IBD – How can cannabinoids help?

They cause considerable suffering: chronic inflammatory bowel diseases (IBD) such as Crohn’s Disease (MC), Colitis Ulcerosa (CU) and some lesser-known forms are associated with unpleasant symptoms such as constant diarrhea, weight loss, severe abdominal pain and reduced performance. Although studies on the mechanism of action in the gastrointestinal tract are inconclusive, there is increasing evidence that medical cannabis improves quality of life. 

Chronic Inflammatory Bowel Disease (IBD): What is behind this term?

The medical community defines IBD as chronic inflammatory bowel disease – persistent, non-contagious diseases of the digestive tract which symptoms usually occur in episodes [1].

In addition to the best-known representatives – Crohn’s Disease and Colitis Ulcerosa – other lesser-known forms are included in IBD [2]:

  • Pouchitis (inflammation of the pouch, a pouch formed from the rectum, which is considered an outlet for the bowel after surgical removal of the colon and rectum)
  • Microscopic Colitis
  • Eosinophilic Gastroenteritis
  • Colitis Cystica Profunda or Enterocolitis Cystica Profunda

What all clinical pictures have in common is that the affected patients show increased inflammation values in blood and stool. Active phases of the disease with symptoms (“relapse”) alternate with symptom-free intervals (“remission”). The fear of the next disease flare-up is often perceived by patients as an additional burden. The goal of any therapy is therefore to achieve remission as quickly as possible and to maintain it for as long as possible. In about 50 percent of cases of IBD, there are additional symptoms outside the intestine (“extraintestinal manifestations”), for example of the joints or of the liver, kidney and gallbladder, as well as of the eyes and mouth [1].

The number of patients with Inflammatory Bowel Disease is increasing worldwide: While 3.7 million people were affected in 1990, 6.8 million people were affected in 2017 [3]. According to estimates, approximately 420,000 to 470,000 people in Germany suffer from IBD, which means that the diseases represent a considerable economic risk. In most cases, young people tend to develop the disease and are subsequently affected throughout their entire lives [4].

Therapy of Inflammatory Bowel Diseases

The drug treatment of IBD depends on the affected bowel segments and the course of the disease. The exact causes of the disease are not known for the entire spectrum of forms. While experts used to assume that the disease was purely autoimmune, an interplay of various factors – including genetic and immunological factors – is now being discussed.

Crohn’s Disease

Acute attacks of Crohn’s Disease are usually treated with the anti-inflammatory agent mesalazine or corticosteriods such as budesonide. The latter acts mainly locally in the intestine and is available as suppositories, enemas or foam. In more severe episodes of the disease or if the stomach, esophagus and duodenum are additionally inflamed, the therapy is supplemented with systemic steroids such as prednisolone. This is to prevent severe involvement of the small intestine, which is responsible for nutrient absorption.

After acute therapy, long-term therapy is usually initiated. In addition to classical immunosuppressants, so-called biologics (“monoclonal antibodies”) are also used.  Both classic immunosuppressants and biologics dampen the immune system’s excessive reaction to its own body.

Colitis Ulcerosa

The therapy of Colitis Ulcerosa also follows a stepwise scheme. In contrast to Crohn’s disease, only the rectum and sometimes also the colon are inflamed in this disease, but not the entire digestive tract. In addition, the center of inflammation are usually found only on the top layer of the intestinal wall. Those suffering from a current episode are usually first treated with 5-aminosalicylic acid (5-ASA), a precursor of the active ingredient mesalazine. Subsequently, the therapy is similar to that for Crohn’s Disease, but must always be adapted to the individual course of the disease. As with all forms of IBD, close medical supervision is indispensable [5].

Side effects of drug therapy

Steroids in particular have an unpleasant side effect profile. Among other things, the drugs can lead to osteoporosis, weight gain, a specific form of diabetes, and skin thinning. The goal of any therapy for IBD is therefore to increase the number of symptom-free intervals and to get by with as few steroids as possible. Unfortunately, treatment with immunosuppressants is not free of side effects either, since the suppression of the body’s own defenses increases the risk of fungal and viral infections.

It remains the task of the patients and their physicians to find out which measures enable the best specific therapy result.

Medical cannabis: Improved quality of life in Inflammatory Bowel Diseases

The anti-inflammatory and analgesic properties of cannabinoids may alleviate some of the distressing symptoms associated with IBD. The endogenous endocannabinoid system is now thought to be involved in the control of key mechanisms of action in the gastrointestinal tract. Thus, it plays a central role in the regulation of motor activity – including intestinal mobility – as well as in the development of nausea and vomiting and the maintenance of the intestinal surface. Even if, according to the current state of research, cannabinoids cannot achieve complete freedom from symptoms (“remission”) in most cases, it is still possible to significantly improve the quality of life of those affected as part of a therapy.

It is also interesting to note that cannabis is already highly accepted by many people with IBD (see below).

Advantages of cannabinoids at a glance

  • Anti-inflammatory
  • Improvement of intestinal mobility
  • Analgesic
  • Increase of the well-being
  • Decrease of the activity of the IBD

Less steroids through treatment with cannabis flowers

2013: In a randomized controlled trial, Israeli researchers investigated the effect of THC-rich cannabis flowers on patients suffering from Crohn’s Disease (22 patients) or Colitis Ulcerosa  (10 patients). The results are promising: after eight weeks of therapy, five of the participants achieved a remission of their symptoms. By comparison, only one person in the placebo group achieved remission. In addition, five patients were able to discontinue treatment with corticosteroids.

THC thus appears to be a therapeutic option for Inflammatory Bowel Disease and to reduce the need for steroids [6].

High acceptance of cannabinoids among people suffering from IBD

In various recent studies, international scientists concluded that patients suffering from IBD already use cannabinoids relatively frequently – and with good individual success. For example, a meta-analysis of various surveys and smaller studies by Austrian experts in 2017 showed relief of typical IBD symptoms such as diarrhea, abdominal pain, or nausea in those affected [7].

German cross-sectional survey shows symptom relief in Crohn’s disease and ulcerative colitis with cannabis-based medicines

A German cross-sectional survey of IBD patients conducted in 2021 yielded a similar result: Respondents also reported improvement in Crohn’s Disease and Colitis Ulcerosa-related symptoms such as abdominal pain, sleep, restlessness, and anxiety. However, more than half used unregulated products from the black market that are not subject to quality control. Thus, there is a need for further clinical research [8].

Patient survey shows high recommendation rate for cannabinoids by CED sufferers.

83 percent of users confirmed relief of their complaint problems such as abdominal pain and bowel problems, and over 90 percent would recommend cannabinoids for therapy. Alarming is the fact that more than half of the users obtain the substances on the black market.

The initiators of the survey conclude that there is a need for action and call on the treating physicians to provide more information to IBD patients about the treatment options with cannabis-based medicines [9].

Sources:

[1] Was ist Morbus Crohn, was ist Colitis ulcerosa? CED-Kompass. Retrieved May 11, 2022, from https://ced-kompass.at/dein-wissen/

[2] Hoffmann J. C., Jörg Carl Hoffmann, Autschbach, F., & Al, E. (2004). Chronisch entzündliche Darmerkrankungen das CED-Handbuch für Klinik und Praxis ; 66 Tabellen. Stuttgart Georg Thieme.

[3] Alatab, S., Sepanlou, S. G., Ikuta, K., Vahedi, H., Bisignano, C., Safiri, S., Sadeghi, A., Nixon, M. R., Abdoli, A., Abolhassani, H., Alipour, V., Almadi, M. A. H., Almasi-Hashiani, A., Anushiravani, A., Arabloo, J., Atique, S., Awasthi, A., Badawi, A., Baig, A. A. A., & Bhala, N. (2020). The global, regional, and national burden of inflammatory bowel disease in 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. The Lancet Gastroenterology & Hepatology, 5(1), 17–30. https://doi.org/10.1016/s2468-1253(19)30333-4

[4] Yumpu.com. (n.d.). Die chronisch entzündlichen Darmerkrankungen … – Barmer GEK. Yumpu.com. Retrieved May 11, 2022, from https://www.yumpu.com/de/document/view/15919925/die-chronisch-entzundlichen-darmerkrankungen-barmer-gek

[5] Sturm, A., Stallmach, A., Atreya, R., Bettenworth, D., Bokemeyer, B., Dignaß, A., Ehehalt, R., Germer, C., Grunert, P. C., Helwig, U., Herrlinger, K., Kienle, P., Kreis, M. E., Kucharzik, T., Langhorst, J., Maaser, C., Ockenga, J., Ott, C., Siegmund, B., & Zeißig, S. (2022). Aktualisierte S3-Leitlinie „Diagnostik und Therapie des Morbus Crohn“ der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – August 2021 – AWMF-Registernummer: 021-004. Zeitschrift Für Gastroenterologie, 60(03), 332–418. https://doi.org/10.1055/a-1713-3941

[6] Naftali, T., Barlev, L., Gabay, G., Chowers, Y., Dotan, I., Stein, A., Bronstein, M., & Konikoff, F. M. (2013). P358 Tetrahydrocannabinol (THC) induces clinical and biochemical improvement with a steroid sparing effect in active inflammatory bowel disease. Journal of Crohn’s and Colitis, 7, S153. https://doi.org/10.1016/s1873-9946(13)60379-7

[7] ] Hasenoehrl, C., Storr, M., & Schicho, R. (2017). Cannabinoids for treating inflammatory bowel diseases: where are we and where do we go? Expert Review of Gastroenterology & Hepatology, 11(4), 329–337. https://doi.org/10.1080/17474124.2017.1292851

[8] Neufeld, T., Pfuhlmann, K., Stock-Schröer, B., Kairey, L., Bauer, N., Häuser, W., & Langhorst, J. (2021). Cannabis use of patients with inflammatory bowel disease in Germany: a cross-sectional survey. Zeitschrift Für Gastroenterologie. https://doi.org/10.1055/a-1400-2768

[9] Langhorst, J., & Häuser, W. (n.d.). Querschnittserhebung: Cannabiskonsum von CED- Betroffenen in Deutschland. Bauchredner, 1/2022, 82-89.

About Mirjam Hübner

Mirjam Hübner ist Diplom-Journalistin und arbeitet als Redakteurin und Kommunikationstrainerin. Sie verfügt über langjährige Erfahrung in Journalismus und Unternehmenskommunikation, vor allem in den Bereichen Gesundheit und Finanzdienstleistung.