2. Is there a role for cannabis as adjuvant therapy in patients with IBD?
Studies to date have included only symptomatic patients with objective evidence of inflammation and assessed clinical, biochemical, or endoscopic endpoints. In Crohn’s disease, two studies showed no improvement in clinical remission rates but showed improvement in clinical response; a third study showed both improvement in clinical remission/response as well as improved quality of life. No study showed a change in disease markers of activity including CRP, fecal calprotectin, or endoscopic scoring. In one study, all patients relapsed shortly after cannabis discontinuation suggesting that, while there was benefit in symptom control, there was no improvement of the underlying chronic inflammation.
Dr. Arun Swaminath
In patients with ulcerative colitis, there were two studies. One study showed no improvement and high rates of intolerance in the treatment group, while the other study reported improved disease activity but no objective improvement. The variation in results between disease states and between studies might be because of cannabis formulations. In patients with persistent symptoms despite current medical therapy, there might be a role in those patients for adjuvant therapy for improvement symptom control but not disease control. Optimization of medical therapy would still be indicated.
3. What dose and formulation of cannabis should I recommend to a patient as adjuvant therapy?
This is an excellent question and one that unfortunately we do not have the answer to. As mentioned previously, the studies have looked at varying formulations (THC alone, CBD:THC with varying percentages of THC, CBD alone) and varying routes of administration (sublingual, oral, inhalation). The IBD studies looking at CBD-alone formulations lacked clinical efficacy. In states where cannabis products have been accessible to IBD patients, no data on the product type (THC:CBD), method of administration, or prescriber preferences have been published.
4. What risks should I advise my patients about with cannabis use?
The challenge is that we don’t have large population-based studies in IBD looking at long-term risks of cannabis use. However, in the small RCT studies there were minimal reported side effects and no major adverse events over 8-10 weeks. Larger IBD population-based studies have shown that cannabis users were more likely to discontinue traditional medical therapy, and there is an increased risk for surgery in patients with Crohn’s disease. Larger studies in non-IBD patients have shown risk for addiction to other substances, diminished life achievement, increased motor vehicle accidents, chronic bronchitis, psychiatric disturbances and cannabis dependence, and cannabis hyperemesis syndrome (with an uncanny presentation resembling Crohn’s disease flare with partial small bowel obstruction). Patients should also be advised about legal implications of use (given its continued classification as a federal schedule 1 drug), possible drug interactions, and special considerations in pediatric patients (increased risk of addiction), elderly patients (increased risk of neuropsychological effects), and during pregnancy (with national obstetric society guidelines warning against use because of fetal exposure and increased risk of stillbirth).
