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 UC⁴. 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 effects⁶.
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.
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