The present study is the first, large-scale nationwide cohort study to evaluate the association between cannabis use and clinical outcomes in hospitalized patients with UC. We found that amongst matched cohorts, cannabis users had a lower prevalence of partial or total colectomies and there was a trend towards lower prevalence of bowel obstruction. Cannabis users also had significantly shorter hospital length of stay compared to noncannabis users.
The efficacy of cannabis for the symptomatic relief of UC is still controversial. A study by Lahat et al reported statistically significant improvement in general health perception, social functioning, ability to work, physical pain, depression, and average Harvey-Bradshaw index for patients with IBD following three months treatment with inhaled cannabis. However, it is unclear whether these benefits are a result of attenuation of the disease process or due to the psychotropic effect of cannabis.
Other studies have shown that activation of enteric cannabinoid (CBD) receptors may reduce colonic motility and propulsion, promote wound healing, and be protective against excessive inflammation in the colon.[19,20] These findings are supported by a recent randomized control trial which demonstrated, clinical and endoscopic improvements among UC patients on cannabis compared to placebo. Conversely, another recent randomized control trial suggested that while there were significant improvements in subject global impression of change scores among trial participants on cannabinoid (CBD)-rich botanical extracts compared to patients on the placebo, remission rates were similar for patients on CBD-rich botanical extracts and placebo.
In clinical practice, colectomies are occasionally indicated for toxic megacolon, perforation, and severe colorectal bleeding. Also, colectomies may be indicated when there is failure of medical management with intractable symptoms, and less commonly with intestinal strictures.[23,24] It is therefore plausible that the lower prevalence of partial or total colectomy seen amongst cannabis users could possibly be due to fewer complications such as bowel obstruction, while shorter length of stay could possibly reflect a less severe exacerbation amongst cannabis users.
While Cannabis use may be associated with potential benefit in patients with UC, several side effects have also been associated with the use of cannabis ranging from mild side effects like nausea and vomiting[25–28] to more serious side effects like postural hypotension, delirium, psychosis, and seizure.[29,30] Cannabis use is also associated with the use of other illicit drugs and this raises potential public health concerns. In order to reduce the risk of most of the adverse effects of cannabis, CB2 receptors could be a potential target as most side effects of cannabis are due to activation of CB1 receptors in the brain. This creates an opportunity for directed therapy targeting CB2 receptors while maintaining its potential anti-inflammatory effect in colitis.
While previous research has been limited in terms of sample size, this study used a large database of hospitalized patients in the US. Also, cannabis users are likely abusers of other substances which could have influenced the outcomes of prior studies. However, in this study, we excluded patients with other drug abuse to avoid interference in our result. Nevertheless, our study has limitations. First, we couldn’t control for the time of diagnosis of ulcerative colitis, the severity of the disease, extent of the disease, historical and ongoing immunomodulator, or biologic therapy. Second, the NIS data is only generalizable to hospitalized populations of the United States and lack postdischarge follow up. Third, some data could have inaccurate coding as demonstrated in other administrative databases. Particularly, there could be under coding of cannabis use, due to which the prevalence of cannabis use is much lower in our population as compared to other studies.[32,33] Despite the mentioned limitations, we believe the large sample, our rigorous methodology, and the scientific rationale adds to the current literature on cannabis use in patients with UC. It should be emphasized that our study lacks data regarding cannabis consumption route, amount, frequency and side-effects related to cannabis use. Therefore, we recommend cautious interpretation of our results until they can be validated through prospective randomized studies.
In summary, our study suggests that cannabis use may mitigate some complications of UC among hospital inpatients and this could be due to an antiinflammatory effect of cannabis and potential improvement in gastrointestinal mucosal healing. Our study has important clinical findings and warrants further investigations.
Conceptualization: Bashar Attar, Wang Yuchen, Isaac Paintsil, Mathew Madhu, Oyintayo Ajiboye, Simons-Linares C. Roberto, William E. Trick, Vikram Kotwal.
Data curation: Wang Yuchen.
Formal analysis: Chimezie Mbachi, Wang Yuchen.
Methodology: Wang Yuchen, William E. Trick, Vikram Kotwal.
Software: Wang Yuchen.
Supervision: Bashar Attar, Wang Yuchen, Isaac Paintsil, Mathew Madhu, Simons-Linares C. Roberto, William E. Trick, Vikram Kotwal.
Visualization: Simons-Linares C. Roberto.
Writing – original draft: Chimezie Mbachi, Bashar Attar, Olamide Oyenubi, Wang Yuchen, Isaac Paintsil, Mathew Madhu, Oyintayo Ajiboye, Simons-Linares C. Roberto, Vikram Kotwal.
Writing – review & editing: Chimezie Mbachi, Olamide Oyenubi, Wang Yuchen, Aisien Efesomwan, Isaac Paintsil, Oyintayo Ajiboye, William E. Trick, Vikram Kotwal.
Chimezie Mbachi orcid: 0000-0002-4046-282X.
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Keywords:Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.
cannabis; complications; inflammatory bowel disease; ulcerative colitis