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Cannabis for the Treatment of Crohn’s Disease and Ulcerative Colitis: Evidence From Cochrane Reviews

Background: We systematically reviewed the safety and effectiveness of cannabis and cannabinoids treatment for Crohn’s disease (CD) and ulcerative colitis (UC).

Methods: MEDLINE, Embase, WHO ICTRP, AMED, PsychINFO, CENTRAL, ClinicalTrials.Gov, and the European Clinical Trials Register were searched for relevant studies.

Main results: Five randomized controlled trials (3 CD and 2 UC studies, 185 participants) were included. One CD study (N = 21) showed 45% (5 of 11) of the cannabis cigarette group experienced clinical remission compared with 10% (1 of 10) of the placebo group (risk ratio [RR] 4.55; 95% CI, 0.63-32.56). Another CD study (N = 19) did not show significant rates of clinical remission. Forty percent (4 of 10) of participants in the cannabis oil group experienced remission compared with 33% (3 of 9) of the placebo group (RR 1.20; 95% CI, 0.36-3.97). A UC study (N = 60) did not have significant clinical remission rates. Twenty-four percent (7 of 29) of cannabis oil participants experienced remission compared with 26% (8 of 31) of placebo participants (RR 0.94; 95% CI, 0.39-2.25). A second UC study (N = 32) showed the effects on disease activity, C-reactive protein levels, and fecal calprotectin levels were uncertain. Adverse events were more prevalent in the cannabis groups for both CD and UC studies. GRADE analysis for the UC and CD studies ranged from very low to moderate.

Conclusions: In summary, no firm conclusions can be made regarding the safety and effectiveness of cannabis and cannabinoids in adults with CD and UC.

Keywords: Crohn’s disease; cannabinoids; cannabis; inflammatory bowel disease; ulcerative colitis.

© 2019 Crohn’s & Colitis Foundation. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: [email protected]

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Cannabis oil improves Crohn’s disease symptoms: study

According to a new study, cannabis oil can “significantly” improve Crohn’s disease symptoms.

“(S)tudies have shown that many people with Crohn’s disease use cannabis regularly to relieve their symptoms,” Dr. Timna Naftali, an Israeli gastroenterologist who also teaches at Tel Aviv University, said in a written statement. “It has always been thought that this improvement was related to a reduction in inflammation in the gut and the aim of this study was to investigate this.”

Crohn’s disease is a lifelong inflammatory bowel disease (IBD) that can cause severe belly pain and chronic diarrhea.

Dr. Naftali, whose study is being billed as the first of its kind, found that an eight-week treatment with cannabis oil containing a four to one CBD to THC ratio produced clinical remission in up to 65 per cent of individuals with Crohn’s disease. The randomized, placebo-controlled study involved 50 people with moderately severe forms of the disease. The group that received cannabis oil also reported significant improvements in their quality of life.

Interestingly, however, cannabis was found to have no effect on the gut inflammation that underscores the disease.

“We have previously demonstrated that cannabis can produce measurable improvements in Crohn’s disease symptoms but, to our surprise, we saw no statistically significant improvements in endoscopic scores or in the inflammatory markers we measured in the cannabis oil group compared with the placebo group,” Dr. Naftali explained. “We know that cannabinoids can have profound anti-inflammatory effects but this study indicates that the improvement in symptoms may not be related to these anti-inflammatory properties.”

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Going forward, Dr. Naftali and her research team plan to further investigate cannabis’ potential anti-inflammatory properties to treat IBDs.

“There are very good grounds to believe that the endocannabinoid system is a potential therapeutic target in Crohn’s disease and other gastrointestinal diseases,” Dr. Naftali said. “For now, however, we can only consider medicinal cannabis as an alternative or additional intervention that provides temporary symptom relief for some people with Crohn’s disease.”

Workers package cannabis oil at Canopy Growth Corporation’s Tweed facility in Smiths Falls, Ont., on Monday, Feb. 12, 2018. (THE CANADIAN PRESS/Sean Kilpatrick)

Does cannabis offer new hope for folks with Crohn’s disease and ulcerative colitis?

Stomach pain, cramps, diarrhea, fatigue, rectal bleeding, fever, weight loss—these are just a few symptoms that are all too familiar to people with inflammatory bowel disease (IBD) (1-4). While people with IBD often feel embarrassed about their condition, there is no shame in it. Talking about IBD can lead to finding better ways to cope.

IBD is an umbrella term that describes chronic inflammatory conditions that affect the digestive tract—which includes the mouth, esophagus, stomach, and the small and large intestines (1-5). Crohn’s disease and ulcerative colitis are the most common forms of IBD (6). In North America, over 1.6 million people live with IBD (1;7-8), including around 270,000 Canadians—projected to be 400,000 by 2030 (9). And you guessed it…the fastest growing group of Canadians with IBD is adults aged 65 years old and over (9;10).

The cause of IBD is still a mystery, but it is thought to arise when environmental factors (e.g., infections, antibiotics, etc.) prompt the immune system to mistakenly attack microorganisms and food in the gut, producing inflammation in the digestive tract. Genetics may also play a role in increasing the risk of IBD (1-4;11). Typically, the disease alternates between periods of inactivity (a.k.a. remission) and periods when symptoms flare-up (a.k.a. relapse) (2-4).

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Unfortunately, there is no cure for IBD. Instead, go-to medications often aim to reduce inflammation or suppress the immune system to get and keep people in remission (2-5). Many of these medications can come with potentially serious side effects, such as lymphoma, non-melanoma skin cancers, and liver issues (9).

One popular and highly debated alternative treatment option is cannabis (2;4). With cannabis touted as a one stop-shop for many of our medical needs, and its increasing accessibility through legalization, where does the evidence stand on its use for Crohn’s and ulcerative colitis, specifically?

What the research tells us

Two recent systematic reviews —one including patients with active Crohn’s (2) and the other including patients with active ulcerative colitis (4)—looked at the effect of cannabis cigarettes and cannabis oil on outcomes such as disease remission or activity, inflammation, side effects, and quality of life.

When reported on, neither review found that cannabis cigarettes or cannabis oil induced remission in patients with active disease or helped with inflammation (2;4). In both Crohn’s and ulcerative colitis, cannabis cigarettes led to a reduction in disease activity (2;4), but in Crohn’s patients, this was accompanied by an increase in mild side effects such as memory loss, drowsiness, confusion, dizziness, and trouble concentrating (2). Cannabis oil produced potentially meaningful increases in quality of life in both types of IBD (2;4), but in patients with ulcerative colitis, this strategy was associated with mild to moderately severe side effects such as headache, tiredness, dizziness, nausea, and trouble concentrating (4).

So, what should patients and caregivers affected by Crohn’s and ulcerative colitis make of these findings?

Ultimately, the evidence-base around the use of cannabis and cannabis oil for Crohn’s or ulcerative colitis is not of high quality. This means, at this time, no concrete conclusions about the effectiveness or safety of cannabis and cannabis oil can be made. Ideally, future research will include a larger number of participants, account for different disease statuses (e.g., active and inactive), and evaluate different types/doses of cannabis (2;4).

If you’re considering using cannabis or cannabis oil to treat your Crohn’s or ulcerative colitis, reach out to your health care provider to help you navigate the potential harms and benefits and factor in where the current evidence lies.