Cbd oil for ulcerative colitis scholarly articles

Cannabis for the Treatment of Inflammatory Bowel Disease: A True Medicine or a False Promise?

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Abstract

Cannabis is the most widely used recreational drug worldwide and is used by some patients with inflammatory bowel disease (IBD) to ameliorate their disease. Whereas epidemiological studies indicate that as many as 15% of IBD patients use cannabis, studies inspecting cannabis use in IBD are few and small. We have conducted several studies looking at the use of cannabis in IBD. In Crohn’s disease, we demonstrated that cannabis reduces the Crohn’s disease activity index (CDAI) by >100 points (on a scale of 0–450).Two small studies in ulcerative colitis showed a marginal benefit. However, no improvement was observed in inflammatory markers or in endoscopic score in either disease. Many questions regarding cannabis use in IBD remain unanswered. For example, cannabis is a complex plant containing many ingredients, and the synergism or antagonism between them likely plays a role in the relative efficacy of various cannabis strains. The optimal doses and mode of consumption are not determined, and the most common form of consumption, i.e. smoking, is unacceptable for delivering medical treatment. Cannabis is a psychotropic drug, and the consequences of long-term use are unknown. Despite all these limitations, public opinion regards cannabis as a harmless drug with substantial medical efficacy. In Israel, the number of licenses issued for the medical use of cannabis is rising rapidly, as are the acknowledged indications for such use, but good-quality evidence for the effectiveness of cannabis is still lacking. Further studies investigating the medical use of cannabis are urgently needed.

BACKGROUND

Cannabis is the most widely used recreational drug worldwide. The cannabis plant contains as many as 100 phytocannabinoids, as well as other ingredients such as terpenes and flavonoids. 1 The phytocannabinoids exert their effect through the endocannabinoid system (ECS), which is an endogenous system with an important role in modulating mood, memory, reward homeostasis, immune regulation, and energy balance. 2 The best-known phytocannabinoids are Δ9-tetrahydrocannabinol (THC), responsible for the psychotropic effect of cannabis, and cannabidiol (CBD), which does not have a central effect but was shown to have an anti-inflammatory effect. 3

REPORTS OF CANNABIS USE IN INFLAMMATORY BOWEL DISEASE

Many animal and laboratory studies demonstrated that cannabis can ameliorate inflammation in inflammatory bowel disease (IBD). 4 Consequently, there are many epidemiological studies and anecdotal reports about cannabis use in IBD patients. Various studies demonstrated that the prevalence of cannabis use among IBD patients varies between 12% and 15%, although a much higher percentage of patients (50%–60%) report ever using cannabis during their lifetime. 5 , 6 Patients claim that cannabis ameliorates their symptoms, including improvement in diarrhea, abdominal pain, and appetite 7 ; however, most studies contain no information about the dose and mode of cannabis consumption. We conducted an observational study of 127 IBD patients who were using cannabis by license from the Ministry of Health in Israel and found that most patients were satisfied with a monthly dose of 30 g and that 70% were consuming cannabis by smoking it, whereas the others were consuming it orally, mostly in the form of oil. 8 Nevertheless, since patients are using many different varieties of cannabis, with different content of cannabinoids, obtaining more accurate information is difficult.

RANDOMIZED CONTROLLED TRIALS OF CANNABIS IN IBD

In view of the many reports about cannabis use in IBD, it is surprising that very few randomized controlled trials (RCTs) have been conducted. Two Cochrane reviews found only three trials performed in Crohn’s disease 9 and only two in ulcerative colitis. 10 This can be partly explained by the fact that investigating cannabis use is inherently difficult. The large variations between different cannabis strains and the many different modes of cannabis consumption make properly standardized cannabis treatment hard to achieve.

In the first RCT, 21 Crohn’s disease patients were randomized to receive either cannabis flowers or a placebo containing 23% THC. A clinical response, defined as a decrease in the Crohn’s disease activity index (CDAI) by >100 points (on a scale of 0–450) was observed in 10/11 (91%) subjects in the cannabis group and 4/10 (40%) in the placebo group (P=0.028). 11 Another trial looking at the use of CBD for Crohn’s disease found no significant difference in the CDAI between the study and the placebo groups (220±122 and 216±121, respectively, P=NS). 12

The first RCT to report cannabis use in ulcerative colitis included 60 patients who received a CBD-rich cannabis botanical extract for 10 weeks. Remission rates were similar for the CBD (28%) and placebo (26%) groups. Although CBD is usually well tolerated, in this study side effects led to a 40% protocol deviation in the study group. 13 We performed a study of cannabis in ulcerative colitis at the Meir Medical Center, demonstrating that the disease activity index (Lichtiger score) after 8 weeks of cannabis treatment was 4 in cannabis participants compared with 8 in the placebo group (P between groups 0.001). 10

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There are no studies regarding the maintenance of remission with cannabis in either Crohn’s disease or ulcerative colitis.

The Israeli Gastroenterological Association issued recommendations for the use of cannabis in IBD. These were adopted by the Israeli Ministry of Health. These recommendations state that since the evidence of cannabis efficacy in IBD is still lacking, cannabis should be used only as a compassionate treatment in patients for whom the established forms of treatment have failed—that is, patients who still suffer from the active disease despite treatment by biologics, and who are not candidates for surgery.

REGULATION OF MEDICAL CANNABIS IN ISRAEL

Despite the lack of scientifically sound evidence, cannabis use is rapidly gaining popularity and legitimacy throughout the world. Medical cannabis treatment was introduced in Israel in 1994, but until 2001 it was approved for only 64 patients. During the last decade, pressure from the media and politicians, together with increasing awareness of physicians and patients, pushed the numbers up. Consequently, the number of permits increased from 12,000 in 2013 to 60,000 in 2019. New instructions published by the Ministry of Health allowed each specialist to recommend the treatment within the limits of his/her specialization. The recommendations were examined by qualified physicians in the Ministry, and 90% of the requests were granted. A license was sent to the patient specifying the dispensary allocated to them, the amount of cannabis, and the consumption method approved. The dispensary supplied cannabis to the patients and instructed them on how to use it. However, there was no specification of the strain of cannabis to be used or the content of THC allowed. Consequently, the treating physician ended up prescribing a treatment but having no control of the doses of the psychoactive substance the patient would consume. During those years more than 80,000 licenses were issued, and, at the time of writing, more than 50,000 are active.

Regarding the various indications for cannabis use so far, 40% of the patients were oncology patients, 30% suffered from intractable pain after the failure of all conventional treatments, and 2,000 patients (4%) were treated for post-traumatic stress disorder after failure of at least 3 years of all conventional, medical, and psychological treatments. More than 1,000 patients (2%) were treated for Crohn’s disease and 150 for ulcerative colitis. More than 1,000 patients (2%) were treated for fibromyalgia (an indication that brought a lot of professional objection). The other patients suffered from neurological disorders, autoimmune diseases, and others (data from M.D., former medical adviser to the Israeli Minister of Health on Cannabis).

THE MINISTRY OF HEALTH CANNABIS REFORM

Lately, in an attempt to define the prescription of cannabis more accurately, the Ministry of Health issued a list of allowed cannabis variations and is removing the dispensing of cannabis from cannabis producers to pharmacies. The allowed variations include flowers or oil, Cannabis sativa or C. indica, and various proportions of THC and CBD, ranging from 3% to 20%. Thus, the physician prescribing cannabis can define the exact dose of THC and CBD.

In parallel, during the last years, the Cannabis Unit of the Israeli Ministry of Health initiated a set of new regulations intended for quality control assurance. The previous system was based on a direct supply of cannabis from the grower to the patients. The new system included strict quality control, high manufacturing standards, and distribution of cannabis products through pharmacies.

A structured process of introducing new indications was initiated. The process is quite complicated, and the implementation was delayed by a court decision for several months.

In an effort to establish more scientifically sound evidence about the medical role of cannabis, a research committee, chaired by Professor Rafael Mechulam, approved more than 400 research projects, including 60 clinical studies. New research is evaluating the possible use of cannabis in the treatment of opioid addiction and the treatment of other psychiatric disorders. New indications explored in recent years include autism in children and intractable epilepsy of childhood; approximately 1,000 children in each group have been treated, with significant success. New ways of administration are being developed, starting from new inhalation devices, 14 and continuing with topical preparations for psoriasis and atopic dermatitis. 15 , 16 New manufacturing methods using nanotechnology are also being investigated.

CONCLUSION

The use of medical cannabis is rapidly increasing, and physicians are faced with an increasing demand from patients to prescribe it. Sadly, this is not accompanied by scientifically sound evidence regarding the efficacy, if any, of cannabis treatment. Very little is known about the effect of cannabis, the significance of various cannabinoid combinations, or the mode of cannabis consumption. On the other hand, we cannot afford to ignore the many reports about the positive effect of cannabis. The current treatment for IBD is successful in about 60% of patients, so if indeed there is a potential for another medication this should be explored using rigorous and scientifically sound methods. Only by conducting large well-designed randomized controlled trials will we be able to benefit from the potential of this plant.

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Using CBD for Ulcerative Colitis

Lindsay Curtis is a health writer with over 20 years of experience in writing health, science & wellness-focused articles.

Verywell Health articles are reviewed by board-certified physicians and healthcare professionals. These medical reviewers confirm the content is thorough and accurate, reflecting the latest evidence-based research. Content is reviewed before publication and upon substantial updates. Learn more.

Robert Burakoff, MD, MPH, is board-certified in gastroentrology. He is the vice chair for ambulatory services for the department of medicine at Weill Cornell Medical College in New York, where he is also a professor. He was the founding editor and co-editor in chief of Inflammatory Bowel Diseases.

Ulcerative colitis (UC) is a chronic disease that affects the large intestine (colon), causing inflammation and small sores (or ulcers). UC symptoms include diarrhea, abdominal cramps and pain, bloody stool, and the need to pass stool frequently.

There is no cure for ulcerative colitis, so treatment prioritizes symptom relief and reducing flare-ups. Many people with ulcerative colitis turn to alternative treatments, such as cannabidiol (CBD), to take control of the disease and improve their quality of life.

Read on to learn more about how CBD may be a useful supplemental therapy in the management of UC symptoms.

Tinnakorn Jorruang / Getty Images

Inflammation, CBD, and Ulcerative Colitis

Cannabis plants contain chemicals called cannabinoids, which are compounds unique to the plant. The two primary cannabinoids are:

  • Tetrahydrocannabinol (THC), which has psychoactive effects that make a person feel “high”
  • Cannabidiol (CBD), which has no psychoactive effects but can provide a number of therapeutic benefits

Both CBD and THC interact with the endocannabinoid system (ECS) in the body. The ECS is a complex biological system that regulates cardiovascular, nervous, and immune system functions.

CBD binds to and activates receptors in the brain that create a therapeutic effect in the body, helping users find relief from painful symptoms without feeling impaired.

CBD has many therapeutic properties and is a known anti-inflammatory, antimicrobial, and antioxidant. Thanks to its anti-inflammatory properties, CBD may be a potential therapeutic treatment for ulcerative colitis.

CBD for Ulcerative Colitis Symptoms

CBD has been explored in several studies as a potential treatment for ulcerative colitis. Research shows that CBD may potentially help reduce inflammation in the gastrointestinal system caused by inflammatory bowel diseases (IBD), such as ulcerative colitis.

One study found that participants with UC who took 50 milligrams (mg) of CBD oil twice a day, increasing to 250 mg per dose if needed and tolerated, experienced significant improvements in their quality of life. However, more research and follow-up studies are needed.

Another study analyzed the efficacy of CBD use in adults with ulcerative colitis. The study concluded that CBD extracts may help alleviate symptoms of IBD and UC.

Although more research is needed, current study results show promise that CBD may be beneficial for treating symptoms of ulcerative colitis.

Are There Any Side Effects?

Though CBD is generally well tolerated, you may experience some side effects. Common side effects include:

  • Changes in mood (e.g., irritability)
  • Diarrhea
  • Decreased appetite
  • Drowsiness
  • Dry mouth

CBD and Your Liver

CBD is metabolized by the liver, and large doses may lead to liver toxicity. Talk with your healthcare provider before using CBD. If you are on any prescription medications, they may recommend regularly monitoring your liver through bloodwork to ensure CBD is safe for you.

How to Use CBD for Ulcerative Colitis

While CBD won’t cure ulcerative colitis, it may help make your symptoms more manageable and help reduce flares.

There are many different forms of CBD, and you may need to try different delivery methods before finding the one that is right for you.

CBD is available in:

  • Edibles (e.g., gummies, CBD-infused beverages)
  • Plants (to be inhaled/smoked)
  • Capsules and pills
  • Tinctures and oils
  • Topicals (e.g., lotions, creams)

To date, CBD has only been approved by the Food and Drug Administration to treat epilepsy. As a result, there is no standard recommended dosage of CBD for treating ulcerative colitis.

Shopping for CBD

When shopping for CBD, you will notice different types available. These include:

  • Full-spectrum CBD: Contains all the natural components found in the cannabis plant, including terpenes, flavonoids, fatty acids, and cannabinoids. Full-spectrum CBD products contain trace amounts of THC. These compounds work in synergy in the body to obtain the desired therapeutic effects.
  • Broad-spectrum CBD: Similar to full-spectrum CBD, broad-spectrum CBD contains compounds in the cannabis plant, but with all traces of THC removed, so you will not experience any mind-altering effects.
  • CBD isolates: All other cannabinoids, terpenes, and flavonoids are removed to create a 99% pure CBD product.
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For the best results, look for broad-spectrum or full-spectrum CBD products. These may combine the effects of multiple cannabis compounds that work together in synergy, creating an “entourage effect” to offer the most health benefits.

Dosage

Because CBD is still a relatively new therapeutic option for managing different health conditions, including inflammatory bowel diseases, there is currently no recommended standard dosage.

In one study, patients with ulcerative colitis were given 50 mg of CBD oil twice a day. Some participants were able to increase to as much as 250 mg twice a day for a period of 10 weeks.

Another study also recorded dose ranges of 50 mg to 250 mg CBD capsules twice daily. Many participants were able to tolerate the higher dosage and saw improvements, though the study authors suggested that more research is needed.

As with many medications, it’s best to start with a lower dose and gradually increase the amount of CBD to determine the appropriate dosage.

Talk to Your Healthcare Provider

It’s important to talk with your healthcare provider before adding any supplemental therapy, such as CBD, to your ulcerative colitis treatment. They will be able to determine if CBD will be beneficial for your individual case and can recommend the right dosage.

How to Buy CBD

With so many different options available, it can be daunting to shop for CBD. CBD is generally safe and well tolerated, but the industry is poorly regulated, and consumers should be aware of what to look for before purchasing CBD.

You’ll want to carefully read the label of any products you are considering and look for:

  • Amount of CBD per serving
  • Suggested use/dosage
  • Type (full-spectrum, broad-spectrum, or isolate)
  • List of ingredients
  • Manufacturer and distributor name

You’ll also want to consider:

  • Cannabis source: Ensure the product you are purchasing is sourced from a company that ensures the quality and safe cultivation of their plants. Look for products that come from organic cannabis/hemp plants when possible.
  • Certificate of Analysis (CoA): CoAs are conducted by independent, accredited labels that verify third-party testing of the products.
  • Customer reviews: Testimonials from other users can tell you a lot about a product’s efficacy.

Avoid products and vendors that make broad, definitive statements or promises of a “cure” for something. If you are currently taking any other medications or supplements for your UC, speak with your healthcare provider before using CBD, as it may interact with other medications you are taking.

A Word From Verywell

People with ulcerative colitis may want to consider alternative treatments such as CBD to help manage their symptoms. It’s important to remember that while CBD may help improve your symptoms, it will not treat or cure the condition.

CBD is best used as a supplemental therapy alongside conventional treatments recommended by your healthcare provider, as well as dietary modifications. As with any supplement or medication, talk with your healthcare provider before trying CBD.

Frequently Asked Questions

Cannabinoids have anti-inflammatory properties that may make them helpful in managing symptoms of gastrointestinal diseases like ulcerative colitis. Research suggests CBD is a promising therapeutic for inflammatory bowel diseases, helping reduce mucosal lesions, ulceration, and inflammation associated with IBD. CBD may also help manage gastrointestinal pain, as well as secondary symptoms that come with IBD, such as anxiety, nausea, and sleep disturbances.

The cannabis plant (to be smoked/vaped) comes in different strains, with varying CBD and THC levels. CBD-dominant cannabis strains may provide the best relief for inflammation. These strains tend to be high in the terpene called myrcene, which helps reduce inflammation.

There are many delivery methods for CBD, including edibles (e.g., gummies), flowers, oils, tinctures, topicals, and suppositories. Finding the right one for you may require a little trial and error. The best method for you depends on personal preference and how quickly you may need relief. For example, you may get relief from painful symptoms sooner by vaping oil vs. consuming an edible. Start off with smaller doses and gradually increase the amount you use until you find the amount that offers you relief from your symptoms. Make sure to talk with your healthcare provider before you begin use.