Exploring the Role of Cannabis in Inflammatory Bowel Disease

Announcer Wrap:
Welcome to Crohn’s & Colitis Foundation Perspectives on ReachMD. Here’s your host, Dr. Shira Johnson.

Dr. Johnson:
According to recent studies, smoking cannabis can improve the debilitating symptoms, like pain and nausea, that are associated with inflammatory bowel disease, or IBD for short. But when it comes to medical cannabis’ ability to reduce IBD inflammation, or improve disease activity, the jury is still out. So with these initial findings, and further research underway, where do we stand in terms of our current understanding of the impact medical cannabis can have on our patients with IBD?
Welcome to Crohn’s and Colitis Foundation Perspectives on ReachMD. I’m Dr. Shira Johnson, and joining me in this discussion is Dr. Arun Swaminath, a practicing gastroenterologist at Northwell Health and Director of the Inflammatory Bowel Diseases Program at Lenox Hill Hospital in New York City. Dr. Swaminath, it’s great to have you with us.

Dr. Swaminath:
My pleasure.

Dr. Johnson:
To begin, Dr. Swaminath, what are some of the medical effects of cannabis?

Dr. Swaminath:
You know, if you look at the mouse studies, and there are a great many of them, you would think it was gonna be a home run, because every mouse study that is a model for human Crohn’s and colitis looked amazing when you were looking at the models of cannabis treating the inflammation and the mouse models of colitis. So we were hoping that you’d see the same thing when it translated to humans. It didn’t turn out to be quite that way. What we’ve mainly found is that people feel better. Their quality of life improves, depending on what questions you ask them. But their bowel disease, meaning their underlying inflammation, doesn’t really change very much.

Dr. Johnson:
Can you explain some of the research on the different formulations out there, from traditional cannabis to cannabidiol or CBD oil and other derivatives?

Dr. Swaminath:
Cannabis is not regulated like the pharmaceuticals we’re used to prescribing for IBD. Because of that, it’s almost treated like an herbal supplement. There’s no specific agency – state or otherwise – that is looking at quality control, or looking at concentrations and formulations of drugs. All those specific state laws may allow certain formulations, or disallow formulations, based on that state law. So it’s important for people to be aware of different formulations, for example, the product can be broken down into different concentrations of THC and CBD, which is sort of the first distinction. THC will have greater changes on the psychological mood-like complaints, and CBD may have more of a focus on the gut-related complaints, such as diarrhea or abdominal pain.

Now, once you go beyond that distinction, you have to choose the type of product you’re gonna fill, and the patient may be based off another dispensary, under the guidance of someone who is local to the product and understands the product, and will make recommendations, as opposed to the physician who has supported the use of cannabis. So, a patient may be choosing between vaping pens or THC cigarettes or vaporizers, or oils that are gonna be mixed into foods. And each of these have slightly different products. It’s important to be aware that inhaled products will achieve a faster and higher levels in the blood, and that some of the side effects associated with that include hyperemesis syndrome which involves abdominal pain, nausea, vomiting – which really look a lot like Crohn’s flare, and that can be confusing both for the patient and for the physician. Products that are ingested – for example, if the oil is mixed into cookies and  brownies, the patient might eat some and not feel anything, and then eat some more and not feel anything, and eat some more and then realize, probably the slow absorption, and they’re starting to have a more intoxicated profile. And so that’s important to know. And finally, each patient and physician probably need to be aware of the exposure history. So someone who’s naïve will have a very narrow therapeutic window, and can have a bad experience versus someone who is already exposed to cannabis and is an experienced user, will have a larger therapeutic window.

Dr. Johnson:
Can you tell us about the current data and some of the ongoing research on cannabis in IBD?

Dr. Swaminath:
Certainly, there have not been very many trials, and the main reason for that is in the U.S., it’s been very difficult to research  cannabis and cannabis diseases that may benefit from exposure to cannabis. The reason for that is cannabis is a Schedule One drug, as scheduled by the federal government, which means it has a high chance of abuse and a loaded value medically, and while people may disagree about that, that schedule categorization has not changed in over thirty years. All of the data that really comes from cannabis and IBD comes from Israel, where the product is available on a compassionate-use basis. Dr. Naftali has been at the forefront of research in cannabis, and has performed several randomized control trials, in both Crohn’s and also colitis. And really, the summary of all of these small trials – with the largest one being about 46 patients in Crohn’s, and the largest in UC being about 60 patients – is that patients felt better, and they often felt better because they had less pain, less nausea, better appetite and fewer IBD-related symptoms.

However, when you did a deeper dive into this, many of the early studies looked very positive because these, products in cannabis make people feel better, and that may have nothing to do with controlling the underlying inflammation. And so, if someone is  getting THC and they are slightly high, well their mood is better, and their pain is less noticeable, and they may have less diarrhea as well. So those quality of life improvement scores will improve. But when the studies became more rigorous and included inflammatory markers, both blood and stool as well as endoscopy, what we noticed were that there were no changes to any of these markers, suggesting that there was no benefit to treating the underlying inflammation. We also saw that patients who had stopped using the product started to have symptoms again, as soon as within two weeks of stopping the product, and so I think there is a little more work to be done here. But so far, we have not seen evidence of improvement in inflammation.

Dr. Johnson:
For those just tuning in, you’re listening to Crohn’s and Colitis Foundation’s Perspectives on ReachMD. I’m Dr. Shira Johnson, and today I’m speaking with Dr. Arun Swaminath, from Northwell Health, about the role of medical cannabis in inflammatory bowel disease, or IBD. So Dr. Swaminath, let’s shift gears a little and talk about access to cannabis for your patients with IBD.

Dr. Swaminath:
Yeah, this is a really important question. Availability of cannabis, either recreationally or legally varies state by state, and so each provider needs to be aware of the process and the availability of the product within their own state. Now, patients have to be open about their own use of cannabis, so that a provider is able to determine whether they’re truly a novice exposure versus someone who is more experienced, and secondly, the provider has to get a good sense of what symptom is being addressed. So, there is no specific society guideline on exactly how cannabis should be used in the management of IBD, and there is no consensus on this. However, I think many of us who treat patients with IBD see patients that are improved with use of cannabis and I think that what I’m saying is really a product of experience as well as the data. And so, I think there is a general consensus that there should not be a replacement of standard therapy with a cannabis product, because we know, based on all the available human data that there is no improvement in the underlying inflammatory process. So a patient may feel better, but the disease may continue to progress. That being said, if a patient is persistently symptomatic on therapy, then we have to put a little bit more thought into that. So is it that the therapy that they’re on isn’t working? Is it that the therapy that they’re on isn’t optimized? If both of those things have been addressed, then is it possible that one of the interventions that might improve the current quality of life recommendation is the use of a cannabis product. And what type of product again is often not in the hands of the provider, but maybe in the hands of a dispensary, based on the systems that are available for patients to access this product in their state.

Dr. Johnson:
Lastly, Dr. Swaminath, I understand you were involved in the Crohn’s and Colitis Foundation’s position on medical cannabis. Can you share the Foundation’s position statement, and your thinking about that with us?

Dr. Swaminath:
Yeah, so this was a really a wonderful group of physicians led by Dr. Rubin, and again, supported under the aegis of the Crohn’s and Colitis Foundation and really came together from across the country, and we had help with lawyers who are knowledgeable about the legal aspects of this issue as well as patients as well as treating providers, adult and pediatric gastroenterologists who see patients with IBD. And so this group came together to look at the current data behind cannabis and IBD. And what we found was basically what we’ve managed to summarize today, which is that although there is no evidence of change in inflammatory markers or the degree of underlying inflammation, that patients may experience benefit, and that these products may be useful as adjunct therapy, based on what we know now. However, the future may look very different. We may have specific medications that are able to affect CB1 and CB2 receptors individually, and that may supersede the need for cannabis which has again – which has over 500 chemical compounds contained in it. And so, I think for now, we’re still learning. There is a call for more research, with the understanding that there are a lot of limitations to address, and we’ll have to see where it goes.

Dr. Johnson:
Well, this has been an extremely valuable discussion, about where we’re currently at and where we could be in terms of medical cannabis and IBD patients. And I’d like to thank my guest, Dr. Arun Swaminath, for joining me today. It was really great having you on the program.

Dr. Swaminath:
It was my pleasure, thank you.

Announcer Wrap:
This episode was brought to you in collaboration with the Crohn’s & Colitis Foundation. To learn more about the Crohn's & Colitis Foundation, please visit crohnscolitisfoundation.org. And if you have missed any part of this discussion, or to find others in the series, visit ReachMD.com/foundation, where you can Be Part of the Knowledge. Thanks for listening!