What is Crohn’s disease?
Crohn’s disease is a long-term condition that results in inflammation of the gastrointestinal tract, occurring anywhere from the mouth to the anus. Common symptoms include fever, diarrhoea, abdominal pain and weight loss. Crohn’s disease is characterized by periods of relapse when people are actively experiencing symptoms and periods of remission when the symptoms stop.
What are Cannabis and Cannabinoids?
Cannabis is a widely used drug which acts on the endocannabinoid system. Cannabis contains multiple components called cannabinoids. The use of cannabis and cannabis oil containing specific cannabinoids produces mental and physical effects such as altered sensory perception and euphoria when consumed. Some cannabinoids, such as cannabidiol, do not have a psychoactive effect. Cannabis and cannabidiol have some anti-inflammatory properties that might help people with Crohn’s disease.
What did the researchers investigate?
The researchers studied whether cannabis is better than placebo (e.g. a sugar pill) therapy for treating adults with active Crohn’s disease or Crohn’s disease that is in remission.
What did the researchers find?
The researchers extensively searched the literature up to 17 October 2018 and found three studies (93 participants) that met the inclusion criteria. One ongoing study was also identified. All of the studies were small in size and had some quality issues. One small study (21 participants) compared eight weeks of treatment with cannabis cigarettes containing 115 mg of D9-tetrahydrocannabinol (THC) to placebo cigarettes containing cannabis with the THC removed in participants with active Crohn’s disease who had failed at least one medical treatment. Although no difference in clinical remission rates was observed, more participants in the cannabis group had improvement in their Crohn’s disease symptoms than participants in the placebo group. More side effects were observed in the cannabis cigarette group compared to placebo. These side effects were considered to be mild in nature and included sleepiness, nausea, difficulty with concentration, memory loss, confusion and dizziness. Participants in the cannabis cigarette group reported improvements in pain, appetite and satisfaction with treatment.
One small study (22 participants) compared cannabis oil (10 mg of cannabidiol twice daily) to placebo oil (i.e. olive oil) in participants with active Crohn’s disease who had failed at least one medical treatment. No difference in clinical remission rates was observed. There was no difference in serious side effects. Serious side effects included worsening Crohn’s disease in one participant in each group.
One small study (50 participants) compared cannabis oil (composed of 15% cannabidiol and 4% THC) to placebo oil in participants with active Crohn’s disease. Positive differences in quality of life and the Crohn’s disease activity index were observed.
The effects of cannabis and cannabis oil on Crohn’s disease are uncertain. No firm conclusions regarding the benefits and harms (e.g. side effects) of cannabis and cannabis oil in adults with Crohn’s disease can be drawn. The effects of cannabis and cannabis oil in people with Crohn’s disease in remission have not been investigated. Further studies with larger numbers of participants are required to assess the potential benefits and harms of cannabis in Crohn’s disease. Future studies should assess the effects of cannabis in people with active and inactive Crohn’s disease. Different doses of cannabis and formulations (e.g. cannabis oil or pills) should be investigated.
The effects of cannabis and cannabis oil on Crohn’s disease are uncertain. Thus no firm conclusions regarding the efficacy and safety of cannabis and cannabis oil in adults with active Crohn’s disease can be drawn. The effects of cannabis or cannabis oil in quiescent Crohn’s disease have not been investigated. Further studies with larger numbers of participants are required to assess the potential benefits and harms of cannabis in Crohn’s disease. Future studies should assess the effects of cannabis in people with active and quiescent Crohn’s disease. Different doses of cannabis and delivery modalities should be investigated.
Crohn’s disease (CD) is a chronic immune-mediated condition of transmural inflammation in the gastrointestinal tract, associated with significant morbidity and decreased quality of life. The endocannabinoid system provides a potential therapeutic target for cannabis and cannabinoids and animal models have shown benefit in decreasing inflammation. However, there is also evidence to suggest transient adverse events such as weakness, dizziness and diarrhea, and an increased risk of surgery in people with CD who use cannabis.
The objectives were to assess the efficacy and safety of cannabis and cannabinoids for induction and maintenance of remission in people with CD.
We searched MEDLINE, Embase, AMED, PsychINFO, the Cochrane IBD Group Specialized Register, CENTRAL, ClinicalTrials.Gov, and the European Clinical Trials Register up to 17 October 2018. We searched conference abstracts, references and we also contacted researchers in this field for upcoming publications.
Randomized controlled trials comparing any form of cannabis or its cannabinoid derivatives (natural or synthetic) to placebo or an active therapy for adults with Crohn’s disease 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. Remission is commonly defined as a Crohn’s disease activity index (CDAI) of 150. Secondary outcomes included clinical response, endoscopic remission, endoscopic improvement, histological improvement, quality of life, C-reactive protein (CRP) and fecal calprotectin measurements, adverse events (AEs), serious AEs, withdrawal due to AEs, and cannabis dependence and withdrawal effects. We calculated the risk ratio (RR) and corresponding 95% confidence interval (95% CI) for dichotomous outcomes. For continuous outcomes, we calculated the mean difference (MD) and 95% CI. Data were combined for analysis when the interventions, patient groups and outcomes were sufficiently similar (determined by consensus). Data were analyzed on an intention-to-treat basis and the overall certainty of the evidence supporting the outcomes was evaluated using the GRADE criteria.
Three studies (93 participants) that assessed cannabis in people with active CD met the inclusion criteria. One ongoing study was also identified. Participants in two of the studies were adults with active Crohn’s disease who had failed at least one medical treatment. The inclusion criteria for the third study were unclear. No studies that assessed cannabis therapy in quiescent CD were identified. The studies were not pooled due to differences in the interventional drug.
One small study (N = 21) compared eight weeks of treatment with cannabis cigarettes containing 115 mg of D9-tetrahydrocannabinol (THC) to placebo cigarettes containing cannabis with the THC removed in participants with active CD. This study was rated as high risk of bias for blinding and other bias (cannabis participants were older than placebo). The effects of cannabis on clinical remission were unclear. Forty-five per cent (5/11) of the cannabis group achieved clinical remission compared with 10% (1/10) of the placebo group (RR 4.55, 95% CI 0.63 to 32.56; very low certainty evidence). A difference was observed in clinical response (decrease in CDAI score of >100 points) rates. Ninety-one per cent (10/11) of the cannabis group achieved a clinical response compared to 40% (4/10) of the placebo group (RR 2.27, 95% CI 1.04 to 4.97; very low certainty evidence). More AEs were observed in the cannabis cigarette group compared to placebo (RR 4.09, 95% CI 1.15 to 14.57; very low certainty evidence). These AEs were considered to be mild in nature and included sleepiness, nausea, difficulty with concentration, memory loss, confusion and dizziness. This study did not report on serious AEs or withdrawal due to AEs.
One small study (N = 22) compared cannabis oil (5% cannabidiol) to placebo oil in people with active CD. This study was rated as high risk of bias for other bias (cannabis participants were more likely than placebo participants to be smokers). There was no difference in clinical remission rates. Forty per cent (4/10) of cannabis oil participants achieved remission at 8 weeks compared to 33% (3/9) of the placebo participants (RR 1.20, 95% CI 0.36 to 3.97; very low certainty evidence). There was no difference in the proportion of participants who had a serious adverse event. Ten per cent (1/10) of participants in the cannabis oil group had a serious adverse event compared to 11% (1/9) of placebo participants (RR 0.90, 95% CI 0.07 to 12.38, very low certainty evidence). Both serious AEs were worsening Crohn’s disease that required rescue intervention. This study did not report on clinical response, CRP, quality of life or withdrawal due to AEs.
One small study (N= 50) compared cannabis oil (15% cannabidiol and 4% THC) to placebo in participants with active CD. This study was rated as low risk of bias. Differences in CDAI and quality of life scores measured by the SF-36 instrument were observed. The mean quality of life score after 8 weeks of treatment was 96.3 in the cannabis oil group compared to 79.9 in the placebo group (MD 16.40, 95% CI 5.72 to 27.08, low certainty evidence). After 8 weeks of treatment, the mean CDAI score was118.6 in the cannabis oil group compared to 212.6 in the placebo group (MD -94.00, 95%CI -148.86 to -39.14, low certainty evidence). This study did not report on clinical remission, clinical response, CRP or AEs.
Cochrane What is Crohn’s disease? Crohn’s disease is a long-term condition that results in inflammation of the gastrointestinal tract, occurring anywhere from the mouth to the anus. Common
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.