Can medicinal cannabis help with IBD?

People with Inflammatory Bowel Disease often ask whether medical cannabis can help

Inflammatory bowel disease (IBD) is a chronic disease mediated by the immune system that affects the gastrointestinal (GI) tract¹,². People with IBD experience cycles of painful inflammatory flares which result in ulcers, pain, bleeding, diarrhoea, nausea, tiredness, fever, weight loss, and considerable psychologic and emotional burden²,³

There are three main types of IBD – Crohn’s disease (CD), ulcerative colitis (UC), and a form of indeterminate IBD (IBD-U) when the condition cannot be distinguished between CD an UC.  It is not clear what causes IBD, but medical evidence suggests that a genetic component coupled with environmental factors such as smoking, diet, or pollution, may make some individuals susceptible to an inappropriate inflammatory reaction to the normal bacteria that live in the gut (also known as the microbiome)⁵,⁶.

The incidence and prevalence of IBD continues to rise around the world⁷⁻¹⁰, with Australia having one of the highest global incidence rates at 29.6 cases per 100,000¹¹, ¹².

Current medical treatment includes aminosalicylates, steroids, immunomodulating drugs, and biologics that block inflammation, as well as surgery when complications occur. However, about 30–40% of people with IBD do not respond to initial treatment¹³, and of those who do respond, 50% stop responding during maintenance treatment¹⁴, leading to long-term risks for the development of colon cancer.

Many people with IBD seek alternative treatments such as cannabis for symptom relief.  Data from epidemiological studies overseas reveal that as many as 15% of individuals with IBD use cannabis to relieve symptoms¹⁵⁻¹⁸.  In 2020, a survey conducted in New Zealand found that of 170 adults with IBD, 31% had used cannabis to reduce IBD symptoms, and the symptoms most reported as improved were pain, nausea, vomiting, and loss of appetite¹⁹.

The ECS and the gut

The endocannabinoid system (ECS) is distributed throughout the human body and consists of  circulating cannabinoids (also referred to as endocannabinoids), enzymes that manufacture and break down the endocannabinoids, and cannabinoid receptors, such as CB1 and CB2²⁰.

In the GI tract, the ECS plays a key role in regulating various aspects of gut function and in protecting the gut from inflammation²⁰, ²¹.  Results from preclinical experiments performed in animal models of human IBD, support an important role for the ECS in gastrointestinal diseases, with several studies showing changes in ECS components during gut inflammation²²⁻²⁵.  In humans, several studies have also observed ECS changes in inflamed colons as compared to noninflamed colons and have revealed a strong link between the microbiome and the ECS⁴, ²⁶.

Experimental animals treated with plant cannabinoids to activate the ECS receptors have shown a reduction in gut motility and secretions, reduced inflammation, and reduced immune activation²¹, ²², ²⁵, ²⁷, ²⁸.  These studies have demonstrated that activating intestinal CB1 decreases large and small bowel muscle tone and inhibits GI motility²⁹, while targeting intestinal CB2 decreases inflammation by reducing the production and release of inflammatory chemicals from activated immune cells³⁰.

CBD and THC in clinical trials of IBD

In animal studies, both non-psychoactive cannabidiol (CBD) and psychoactive delta -9-tetrahydrocannabinol (THC) have improved gut function. While CBD exhibits potent anti-inflammatory and immunomodulatory properties in acute and chronic animal models of inflammation³¹, ³²,  THC  improves colon health by stimulating mucus and increasing good gut bacteria by acting on both gut and immune cells to attenuate inflammation³³.

Unfortunately, clinical studies in humans have yielded varied results:

  • In two 2021 double-blind, randomised, placebo-controlled trials of 32 people with UC and 56 people with CD, short-term treatment with either THC-rich cannabis or CBD-rich cannabis induced clinical remission and improved  quality of life, but these beneficial clinical effects were not associated with significant anti-inflammatory improvement³⁴, ³⁵.
  • A 2020 survey of 838 Australian patients with IBD found that 25% of respondents were current or previous users of medicinal cannabis. IBD symptoms reported as improved with cannabis included abdominal pain, stress, sleep, cramping, and anxiety. Most users (92.7%) endorsed cannabis as effective in symptom management, and cannabis-using UC patients reported better quality of life than nonusers¹².
  • In a 2018 multi-centre, double-blind, placebo-controlled, randomised study in 60 people with UC, CBD-rich cannabis did not improve clinical remission but did improve quality of life compared to placebo³⁶.  
  • A 2018 randomised, placebo controlled trial with 28 UC patients found that inhaled THC-rich cannabis significantly decreased disease activity and inflammatory markers³⁷.
  • A 2017, randomised placebo-controlled study with 20 patients with treatment-resistant CD found that 8 weeks of treatment with low-dose (20 mg/day) CBD oil was safe but had no beneficial effects.

In summary, cannabinoids have not been effective at inducing remission from IBD or in reducing inflammation in humans. However, clinical symptoms such as abdominal pain, general well-being, nausea, diarrhoea, and poor appetite, have all improved with cannabinoids. In addition, overall quality of life has improved significantly³⁸

It appears that although cannabis may help control symptoms and improve quality of life in people with IBD, it has not been proven to modify disease activity². Thus, cannabinoids should not replace current IBD treatments, but they may have the potential to become an addition to current standard medications in helping to control inflammation, as well as improving symptoms and quality of life in some people²

If you have IBD, it is important to discuss with your doctor whether the addition of cannabinoids to your standard treatment may be suitable for you, particularly if formulations containing THC are used. These carry a risk of adverse side effects at higher doses and of dependence with long-term use. It is also important to remember that the long-term safety profile of cannabis in patients with IBD has not been established and therefore, the risks and benefits of treatment should be discussed with your doctor.

If you have IBD and are currently undergoing medicinal cannabis therapy, an observational study (ACTRN12620000741987) to assess the safety, tolerability and efficacy of a pharmaceutical grade CBD medicine is currently recruiting through Tetra Health. Please contact our team to find out whether you may be eligible for the study.

Further information about IBD can be found at Crohn’s & Colitis Australia

Further information about medicinal cannabis can be obtained from the Therapeutic Goods Administration.

  1. Mowat C, Cole A, Windsor A, Ahmad T, Arnott I, Driscoll R, et al. Guidelines for the management of inflammatory bowel disease in adults. Gut. 2011;60(5):571-607.
  2. Picardo S, Kaplan GG, Sharkey KA, Seow CH. Insights into the role of cannabis in the management of inflammatory bowel disease. Therap Adv Gastroenterol. 2019;12:1756284819870977.
  3. Devlen J, Beusterien K, Yen L, Ahmed A, Cheifetz AS, Moss AC. The burden of inflammatory bowel disease: a patient-reported qualitative analysis and development of a conceptual model. Inflamm Bowel Dis. 2014;20(3):545-52.
  4. Szczepaniak A, Fichna J. What role do cannabinoids have in modern medicine as gastrointestinal anti-inflammatory drugs? Expert Opin Pharmacother. 2020:1-4.
  5. Mbachi C, Attar B, Wang Y, Paintsil I, Mba B, Fugar S, et al. Association Between Cannabis Use and Complications Related to Crohn’s Disease: A Retrospective Cohort Study. Dig Dis Sci. 2019;64(10):2939-44.
  6. Naftali T, Mechulam R, Marii A, Gabay G, Stein A, Bronshtain M, et al. Low-Dose Cannabidiol Is Safe but Not Effective in the Treatment for Crohn’s Disease, a Randomized Controlled Trial. Dig Dis Sci. 2017;62(6):1615-20.
  7. Kaplan GG, Ng SC. Understanding and Preventing the Global Increase of Inflammatory Bowel Disease. Gastroenterology. 2017;152(2):313-21.e2.
  8. Coward S, Clement F, Benchimol EI, Bernstein CN, Avina-Zubieta JA, Bitton A, et al. Past and Future Burden of Inflammatory Bowel Diseases Based on Modeling of Population-Based Data. Gastroenterology. 2019;156(5):1345-53.e4.
  9. Ng SC, Shi HY, Hamidi N, Underwood FE, Tang W, Benchimol EI, et al. Worldwide incidence and prevalence of inflammatory bowel disease in the 21st century: a systematic review of population-based studies. Lancet. 2017;390(10114):2769-78.
  10. Kaplan GG. The global burden of IBD: from 2015 to 2025. Nat Rev Gastroenterol Hepatol. 2015;12(12):720-7.
  11. Wilson J, Hair C, Knight R, Catto-Smith A, Bell S, Kamm M, et al. High incidence of inflammatory bowel disease in Australia: a prospective population-based Australian incidence study. Inflamm Bowel Dis. 2010;16(9):1550-6.
  12. Benson MJ, Abelev SV, Connor SJ, Corte CJ, Martin LJ, Gold LK, et al. Medicinal Cannabis for Inflammatory Bowel Disease: A Survey of Perspectives, Experiences, and Current Use in Australian Patients. Crohn’s Colitis 360. 2020;2(2):1-15.
  13. Pariente B, Laharie D. Review article: why, when and how to de-escalate therapy in inflammatory bowel diseases. Aliment Pharmacol Ther. 2014;40(4):338-53.
  14. Ma C, Huang V, Fedorak DK, Kroeker KI, Dieleman LA, Halloran BP, et al. Outpatient Ulcerative Colitis Primary Anti-TNF Responders Receiving Adalimumab or Infliximab Maintenance Therapy Have Similar Rates of Secondary Loss of Response. J Clin Gastroenterol. 2015;49(8):675-82.
  15. Ahmed W, Katz S. Therapeutic Use of Cannabis in Inflammatory Bowel Disease. Gastroenterol Hepatol (N Y). 2016;12(11):668-79.
  16. Weiss A, Friedenberg F. Patterns of cannabis use in patients with Inflammatory Bowel Disease: A population based analysis. Drug Alcohol Depend. 2015;156:84-9.
  17. Lal S, Prasad N, Ryan M, Tangri S, Silverberg MS, Gordon A, et al. Cannabis use amongst patients with inflammatory bowel disease. Eur J Gastroenterol Hepatol. 2011;23(10):891-6.
  18. Naftali T, Lev LB, Yablecovitch D, Half E, Konikoff FM. Treatment of Crohn’s disease with cannabis: an observational study. Isr Med Assoc J. 2011;13(8):455-8.
  19. Appleton K, Whittaker E, Cohen Z, Rhodes HM, Dunn C, Murphy S, et al. Attitudes towards and use of cannabis in New Zealand patients with inflammatory bowel disease: an exploratory study. N Z Med J. 2021;134(1530):38-47.
  20. Perisetti A, Rimu AH, Khan SA, Bansal P, Goyal H. Role of cannabis in inflammatory bowel diseases. Annals of gastroenterology. 2020;33(2):134-44.
  21. Nasser Y, Woo M, Andrews CN. Cannabis in Gastroenterology: Watch Your Head! A Review of Use in Inflammatory Bowel Disease, Functional Gut Disorders, and Gut-Related Adverse Effects. Curr Treat Options Gastroenterol. 2020:1-12.
  22. Massa F, Marsicano G, Hermann H, Cannich A, Monory K, Cravatt BF, et al. The endogenous cannabinoid system protects against colonic inflammation. J Clin Invest. 2004;113(8):1202-9.
  23. D’Argenio G, Valenti M, Scaglione G, Cosenza V, Sorrentini I, Di Marzo V. Up-regulation of anandamide levels as an endogenous mechanism and a pharmacological strategy to limit colon inflammation. Faseb j. 2006;20(3):568-70.
  24. Storr MA, Keenan CM, Emmerdinger D, Zhang H, Yüce B, Sibaev A, et al. Targeting endocannabinoid degradation protects against experimental colitis in mice: involvement of CB1 and CB2 receptors. J Mol Med (Berl). 2008;86(8):925-36.
  25. Massa F, Storr M, Lutz B. The endocannabinoid system in the physiology and pathophysiology of the gastrointestinal tract. J Mol Med (Berl). 2005;83(12):944-54.
  26. Muccioli GG, Naslain D, Bäckhed F, Reigstad CS, Lambert DM, Delzenne NM, et al. The endocannabinoid system links gut microbiota to adipogenesis. Mol Syst Biol. 2010;6:392.
  27. Izzo AA, Camilleri M. Emerging role of cannabinoids in gastrointestinal and liver diseases: basic and clinical aspects. Gut. 2008;57(8):1140-55.
  28. Pacher P, Bátkai S, Kunos G. The endocannabinoid system as an emerging target of pharmacotherapy. Pharmacol Rev. 2006;58(3):389-462.
  29. Wright K, Rooney N, Feeney M, Tate J, Robertson D, Welham M, et al. Differential expression of cannabinoid receptors in the human colon: cannabinoids promote epithelial wound healing. Gastroenterology. 2005;129(2):437-53.
  30. Wright KL, Duncan M, Sharkey KA. Cannabinoid CB2 receptors in the gastrointestinal tract: a regulatory system in states of inflammation. Br J Pharmacol. 2008;153(2):263-70.
  31. Zuardi AW. Cannabidiol: from an inactive cannabinoid to a drug with wide spectrum of action. Braz J Psychiatry. 2008;30(3):271-80.
  32. Esposito G, Filippis DD, Cirillo C, Iuvone T, Capoccia E, Scuderi C, et al. Cannabidiol in inflammatory bowel diseases: a brief overview. Phytother Res. 2013;27(5):633-6.
  33. Becker W, Alrafas HR, Busbee PB, Walla MD, Wilson K, Miranda K, et al. Cannabinoid receptor activation on hematopoietic cells and enterocytes protects against colitis. J Crohns Colitis. 2020. In Press.
  34. Naftali T, Bar-Lev Schleider L, Scklerovsky Benjaminov F, Konikoff FM, Matalon ST, Ringel Y. Cannabis is associated with clinical but not endoscopic remission in ulcerative colitis: A randomized controlled trial. PLoS One. 2021;16(2):e0246871.
  35. Naftali T, Bar-Lev Schleider L, Almog S, Meiri D, Konikoff FM. Oral CBD-rich cannabis induces clinical but not endoscopic response in patients with Crohn’s disease, a randomized controlled trial. J Crohns Colitis. 2021. In Press.
  36. Irving PM, Iqbal T, Nwokolo C, Subramanian S, Bloom S, Prasad N, et al. A Randomized, Double-blind, Placebo-controlled, Parallel-group, Pilot Study of Cannabidiol-rich Botanical Extract in the Symptomatic Treatment of Ulcerative Colitis. Inflamm Bowel Dis. 2018;24(4):714-24.
  37. Naftali T, Bar Lev Schlieder, L., Sklerovsky Benjaminov, F., Lish, I., Hirsch, J., Konikoff, F.M. Cannabis induces clinical and endoscopic improvement in moderately active ulcerative colitis. Journal of Crohn’s and Colitis. 2018;12(Suppl 1):S306.
  38. Doeve BH, van de Meeberg MM, van Schaik FDM, Fidder HH. A Systematic Review With Meta-Analysis of the Efficacy of Cannabis and Cannabinoids for Inflammatory Bowel Disease: What Can We Learn From Randomized and Nonrandomized Studies? J Clin Gastroenterol. 2020. In Press.

Stay up to date

Sign up to the Tetra Health Newsletter