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Cited by 25Cannabis and Cannabinoid ResearchComplementary and Alternative Medicine StudiesGastrointestinal motility and disorders

Canadian Association of Gastroenterology Position Statement: Use of Cannabis in Gastroenterological and Hepatic Disorders

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Andrews, Christopher N, Devlin, Shane M, Le Foll, Bernard, Fischer, Benedikt, Tse, Frances, Storr, Martin, Congly, Stephen E·2019·Journal of the Canadian Association of Gastroenterology
DOI 10.1093/jcag/gwy064PMC PMC6507278
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Abstract

Medical cannabinoid products are widely used in Canada to treat medical symptoms of all kinds, and gastrointestinal (GI) symptoms are among the most commonly cited reasons for use (1). Cannabis is also widely used recreationally (2), and legalization of recreational use has occurred in Canada. Currently, cannabis is not an approved therapeutic product in Canada. However, health care practitioners may authorize the use of cannabis in various forms or synthetic cannabinoids for the relief of symptoms associated with a variety of disorders which have not responded to conventional medical treatments. These include pain and spasticity due to multiple sclerosis; severe nausea and vomiting related to cancer chemotherapy; loss of appetite and body weight in cancer patients and patients with HIV/AIDS; chronic noncancer pain (mainly neuropathic); severe refractory cancer-associated pain; insomnia and depressed mood associated with chronic diseases (HIV/AIDS, chronic noncancer pain); and symptoms encountered in the palliative/end-of-life setting (3). Yet, evidence supporting the safety and efficacy of cannabis for the treatment of many of these conditions is often limited and inconsistent. Certainly, a biological rationale exists for cannabinoids to have possible benefit for GI symptoms based on its known physiologic actions (3, 4) but research in the field has been hampered by its historical illegality, plus the inability to patent a natural product which is widely available. However, there are also concerns regarding potential adverse effects of acute and chronic cannabis use including dependence, tolerance, psychiatric disorders, poor school or work performance, nervous system disorders, vascular and cardiac disorders, carcinogenesis and gastrointestinal disorders such as cannabis hyperemesis syndrome (CHS) and fibrosis progression in chronic hepatitis C. The pharmacodynamics and pharmacokinetics of inhaled and ingested cannabis are reasonably well known and are reviewed elsewhere (3). However, very few randomized clinical trials of cannabis exist for GI indications, and the evidence that does exist is typically low or very low quality (such as case series or open-label studies). Further hampering a clear picture is the lack of standardization of cannabinoid products, which may contain hundreds of bioactive compounds, of which most have unknown effects. Two cannabinoids are better understood and are typically used to guide prescribing (specifically delta-9 tetrahydrocannabidiol [THC] and cannabidiol [CBD]), but these also vary substantially across strains of cannabis. Variability in inhalation or ingestion methods can also dramatically affect levels and effects of bioactive substances in the body. Given these factors, the Canadian Association of Gastroenterology (CAG) has determined that guidance is required on the issues of relevance for clinical practitioners in the area of cannabis benefits and harms and particularly so with the anticipation of increased recreational use in Canada and more widespread medical use worldwide. The lack of prospective clinical trial data for GI indications of cannabis precludes the possibility of meta-analysis in most cases. It was anticipated that the quality of evidence would generally be low or very low, and for some statements, only indirect evidence would exist. Where appropriate, a nonexhaustive evidence review was undertaken (MEDLINE, full text only, English language, humans only, with keywords ‘cannab*’ and ‘marijuana or hemp’ with the disease state) to inform the statements. Literature of significant importance is cited, but readers will be directed to appropriate recent reviews for more comprehensive information. It should also be noted that the CAG position statement is based on the literature as it stands at this time and could be subject to change in the future. As the literature grows in the field of cannabis and GI, especially if and when new clinical trial data become available, it is possible that the recommendations may change. The position statements were reviewed and approved by the CAG Practice Affairs committee. Medical cannabis use should not replace Health Canada–approved medical therapy for treatment of any gastroenterologic or hepatologic disease if the approved therapy is available and has not been used. Pharmaceutical agents approved by Health Canada have been evaluated to very high standards with both preclinical testing and prospective trials in order to obtain an indication for use. Cannabinoid medications have a very limited scope of approved GI-related indications at this time: treatment of severe nausea and vomiting associated with cancer chemotherapy (dronabinol, nabilone) (5, 6), AIDS-related anorexia associated with weight loss (dronabinol) (5), and intractable pain related to advanced cancer (nabiximols) (7). However, medical cannabis (as dried flower for inhalation, oil or other oral forms) is not an approved therapeutic substance per Health Can

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  • Transaminitis typically improves by lowering the dose of CBD.

    “Transaminitis typically improves by lowering the dose of CBD.”

    From Clinical Practice Guidelines for Cannabis and Cannabinoid-Based Medicines in the Management of Chronic Pain and Co-Occurring Conditions (2024) · cites this paper as [128]

    The Hepatology and Nonalcoholic Fatty Liver Disease commentary (page unavailable) discusses possible cannabis-related liver enzyme abnormalities, but does not say whether CBD-related transaminitis improves after dose reduction. Searches for transaminitis and CBD dose reduction found no passage addressing that outcome. (LLM, conf=0.76)

    Experimental — accuracy not yet measured

  • The CBD can be associated with transaminitis, which is typically dose-related and more common at very high doses (800 mg/day).

    “The CBD can be associated with transaminitis, which is typically dose-related and more common at very high doses (800 mg/day).”

    From Clinical Practice Guidelines for Cannabis and Cannabinoid-Based Medicines in the Management of Chronic Pain and Co-Occurring Conditions (2024) · cites this paper as [128]

    The hepatotoxicity commentary under Nonalcoholic Fatty Liver Disease reports mildly abnormal liver enzymes associated with cannabis use, but it does not address CBD specifically. Searches for CBD-related transaminitis, dose dependence, and 800 mg/day found no passage supporting those points in our copy. (LLM, conf=0.72)

    Experimental — accuracy not yet measured

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Authors
Andrews, C. N., Devlin, S. M., Le Foll, B., Fischer, B., Tse, F., Storr, M., & Congly, S. E.
Affiliations
  • University of Calgary (CA)
  • Translational Addiction Research Laboratory, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
  • Centre for Addiction and Mental Health (CA)
  • McMaster University (CA)
  • Ludwig-Maximilians-Universität München (DE)
Corresponding author
Andrews, Christopher N
ORCID
Venue
Journal of the Canadian Association of Gastroenterology
Publisher
Oxford University Press (OUP)
Published
2018-11-08
Volume
2
Issue
1
Pages
37-43
ISSN
  • 2515-2084 (ISSN-L)
  • 2515-2092
DOI
10.1093/jcag/gwy064
PMC
PMC6507278
OpenAlex
W2899677510
Cited by
25
References
54
Citations by year
2026: 3 · 2025: 4 · 2023: 2 · 2022: 3 · 2021: 5 · 2020: 6 · 2019: 1 · 2018: 1
FWCI
2.10
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of the Canadian Association of Gastroenterology (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Pharmacology › Cannabis and Cannabinoid Research
  • Health Sciences › Medicine › Complementary and alternative medicine › Complementary and Alternative Medicine Studies
  • Health Sciences › Medicine › Gastroenterology › Gastrointestinal motility and disorders
Keywords
cannabis, cannabinoids, gastrointestinal diseases, hepatic disorders, cannabis hyperemesis syndrome, delta-9-tetrahydrocannabinol, cannabidiol, cannabis adverse effects, palliative care, end-of-life care, chronic non-cancer pain

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