Over the past decade, interest in the potential of the 500-plus compounds in the cannabis plant to treat inflammatory bowel disease (IBD), which includes ulcerative colitis and Crohn’s disease, has led to the expansion of medical research in that area. While current IBD treatments have made huge inroads in controlling the impact of the disease, many sufferers continue to experience symptoms related to their condition. Here enters the potential of cannabis to improve the quality of life of those suffering from Ulcerative Colitis.
The potential for cannabis as a safe and effective treatment for patients with ulcerative colitis is promising. A number of small, randomized, blind, and double-blind studies are bringing more awareness to cannabis as an alternative medication in place of or to supplement medical procedures and or other prescriptions. More substantial and long-term clinical studies are necessary for wide-scale approval of medical cannabis treatment for colitis.
The Endocannabinoid System
The endocannabinoid system (ECS) is a complex system found in all vertebrates that helps maintain homeostasis (balance) throughout the body. Research identifying and studying the major neuromodulatory system has been ongoing for over 25 years. The ECS consists of cannabinoid receptors, endocannabinoids, and the enzymes that break down the endocannabinoids.
The endocannabinoids, molecules also known as endogenous cannabinoids because they are produced inside the body, are primarily anandamide (AEA) and 2-arachidonoylglycerol (2-AG). These are produced by the body when a system has a deficit. The ECS maintains levels through the signaling process between the cannabinoid receptors and endocannabinoids.
The two most abundant cannabinoid receptors are CB1 and CB2. Though found throughout the body, CB1 receptors are concentrated along the central nervous system, and CB2 receptors are mainly in the immune system. Endocannabinoids bind to these receptors to send signals to the ECS. After the CB1 and CB2 connect with the ECS, the enzymes break down the endogenous cannabinoids. The two main enzymes are fatty acid amide hydrolase (FAAH) and monoacylglycerol acid lipase (MAGL).
The ECS also interact with phytocannabinoids, plant-based cannabinoids similar to those found in the body, including the ones found in cannabis. Scientists have isolated at least 144 cannabis plant-based cannabinoids. Researchers have the most data about the cannabinoids delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD), and many of the studies involving ulcerative colitis and cannabis are specific to these compounds.
Many cannabinoid receptors are located in areas significant to ulcerative colitis, such as the gastrointestinal tract, brain, immune cells, and the enteric nervous system. A 2009 study of mice with colitis found when the CB1 and or CB2 receptors signal the ECS in the colon or rectum, inflammation, which leads to the symptoms of ulcerative colitis decreased.
Dozens of peer-reviewed research papers and anecdotal reports show that THC and CBD reduce inflammation in patients with a variety of conditions, including many gastrointestinal diseases. Survey-based results also concur that cannabis can reduce the symptoms, such as stomach pain, nausea, and diarrhea. In addition to THC and CBD, many of the plant’s lesser-known cannabinoids and terpenes have anti-inflammatory properties.
Cannabis & Ulcerative Colitis
Ulcerative colitis can cause painful inflammation in the colon and/or rectum. Several clinical studies conducted over the past several years provide evidence that whole-plant cannabis treatments and CBD isolates may reduce associated symptoms and improve patients’ quality of life.
A 2018 journal review of studies and clinical trials in 51 publications took a look at the findings about the role of cannabinoids on murine colitis (colitis induced in mice). Most of the studies involved CBD rather than THC or other cannabinoids, likely because CBD is easier to access legally due to its non-psychoactive nature. The authors concluded that the amount of quality reviews provided enough information to warrant more large-scale clinical studies.
- In 2017, the Inflammatory Bowel Disease Journal published a review of the CB1 and CB2, endocannabinoids, and murine colitis. It found the manipulation of the ECS had the potential to reduce inflammation in the colon and rectum. This study looked at the method of delivery, too—rectal administration (suppositories) showed the most significant results, and oral methods did not reduce inflammation. This anatomically correlates with disease activity of UC, where inflammation is most often found in the rectum.
- A 2018 report in the Inflammatory Bowel Disease Journal published the results of a randomized, double-blind, placebo-controlled, parallel-group, pilot study of cannabidiol-rich treatment of patients over 18 with left-sided or extensive ulcerative colitis. The CBD-rich extract, GWP42003, contained 4% THC. Patients in the study receiving the CBD achieved positive results by the end of the 10 weeks. The results found that 59% of the participants had remission rates of 28%.
- In 2018, researchers reviewed two studies involving 92 adult patients with active ulcerative colitis. The first study included 60 participants using cannabis oil capsules containing up to 4.7% THC. Of 60 participants, 24% went into clinical remission. The second study took place over 8 weeks, and patients smoked two cannabis cigarettes with a half gram of flowers in each. These participants had lower disease activity index scores. The second study didn’t include remission rates.
In addition to these studies, there are patient surveys providing anecdotal results. These aren’t science-based. Instead, they recorded the responses of current cannabis users with ulcerative colitis. A survey of patients in the US found less abdominal pain, an increase in appetite, and reductions in nausea and diarrhea.
Cannabis as medication used in conjunction with a physician’s care is considered safe. The most common side effects that patients experience are mild compared to other medications. They include drowsiness, fatigue, dizziness, feelings of euphoria, dry mouth, paranoia, anxiety, increased appetite, reduced attention, headaches, and nausea.
Side effects can vary depending on dosage, and differ depending on the cannabinoid. For instance, a CBD-isolate, a single-compound oil extract, doesn’t produce extreme feelings of euphoria or paranoia because CBD is a non-psychoactive compound.
To this day, there are no recorded fatalities secondary to direct intake of cannabis.
Drug interactions may occur with cannabinoid treatments. Studies show that the phytocannabinoids THC and CBD may interfere with patients taking warfarin, a medication that helps prevent blood clots. The compounds might interfere with specific cancer breast cancer chemotherapies and antiepileptic drugs. Like any other medicine, always discuss taking medical cannabis with your doctor prior to starting.
Multiple states and countries have approved cannabis for the treatment of IBD. Many others don’t specifically mention IBD, but have indications for chronic pain which patients may experience secondary to Ulcerative Colitis. Specific laws differ from state to state and country.
Medical cannabis programs in Israel, Canada, the Netherlands, Italy, Switzerland, Uruguay, and Australia, include chronic pain as an acceptable disease, which would allow its use to treat ulcerative colitis symptoms. Most programs require traditional medications to be unsuccessful before approving medical cannabis.
US laws governing medical use vary by state. The cannabis plant remains illegal under federal law. However, states have enacted separate laws over the past 20 years approving the use of specific cannabis compounds and products for a variety of medical conditions. Each state has different conditions that can qualify a patient to use medical cannabis treatments. States that list ulcerative colitis as an approved condition include New York, Connecticut, Ohio, and Michigan.
Some therapeutic programs allow treatment for patients with chronic, debilitating diseases. These states include,
Ulcerative colitis is a chronic, long-term disease that affects the large intestine—also called the colon—and the rectum, which is the end of the large intestine.
When you have ulcerative colitis, the lining of the colon and/or rectum becomes inflamed, developing painful ulcers that produce blood and pus, or mucus, which can cause multiple complications that can even be life threatening.
For most people, ulcerative colitis develops slowly over time. It’s usually first diagnosed when a patient is in their early 30s, but can also come earlier or later. The disease can affect anyone, from any ethnic group, and of both genders.
Ulcerative colitis has many of the same symptoms as Crohn’s disease. They are both types of inflammatory bowel disease (IBD), but it’s not the same illness. Ulcerative colitis is limited to one part of the digestive system while Crohn’s disease can affect any part of the GI tract.
There are a few types of ulcerative colitis, which are classified according to the part of the digestive tract most affected by ulcers:
- Ulcerative proctitis is the least severe form of ulcerative colitis. It affects only the rectum, close to the anus, and often you’ll only see rectal bleeding but won’t feel any other symptoms.
- Proctosigmoiditis affects the rectum and the lower end of the colon, called the sigmoid colon. If you have proctosigmoiditis, you might feel cramps and pain in your abdomen, see bloody diarrhea, and find it difficult to empty your bowels.
- Left-sided colitis is when the inflammation continues a little further up your colon, causing cramps and pain in the left side of your abdomen, bloody diarrhea, and weight loss.
- Pancolitis can affect the rectum and entire colon. It’s painful, causing severe bloody diarrhea, stomach pains and cramps, fatigue, and weight loss.
- Acute severe ulcerative colitis is the most rare and most severe form of ulcerative colitis. It causes such severe pain, diarrhea, and bleeding that it’s almost impossible for you to eat.
It’s estimated that between 2.5 and 3 million people in Europe and 10 million worldwide live with either ulcerative colitis or Crohn’s disease. It seems to occur the most in northern Europe, particularly in Scandinavia and the UK, and is less common in eastern Europe. Norway has the highest incidence, with 505 cases per 100,000 people. In the US, 1.3% of the population has been diagnosed with either ulcerative colitis or Crohn’s disease, numbering around 3 million people.
Most people with ulcerative colitis have mild to moderate symptoms, especially when ulcerative colitis first appears. About 10% of people have severe symptoms when they first experience ulcerative colitis.
The severity of symptoms depends on how much of the colon is inflamed, and how severe the inflammation is. The main symptoms are:
- Blood or pus in your stool
- Persistent and bloody diarrhea
- Pain and cramps in your abdomen or rectal area
- Weight loss, fatigue
You might also feel like you urgently need to empty your bowels, but then be unable to do so fully, and feel tired, nauseous, and lacking in appetite. On rare occasions, some people also develop a fever, or become anemic, which is when the red blood cell count is low.
It’s common for ulcerative colitis patients to have periods of remission, when symptoms are mild or even disappear entirely, and flare-ups, when symptoms get worse. During a flare-up, one can experience symptoms elsewhere in your body, including:
- Inflamed, swollen joints
- Areas of itchy, painful rashes on the skin
- Mouth ulcers
- Sore red eyes
- Shortness of breath
- A fast, irregular heartbeat
When to see a doctor
If you have the main symptoms of ulcerative colitis that are listed above, or you notice a persistent change in your bowel movements, you should discuss it with your doctor as soon as possible. Ulcerative colitis is rarely fatal, but it is a serious disease that can cause great discomfort if it’s not managed properly.
Your doctor will begin by taking your medical history, giving you a thorough physical examination, and checking you for paleness, a sign of anemia, and tender areas in your abdomen that could be caused by inflammation in your digestive tract.
You can expect to have blood and stool tests so that the doctor can rule out stomach infections like gastroenteritis, which can have similar symptoms to ulcerative colitis.
If your doctor suspects that you have IBD, you’ll be sent for more tests to diagnose whether you have Crohn’s disease or ulcerative colitis. These usually include a sigmoidoscopy, which uses a camera in a thin, flexible tube to examine your rectum and the lower part of your colon for inflammation. The doctor might take a small tissue sample as a biopsy to be tested in a lab. The process takes about 15 minutes, and you can go home the same day.
For a full diagnosis you will also undergo a full colonoscopy. This is similar to a sigmoidoscopy, but it examines your entire colon. The doctor might take a biopsy during your colonoscopy as well. The procedure is usually ambulatory and people go home the same day.
If symptoms are acute and severe, you might have an X-ray or CT scan to check for serious complications, like a perforated colon. A CT scan also helps show how much of the colon is inflamed. On rare occasions, your doctor might recommend non-invasive CT or MR enterography. These are sensitive medical imaging tests that can pick up inflammation in your small intestine, to check how far the inflammation stretches.
It’s not known exactly what causes ulcerative colitis, but it’s considered to be an auto-immune disorder. The immune system starts to attack the body instead of infections, causing inflammation. In the case of ulcerative colitis, the immune system attacks areas of the digestive tract. People suffering from ulcerative colitis also have a higher likelihood of having other autoimmune diseases as well.
There are a few risk factors that make it more likely to develop ulcerative colitis:
- Race and ethnicity. Ashkenazi Jews are most likely to develop ulcerative colitis.
- Genetics. One in four people with ulcerative colitis have a family history of IBD.
- Environmental factors. Air pollution, medication, and diet have been linked to ulcerative colitis.
- Location. Ulcerative colitis occurs more often in people who live in cities in northern areas of western Europe and the US, and in countries with improved sanitation.
It’s not always clear what causes a flare-up, but stress and gut infections are frequently blamed.
Ulcerative colitis can be treated but there is no complete cure without significant complications. Treatment is aimed to reduce symptoms and improve quality of life. If severe enough, the entire large colon and rectum can be removed but this does impact quality of life.
Generally, the first step in treating ulcerative colitis is to prescribe medication that reduces the symptoms. There are a number of different medications for ulcerative colitis, and it might take some time and trial and error to find the one that is the most effective and has the least side effects. The primary medications include:
- Aminosalicylates, or 5-ASAs, are the first option for most people with mild or moderate ulcerative colitis. They reduce inflammation, allowing damaged tissue to heal. You can take them long term, or as a short-term treatment for flare-ups. Side effects are usually minimal, including headaches, stomach pain, and nausea. You can take 5-ASAs as an enema or suppository, or in tablet and capsule form.
- Corticosteroids, such as prednisone, are a more powerful class of medications. They are used to treat flare-ups or moderate to severe ulcerative colitis, but they can have serious side effects like osteoporosis and cataracts if taken long term. They counteract the immune system and reduce its ability to cause harm in ulcerative colitis. However, they have significant side effects associated with taking them long term.
- Immunosuppressants reduce the activity of your immune system to help prevent it from attacking your colon lining. They’re usually prescribed as tablets. Immunosuppressants generally work well to treat ulcerative colitis, but they tend to take between two-to-three months to start having an effect. Immunosuppressants can increase vulnerability to infection and lower the blood cell count.
- Biologic therapies are also used to treat ulcerative colitis include. They quickly reduce inflammation by targeting the immune system’s TNF proteins which are closely involved in the inflammatory process in ulcerative colitis. They also have side effects and are usually given as injections or infusions.
You might also be prescribed:
- Acetaminophen and other painkillers, but not analgesics like ibuprofen and aspirin which can make your symptoms worse.
- Antibiotics to treat secondary infections.
- Anti-diarrheal medications like loperamide help stop diarrhea, but they need to be prescribed carefully because they increase the risk of developing megacolon (an enlarged colon).
- Iron supplements, since it’s common for the intestinal bleeding of ulcerative colitis to cause an iron deficiency.
Surgery to remove your colon and rectum through a colectomy or proctocolectomy can entirely eliminate ulcerative colitis. You can’t get it again once your colon and rectum have been removed.
The surgeon usually creates a small pouch to collect your stool, called an ileoanal pouch, or a J-pouch, which allows you to still empty your bowels in the natural way. If this isn’t possible, they might make an opening to your small intestine in your abdomen so that the stool is collected in a bag outside your body.
Although it’s not clear that what you eat causes ulcerative colitis, your diet can help you to control flare-ups and reduce your symptoms. Some dietary changes that help improve your quality of life include:
- Reducing the consumption of dairy products
- Eating small, frequent meals
- Avoiding spicy food, caffeine, and alcohol
- Avoiding carbonated drinks
- Not eating high-fiber foods like fresh fruit and vegetables and whole grains
- Drinking plenty of liquids
- Some people find that drinking probiotics on a regular basis and following a specific diet like a lactose-free diet, low salt, low fiber, or low fat diet, helps ease their symptoms.
Since stress can be a factor in flare-ups, it’s recommended to use strategies to reduce stress, like taking regular exercise and using relaxation techniques, and meditation.
Popular alternative therapies include:
- Herbal and nutritional supplements, like omega-3 fish oil and turmeric, can help reduce the symptoms of ulcerative colitis. Before taking any nutritional or herbal supplements, it’s important to check with your doctor that they won’t interact badly with any of your medication.
- Some people find that aloe vera can help reduce inflammation, although it can also increase diarrhea.
- Acupuncture can encourage the body to release natural painkillers and help you to manage the discomfort of ulcerative colitis.