of products available, see our quick guide on routes and dosage .
For most of the studies we’ve discussed, patients either inhaled or ingested the cannabinoids. However, rodent studies have also tested the effects of injections and rectal suppositories.
One study which compared these different routes found that an oral treatment of CBD was ineffective, while an equivalent or lower rectal or injected dose actually improved colitis. There are no current human studies which suggest one route over another for IBD, but if you’re considering self-experimentation, you should be familiar with your options, and be open to trying suppositories.
Should you use CBD oil to supplement your IBD treatment?
As you know, achieving and maintaining remission is vital to your health and happiness. Ultimately, we don’t have enough evidence to say for sure whether or not cannabis or CBD oil will work for you. The standard recommendation is that cannabinoids might be a good choice for improving your symptoms and wellbeing when standard therapies fall short.
When taking cannabidiol or medical cannabis for IBD, consider it a supplement, not a replacement for your current treatment. Always discuss your decision with a trusted medical professional. And when choosing a product, be wary of bold claims and brands without a solid reputation – unfortunately, since it’s still largely unregulated, this industry is rife with fraudulent products and misinformation.
If you use or have previously used cannabinoids to treat your IBD symptoms, we’d love to hear about your experience. Email [email protected] to share your story.
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Hemp and cannabis products, and CBD oil, are popular supplements for people suffering from IBD. But are they effective? Are there any risks involved? Read on to learn about the current research and what it means for people suffering from Crohn’s disease, ulcerative colitis, and other inflammatory bowel diseases.