Cannabis and Digestive Disorders

1. Cannabis and Digestive Disorders Dr. Nick Salamie PharmD, RPh PDI Medical

2. Crohn’s Disease • Inflammatory Bowel Disease • Affects the ileum and/or the colon • Symptoms range in severity • Cause is unknown • 1 of the 41 qualifying conditions in IL

3. Ulcerative Colitis • Inflammatory Bowel Disease • Affects large intestine and rectum • Inflammation and ulcers • Symptoms vary depending on where the inflammation occurs • NOT one of the qualifying conditions in IL

4. Pharmaceutical Treatments • azathioprine • mercaptoprine • infliximab (Remicade) • adalimumab (Humira) • certolizumabpegol (Cimzia) • methotrexate (Trexall) • natalizumab • vedolizumab

6. Endocannabinoid System • Found in all animals • CB1 and CB2 receptors • Located all over body • Anandamide and 2-AG • Balance In the body • Regulatory Function in the GI tract • Phytocannabinoids as treatment • THC • CBD

7. THC • Major Therapeutic Cannabinoid • Potent anti-inflammatory and analgesic activity • Excellent Appetite Stimulant • Reduces Nausea • Slows down movement through intestinal tract

8. CBD • Non Psychoactive • Potent Anti-inflammatory action • May increase gut motility • CBD more effective with THC • “Power Couple” • Hemp CBD vs. Whole Plant CBD

9. Beta-Caryophyllene • Terpene/Cannabinoid • Found in Black Pepper and Cloves • Drug Dogs • Potent anti-inflammatory compound • Effective in mouse model of colitis

10. First PDI Visit • Goals • Increase Quality of Life • Drug Interactions • Assess Patients Cannabis Experience • No or little cannabis experience • Intermediate cannabis experience • Advanced Cannabis Experience • Tapering Strategy if Necessary • Product selection and initial strategy • Minimum Effective Dose • Follow Up

11. Products/Dosage Forms • Inhalation • Combustion • Vaporization • Oral • Sublingual • Oromucosal • Gastrointestinal • Transdermal • Rectal

12. PDI Patient X • 22 y/o male • Crohns Disease • Medications • Cimzia • Humira • Caused Psoriasis • Remicade • methotrexate • prednisone • Moody and weight gain • Lialda • Proctofoam • Canasa • Currently uses cannabis and bi-monthly infusions of Entyvio

13. Irritable Bowel Syndrome • Affects the large intestine • Signs and Symptoms vary • Cause unknown • More prevalent in females • Cannabis Treatment • Depends on Symptoms • Not a qualifying condition

14. Cachexia and Appetite Loss • Complex metabolic syndrome • One of the 41 qualifying conditions • Treatment • “Munchies”

15. Cancer • Controversial/Experimental • Promising evidence in intestinal cancer • Chemotherapy-Induced Nausea • Appetite • Quality of Life • One of the qualifying conditions

16. Cannabis Oils/RSOs • Best medical dosage form • Whole Plant/Full Spectrum Extract/Herbal Shotgun • Varying Cannabinoid Profiles • Different CBD:THC ratios • Acidic Cannabinoids: THCa, CBDa, CBGa • “Varin” Cannabinoids: THCV, CBDV • Less abundant Cannabinoids: CBN, CBG, CBC • Terpenes Captured • Beta-Caryophyllene

17. Getting Your Cannabis Card • Formal Diagnosis of 1 of the 41 qualifying conditions • Completion of Physician Written Certification Form by Licensed Physician • Fingerprint/Background Check • Completion of Online Forms and Payment • Provisional Registration • Dispensary Transfer

18. Down The Pipeline • Adult Use • Higher Taxes • Flower 10% • Edibles 20% • Concentrates 25% • Medical Patient Side • Separate From Adult Use • Inventory Control Measures • New Qualifying Conditions • Autism • Chronic Pain • Irritable Bowel Syndrome • Migraines • Osteoarthritis • Anorexia Nervosa • Ehler-Danlos Syndrome • Neuro-Behcet’s Autoimmune Disease • Neuropathy • Polycystic kidney disease • Superior Canal Dehiscense Syndrome • New Vet Pathway • OAPP

19. References • Backes, Michael, et al. Cannabis Pharmacy: the Practical Guide to Medical Marijuana. Black Dog & Leventhal Publishers, 2017. • Bersten, Melani PharmD, RPh. “Advanced Medical Cannabis: Dispensing and Dosing Considerations.” Powerpoint File. • “Crohn's Disease.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 8 Mar. 2018, www.mayoclinic.org/diseases-conditions/crohns-disease/diagnosis-treatment/drc-20353309. • “Crohn's Disease.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 8 Mar. 2018, www.mayoclinic.org/diseases-conditions/crohns-disease/symptoms-causes/syc-20353304. • d29jlv5g6rsjhb.cloudfront.net/images/thumbs/md/d7b6eb53f8d5083a174750307c6f222e82e87d93.jpg. • Goldstrich, Joe D MD, FACC. “Unleashing the Full Potential of Cannabis’ Antineoplastic Benefits: Reimagining the Concept of Full Extract.” Powerpoing File. • “Https://Www.paxvapor.com/Skin/Frontend/Plm/Default/Images/Pax-Meta.jpg.” Https://Www.paxvapor.com/Skin/Frontend/Plm/Default/Images/Pax-Meta.jpg. • “Important Safety Information | HUMIRA.” English |US, www.humira.com/important-safety-information?cid=ppc_ppd_ggl_franchise_brand_2015_exact_Important_Safety_Info_stlk_64X1790908. • “Irritiable Bowel Syndrome.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 17 Mar. 2018, www.mayoclinic.org/diseases-conditions/irritable-bowel-syndrome-causes/syc-20360016. • nurseslabs.com/wp-content/uploads/2017/04/Small-and-Large-Intestine-Digestive-System-Anatomy-and-Physiology.png. • Russo, Ethan B., and Jahan Marcu. “Cannabis Pharmacology: The Usual Suspects and a Few Promising Leads.” Cannabinoid Pharmacology Advances in Pharmacology, 2017, pp. 67–134., doi:10.1016/bs.apha.2017.03.004. • “Ulcerative Colitis.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 8 Mar. 2018, www.mayoclinic.org/diseases-conditions/ulcerative-colitis/symptoms-causes/syc-20353326. • www.legalweedleaf.com/wp-content/uploads/2017/08/prerolled-joint-sandiego-600x308.jpg.

20. Questions?