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Rheumatoid Arthritis

By Mariano Garcia de Palau

Born in Barcelona, 17 February 1956. Graduated in medicine and surgery from the University of Barcelona in 1979. For 38 years has worked as an emergency physician in the area of occupational medicine. He became interested in cannabis by chance, and for the last 15 years has studied its therapeutic uses. He currently works at Kalapa Clinic, where he advises on treatments with cannabinoids, performs clinical work with patients and collaborates with different organisations and associations such as Catfac. He is a member of the Spanish Observatory for Medicinal Cannabis. He is a regular member of IACM.

Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disease. It is characterised by affecting multiple joints simultaneously and by the presentation of diverse general non-specific symptoms and manifestations in other parts of the body. Without proper treatment, in its advanced phases, the disease can result in major physical limitations and a marked deterioration in quality of life.

RA is typically manifested through pain, swelling and stiffness or difficulty in moving different large and small joints. In some cases, the joints affected follow a characteristic pattern. The general symptoms, which sometimes precede manifestations of the disease in the joints and tend to persist throughout its development, basically include general tiredness, malaise, slight fever, loss of appetite and loss of weight. Extra-articular manifestations —which normally occur after the disease is fully established— mainly affect the skin, blood vessels, heart, lungs, eyes and blood.

RA is much more frequent among women than men and tends to appear in elderly patients, although it can begin at any stage of life and can affect anyone, regardless of race, sex or occupation.

The most frequent initial symptom is morning stiffness (especially in the joints of the hands and feet), experienced after night-time rest. This entails considerable difficulty in moving the joints accompanied by pain. Morning stiffness may be accompanied by tiredness, fever, loss of appetite and muscle weakness (which sometimes appear weeks or months before the pain) as well as indications of inflammation of the joints — swelling, warmth and redness of the affected joints.

The course of the disease varies greatly; in some people, advance of the lesions stops spontaneously, whereas in others it continues throughout their lives. In the most common scenario, the disorder develops over many years or throughout the patient’s entire life, alternating between periods of relative or complete calm and other periods –known as “flare-ups”– when symptoms are exacerbated. Flare-ups normally last a few weeks or even months.

During flare-ups, the joints affected become swollen and hot and are painful and difficult to move, especially on waking in the morning. Without proper treatment, these flare-ups tend to become more frequent and longer-lasting. As a result, the affected joints gradually lose mobility, with the appearance of very characteristic deformities which distinguish RA from other forms of arthritis. Without treatment, RA usually results in a significant deterioration in functionality and quality of life.

Treatment for RA consists of a series of general measures related to lifestyle, rest and exercise, combined with pharmacological therapy, in which a wide range of drugs may be used; in some cases, surgical intervention may be recommended. Unfortunately, there is still no cure for the disease. However, taken together, all the therapeutic measures currently available can alleviate the symptoms and improve the prognosis, with a very positive impact on the patient’s quality of life.

The best therapeutic results are achieved with early diagnosis and when treatment is established in the initial phases of the disease.

Autoimmune diseases constitute a major group of illnesses. For reasons that are not fully understood, the immune system, responsible for defending the body erroneously identifies certain tissues as being foreign and reacts against them as if they posed a threat.

Cannabinoids and rheumatoid arthritis

Cannabinoids such as THC and CBD can be useful for treating rheumatoid arthritis. RA is an autoimmune disease and we know that cannabinoids act by modulating the activity of the immune system. When the immune system over-reacts and its activity increases, autoimmune diseases may occur. The immune system erroneously identifies normal structures and tissues in the body as being foreign and rejects them. This is what happens after a transplant, and it is why immunosuppressant drugs are administered to prevent the tissue or organ from being attacked and destroyed by the patient’s own immune system.

Cannabinoids modulate the activity of the immune system. We know that the endocannabinoid system regulates activity of the immune system, and in autoimmune diseases, they have an immunosuppressive effect, reducing the activity of the system, and thus contributing to improvement in such pathologies.

Although cannabinoids are immunosuppressive, there is no evidence that already immunodepressed subjects (e.g. patients with HIV) suffer more opportunistic infections as a result of consuming cannabis. Indeed, cannabis is commonly used among HIV patients to alleviate symptoms, increase appetite and improve general quality of life.

Cannabinoids also have an analgesic effect which is mainly attributed to THC, but can be implemented by using different ratios of THC/CBD. By managing the relative proportions, it is possible to minimise the psychoactive effect of THC without reducing its analgesic effect.

In this way, the patient’s activity will not be limited by psychoactive effects (which many find unpleasant). In RA, the analgesic effect is very important, since the essential problem is inflammation, which causes varying degrees of pain, moderate or severe in some cases.

When working with RA patients, it is also important to treat the inflammation with the fewest possible side effects. We know that corticoids can be effective in acute phases of the disease. Nonsteroidal anti-inflammatory drugs, or NSAIDs (aspirin, ibuprofen, diclofenac, indometacin, etc.) can also be used. However, nearly all these drugs are gastrolesive and in the medium term can result in metabolic overload in the liver. In addition, they inhibit the action of THC when administered with it.

Lifetime treatment with corticoids or NSAIDs should therefore not be considered, given their side effects.

In analgesic doses, cannabinoids have never posed a metabolic problem in the liver, which is where they too are metabolised. Similarly, no problem of renal excretion or toxicity has ever been detected with such treatments.

Patients suffering chronic pain may also suffer sleep alteration. In the case of RA, nocturnal pain may also prevent proper rest and the structuring of the different sleep phases. The result is that sleep is non-restorative. Cannabinoids can be of use in improving sleep quality. By using THC and CBD, it is possible to induce sleep quite effectively, determining the night-time dose with different proportions of THC/CBD.

Proper rest is very important and for many patients, it is the first problem that needs to be addressed. Without restorative rest, little improvement can be expected in the other symptoms.

Appetite loss can also be a problem for many patients. Small doses of THC administered half an hour before meals increase appetite and ensure the patient does not suffer pathological weight loss. For some patients, THC/CBD treatment improves appetite. However, in some cases, it may be necessary to resort to THC on its own, administered before meals.

Because the doses of THC involved are low (around 5 mg), there is no limiting psychoactive effect, given that CBD is also being taken, which minimises any such effect.

Mood alteration is another issue for some people with RA, a chronic autoimmune disease, for which treatments are currently only available for the symptoms (pain and inflammation), but not the underlying cause. In such cases, the anxiolytic and anti-depressant effect of CBD may be very useful.

One of the great advantages of using cannabinoids is that many different symptoms can be treated with the same family of molecules. This aids better tolerance and makes management easier for the doctor as well.

Because of their low toxicity, cannabinoids have no potentially serious toxic side effects. This is another reason why they may be very useful for RA patients. Nonetheless, it should be noted that, the results of studies in this area with RA patients have not been as satisfactory as hoped, although they have been very positive for some patients. It is also important to remember that treatment may require therapeutic tools, as well as pharmaceuticals.

Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disease. It is characterised by affecting multiple joints simultaneously and by the presentation of diverse general non-specific symptoms and manifestations in other parts of the body. Without proper treatment, in its advanced phases, the disease can result in major physical limitations and a marked deterioration

CBD For Rheumatoid Arthritis

Kimberly is a health and wellness writer with 8 years of experience in healthcare and a special passion for mental health awareness.

Scott J. Zashin, MD, is board-certified in internal medicine and rheumatology. He was a volunteer clinical professor of internal medicine at the University of Texas Southwestern Medical School Dallas.

As cannabidiol (CBD) has grown in popularity over the years, major organizations like the Arthritis Foundation have released guidelines pertaining to its use in the treatment of rheumatoid arthritis (RA). CBD is a non-psychoactive component of cannabis. The CBD in most products is extracted from hemp, a variety of cannabis that only has traces (up to 0.3%) of THC, the active compound that gets people high. Studies have shown CBD can help reduce chronic pain by impacting endocannabinoid receptor activity, which may also reduce inflammation.

CBD comes in different forms, including oil, vape, edible, and topical. Oils, vapes, and edibles are taken orally, while topical CBD lotions can be applied to the skin. CBD dosage varies depending on the form, the indication, and other treatments being used.

What Is Rheumatoid Arthritis?

RA is an autoimmune inflammatory disease, in which the immune system attacks healthy cells in the body and causes inflammation. RA commonly affects joints in the hands, wrists, and knees, causing the joint lining to become inflamed and damaging the tissue. This causes chronic joint pain and leads to deformity. RA can also affect other tissues throughout the body, such as the lungs, heart, and eyes.

medicinal cream with CBD oil, bottle of cannabis oil, capsule

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Health Benefits of CBD for RA

Animal studies have suggested that CBD has pain-relieving and anti-inflammatory properties, but these effects have not been validated with quality studies in humans. Anecdotally, some people who have tried CBD for treatment of arthritis symptoms report noticeable pain relief, improved sleep improvement, and reduced anxiety.

The trials that have been conducted in humans have not yielded strong evidence for the use of CBD in managing arthritic pain.

  • A randomized trial of topical CBD for treatment of knee osteoarthritis lasted only 12 weeks, and results were mixed.
  • One of the largest reviews examining the health effects of cannabis and CBD concluded that there is substantial evidence that cannabis is an effective treatment for chronic pain in adults. There was, however, no specific conclusion regarding CBD, as definitive studies were not available.
  • More recently, a new study showed that CBD can potentially help alleviate RA pain and inflammation by acting on immune cells that are attacking healthy cells in the body. It’s important to note that this study was also not conducted with human subjects.

Research in this area is ongoing.

If you are interested in trying CBD for RA pain management, be sure to talk to your doctor first before using any CBD products.

Rising Popularity of CBD for RA

Based on a 2019 national survey of 2,600 people conducted by the Arthritis Foundation, 79% of respondents said they were using CBD, have used it in the past, or were considering using it to help with their arthritis pain.

Health Benefits Related to Arthritis

Given the lack of strong scientific evidence supporting the use of CBD, it is not recommended as the first choice for pain relief in RA.

If you have RA, you should not stop taking your prescribed medications that may be protecting your joints from future damage. You should discuss any changes you want to make to your medication regimen with your doctor.

Additional Health Benefits

The strongest scientific evidence for effectiveness of CBD as a medical treatment is for seizure prevention in Dravet syndrome and Lennox-Gastaut syndrome, which are severe childhood epilepsy disorders that typically don’t respond to antiseizure medications. Several years ago, the FDA approved the first cannabis-derived medicine for these conditions, Epidiolex, which contains CBD.

Other potential health benefits of CBD include:

  • Reduce anxiety, insomnia, and depression
  • Relieve cancer or cancer treatment symptoms
  • Clear acne
  • Slow the progress of neurologic disease like Alzheimer’s disease

Possible Side Effects

Treatment with CBD should be started slowly and under the supervision of a doctor, who will oversee its effectiveness and side effects. There have been reports of mild side effects of CBD.

The most common side effects include:

  • Nausea
  • Fatigue
  • Irritability
  • Diarrhea
  • Dry mouth
  • Lightheadedness
  • Sleepiness
  • Low blood pressure
  • Appetite changes

It’s important to note that CBD may interact with other drugs, including some of the medications that are prescribed for the treatment of RA.

Warnings and Interactions

There are some warnings and adverse drug interactions to be aware of before beginning using CBD for management of RA-associated pain.

Warnings

Do not stop taking any other treatments without consulting your doctor. Additionally, CBD shouldn’t be a replacement for other therapies you are using.

Pregnant people and children should consult a doctor before using CBD since there isn’t enough research on the effects of CBD on these populations. There has been concern about a possible link between inhaled cannabis and lower-birthweight babies, but it’s not clear if this applies to CBD.

Currently, the U.S. Food and Drug Administration (FDA) does not regulate the safety and purity of CBD products, so you cannot know for sure that the product you buy has active ingredients at the dose listed on the label. The product may contain other unknown elements. The most effective therapeutic dose of CBD for any particular medical condition has not been established.

Are CBD Products Legal?

CBD products derived from hemp are no longer considered schedule I drugs under the federal Controlled Substances Act, but they still remain in a legal gray zone.   There are changes underway on federal and state levels that will ultimately clarify the laws and regulations related to CBD-based products and sales. Despite that, they’re widely available in nearly every state and online. People who want to use CBD should check their own state laws.

Interactions

Studies have found moderate interactions between CBD and medications commonly prescribed for treating RA.

Interactions can occur with these medications:

  • Corticosteroids
  • Tofacitinib
  • Naproxen
  • Celecoxib
  • Tramadol
  • Some antidepressants, including amitriptyline, citalopram, fluoxetine, mirtazapine, paroxetine, and sertraline
  • Some medications used for treating fibromyalgia, including gabapentin and pregabalin

CBD can increase your level of coumadin, a blood thinner.

CBD may also raise levels of other medications in your blood by the same mechanism that grapefruit juice does.

Medications that interact with grapefruit juice can potentially interact with CBD, including:

  • Cholesterol medications
  • High blood pressure medications
  • Organ-rejection medications
  • Anti-anxiety medications
  • Corticosteroids
  • Heart medications
  • Some antihistamines

Preparation and Dosage

If you’ve decided to try CBD for treating your RA pain, the next step is figuring out how much to take.

Your dosage depends on a number of factors:

  • Body weight
  • Medical indication
  • The concentration and form of CBD that you’re taking

You will likely need to start with a low dose and find what works for you. Studies have found extreme differences in dosages, with some people using 5 milligrams (mg) and others as much as 600 mg.

Your healthcare provider may direct you to start with 20-40 mg per day and increase slowly each day until you feel the relief you’re looking for.

To ensure that you are using CBD safely and effectively for pain management, you should:

  • Choose an oral treatment (rather than inhaled products) and start with a low dose
  • Establish initial goals of treatment within a realistic period of time. For example, a reduction in knee pain that allows you to walk around the block within two weeks of starting treatment; later, if improved, the goals can be adjusted
  • Tell your doctor(s) about your planned and current CBD treatment; monitor your pain and adjust medications with your medical providers, rather than with non-medical practitioners
  • When preparing to take a liquid form, be aware that the CBD extract is mixed with a carrier oil, so there are two measures to know: the amount of the liquid product to take (the dose) and the amount of CBD in each dose

If CBD alone doesn’t work and you are in a state where medical or recreational marijuana is legal, you could consider talking to your doctor about taking CBD with a very low-dose THC product. Be aware that even at low levels, THC may make you feel high, resulting in cognitive, motor, and balance impairment.

If you experience any unwanted side effects when using a CBD product, immediately discontinue use and inform your doctor.

What To Look For

Look for the following when choosing a CBD product:  

  • Look for products manufactured in the United States with ingredients grown domestically
  • Choose products made by companies that follow good manufacturing practices established by the FDA for pharmaceuticals or dietary supplements or required by the state where they are manufactured
  • Buy from companies that test each batch and provide a certificate of analysis from an independent lab that uses validated standardized testing methods approved by the American Herbal Pharmacopoeia (AHP), the U.S. Pharmacopeia (USP), or the Association of Official Agricultural Chemists (AOAC)
  • Avoid companies that claim their products have disease benefits
  • Be aware that marketers and people behind retail counters are not health professionals. Your doctor is your best source for guidance and monitoring when using an unregulated product

A Word From Verywell

CBD may sound like an appealing option for pain relief, but do your due diligence before jumping on the bandwagon. A lot of people say CBD can help reduce pain and inflammation for those with RA, but not a lot of strong scientific data have substantiated that claim. That said, serious effects are not commonly associated with CBD use.

If this is something you are interested in, you can work with your doctor to figure out whether CBD is something you can try safely. Remember that CBD should not be used as a first-line treatment for RA pain and that it’s not advisable to stop taking disease-modifying treatments for RA.

Cannabidiol, a non-psychoactive component of marijuana, may help to relieve pain and joint stiffness in people with RA. Here’s what you need to know.