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Inflammatory Bowel Disease and Cannabis: A Practical Approach for Clinicians

Although still not approved at the federal level for medical or adult recreational use, cannabis has been approved in the United States (USA) by individual states for both of these purposes. A total of 15 states now regulate cannabis for adult use and 36 states for medical use. In more recent years, cannabis has gained popularity for the treatment of chronic conditions, inflammatory bowel disease (IBD) being one of them. However, the exact role of cannabis in the treatment of IBD remains uncertain. While cannabis may help in some instances with symptom management, it has not been proven to help with inflammation or to fundamentally correct underlying disease processes. Additionally, along with the perceived symptom benefits of cannabis come concerning issues like dosing inconsistencies, dependence, and cannabinoid hyperemesis syndrome. In this review article, we explore the nuanced relationship between cannabis and the treatment of IBD by summarizing the current research. We also use clinical vignettes to discuss the more practical considerations surrounding its use.

Key Summary Points

Although classified as a Schedule I substance and not approved for medical or recreational purposes at the federal level, cannabis has now been approved by 36 states for medical use.
Through population studies, cannabis has been shown to alleviate symptoms associated with inflammatory bowel disease (IBD), like abdominal pain, joint pain, abdominal cramping, and diarrhea.
Although the clinical studies are limited, cannabis has not been shown to significantly reduce inflammation or improve endoscopic healing in patients with IBD.
Important considerations for patients with IBD who use cannabis include legal constraints, dosing inconsistencies, dependence, smoking, and cannabinoid hyperemesis syndrome.
Ultimately, the role of cannabis in the treatment of IBD is a decision that will be made on a case by case basis, taking into account the unique attributes of each individual patient, as illustrated through the clinical vignettes featured in this review.

Digital Features

This article is published with digital features, including a summary slide, to facilitate understanding of the article. To view digital features for this article, go to https://doi.org/10.6084/m9.figshare.14625798.

Background of Medical Cannabis Use

Although terms often used interchangeably, “cannabis” and “marijuana” do not refer to the same substance. Cannabis is a more general term that refers to the plant family Cannabis sativa, which includes both hemp and marijuana. The main difference between hemp and marijuana is that marijuana contains greater amounts of delta-9-tetrahydrocannabinol (THC). Hemp, which consists of little THC, is found to have higher levels of cannabidiol (CBD) [1].

In 2009, approximately 10.7% of North Americans between the ages of 15 and 64 years of age reported cannabis use [2]. As classified by the US federal government, cannabis is currently a Schedule I substance. On the federal level, it is not approved within the USA for recreational or medical purposes. Schedule I substances are defined as having no accepted medical use as well as high potential for abuse, and thus generally they cannot be used in research studies. However, despite these federal regulations, individual states within the USA have now gone on to pass laws approving cannabis for both medical and recreational use [3, 4].

Historically speaking, Proposition 215 in 1996 made California the first state to enable residents to use cannabis for medical purposes. Since then, 35 additional states, the District of Columbia, Guam, Puerto Rico, and the United States Virgin Islands have passed similar legislation. As of the November 2020 elections, Mississippi and South Dakota joined 34 states and four territories in sanctioning the medical use of cannabis. Arizona, Montana, New Jersey, and South Dakota also approved the regulation of adult recreational cannabis use, totaling 17 states, two territories, and the District of Columbia who have now done so [4].

Internationally, there is considerable variation in terms of the legality surrounding cannabis use. In the majority of countries and regions, however, cannabis is prohibited for medical and recreational purposes. To date, cannabis regulation is one of the more dynamic regulatory issues, and some countries, like Canada, the Netherlands, and Uruguay, have even gone on to approve recreational consumption of cannabis at the national level [5].

Physiology of Cannabis

To understand the role of cannabis in the management of inflammatory bowel disease (IBD), it is essential to consider the physiological mechanisms of the substance. Cannabis contains a variety of cannabinoids, chemical compounds that have long been thought to have anti-inflammatory and analgesic properties. The two main cannabinoids are delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). The more pharmacologically active component of cannabis, 9-tetrahydrocannabinol (THC) possesses psychoactive properties [6]. Cannabinoid receptors, CB1 and CB2, are located in the nervous system, gastrointestinal tract, and immune cells, particularly within mast and plasma cells. These receptors are stimulated by the endogenous ligands anandamide and 2-arachidonoylglycerol (2-AG) in addition to THC, which is a partial agonist of CB1 and CB2 [7]. For this reason, it was hypothesized that cannabis might be a mediator within the gastrointestinal system, affecting inflammation, motility, and the secretory response.

Case 1

A 30-year-old man with Crohn’s disease in remission on adalimumab maintenance therapy expresses an interest in using cannabis for occasional complaints of abdominal pain. He has intermittently smoked cannabis in the past and felt that it improved his symptoms. He works in advertising and travels throughout the USA frequently.

This case illustrates two important considerations. To begin with, this patient was forthcoming about his cannabis use, but as clinicians, it is essential to realize that many patients with IBD may not be. For this reason, clinicians should inquire about cannabis use in general in order to initiate a discussion of the risks and benefits surrounding it. In this specific instance, the patient is currently in remission, and thus there is no need for additional therapy.

Secondly, given that this patient travels frequently for work, cannabis may not be an ideal adjuvant therapy for him. It is important to counsel this patient on the fact that while cannabis may be approved for medical use in his home state, if he were to travel to a different state for work, he would then be subjected to the legal constraints of that state. Furthermore, this patient should be informed that airports represent federal property and as a result it would be a criminal offense to have cannabis in his possession within any US airport.

Cannabis and IBD: Population Studies

In order to understand the cannabis use patterns among patients with IBD, numerous population studies were performed. Lal et al. [8] performed a study of 100 patients with ulcerative colitis (UC) and 191 patients with Crohn’s disease (CD), determining that 51% and 48% of patients with UC and CD , respectively, reported being lifetime users of cannabis. The patients cited symptom relief from diarrhea and abdominal pain in addition to increased appetite as benefits of cannabis. Patients with IBD with a history of abdominal surgery and long-term use of pain medications were also more likely to use cannabis, further highlighting its role in the symptom management of IBD.

One of the largest cannabis population studies consisted of 2,084,895 patients with IBD and 2,013,901 healthy controls from the National Health and Nutrition Examination Survey (NHANES) database. Survey data revealed that patients with CD and UC were more likely to use marijuana or hashish (67.3% versus 60.0%) and to begin doing so at a younger age (15.7 years versus 19.6 years) in comparison to healthy controls. Those with IBD were also found to consume cannabis less frequently than controls but in greater amounts at a time when they did use it. More specifically, male gender, age above 40 years, and history of IBD were all predictive factors for cannabis use [9].

Storr et al. [10] collected survey data on 313 patients with IBD, discovering that 17.6% of these patients regularly used cannabis to alleviate IBD symptoms, with over 96% of this group preferring inhalation as the means of consumption. The most common symptoms mitigated by the use of cannabis were abdominal pain (83.9%), abdominal cramping (76.8%), joint pain (48.2%), and diarrhea (28.6%), all of which suggests that cannabis is beneficial in terms of symptom relief. One potentially concerning finding from this study was that patients with CD who consumed cannabis for more than 6 months were more likely to need surgery (odds ratio = 5.03, 95% CI 1.45–17.46). It is difficult to say why this was the case. However, one possible explanation is that cannabis use masks symptoms, which may be early signs of worsening inflammatory disease processes, thereby causing patients to delay in seeking treatment.

Cannabis and IBD: Clinical Studies

It has proven difficult to perform clinical studies on cannabis in the USA largely because of its Schedule I classification. For this reason, initial studies to assess the clinical benefit of cannabis in IBD were performed using mice models. In a study by Pagano et al. [11], colitis was induced in mice with intracolonic injections of dinitrobenzene sulfonic acid (DNBS). CBD was given to mice either intraperitoneally or by oral gavage. Regardless of administration route, it was found to decrease the extent of colonic damage based on myeloperoxidase activity (MPO) and reduce intestinal hypermotility. This study in conjunction with other mice studies suggested cannabis might help slow gastric motility and reduce inflammation [11–14]. However, one critique of this study was that the cannabis given to mice contained a high concentration of CBD, amplifying the effect seen, making findings less applicable to human models.

Many of the original human studies examining cannabis use and IBD were performed in Israel. One of the most promising was a retrospective observational study in 2011 involving 30 patients with CD. Outcome metrics such as disease activity (based on a Harvey–Bradshaw index), need for additional medications, and total number of surgeries were assessed both before and after cannabis use. This study found 21 of 30 patients experienced significant benefits from using cannabis. Overall, the average Harvey–Bradshaw index improved from 14 to 7 (p < 0.001) and fewer surgeries were required in the years after cannabis use. Furthermore, only 4 of the initial 26 patients on corticosteroids continued to require corticosteroids, and patients demonstrated less of a need overall for additional medications. While not double-blind or placebo-controlled, this study suggested cannabis might improve underlying disease [15].

In addition to improving quality of life metrics, it has been proposed that regular cannabis use might stimulate appetite, thereby facilitating weight gain in patients with IBD. A prospective pilot study in 2012 by Lahat et al. [16] found that after receiving inhaled cannabis for 3 months, patients with IBD reported having less physical pain (p = 0.004), less depression (p = 0.007), and an improved ability to work (p = 0.0005). Patients on average gained 4.3 kg (p = 0.0002) and had lower average Harvey—Bradshaw index scores by a difference of 11.36 (p = 0.001). It is important to note though that this study only consisted of 13 patients in total. It was also susceptible to bias given that knowledge of having received cannabis might impact final results from self-reported questionnaire data.

Ultimately, the majority of subsequent studies on cannabis were unable to replicate these findings, concluding that while cannabis helped with IBD symptom management, it does not change inflammatory markers or affect endoscopic healing. Naftali et al. [17] performed a second study, this time a placebo-controlled study of 21 patients with a Crohn’s Disease Activity Index (CDAI > 200), who had failed to respond to therapy. Patients were assigned to cannabis (THC cigarettes twice daily) or a placebo group (flowers without THC) for 8 weeks. Though not statistically significant, 45% of those in the THC group achieved complete remission (CDAI < 150), whereas only 10% of patients in the placebo group achieved complete remission. Patients who received cannabis cited having improved sleep and appetite. As a result of the sample size, however, this study was underpowered, and no difference was seen between placebo versus THC groups in terms of C-reactive protein (CRP), a marker of inflammation.

Even if cannabis is beneficial for alleviating IBD-related symptoms, it is difficult to establish exactly what dose of cannabis would be optimal. Irving et al. [18] conducted a randomized control study of 60 patients with left-sided or extensive UC (Mayo score 4–10), who were assigned at random to either a cannabidiol (CBD) or placebo group. Patients were gradually uptitrated to a gelatin capsule dose of 250 mg twice daily, which they continued for 8 weeks. Interestingly, patients found the gelatin capsules difficult to tolerate, and tended to take one-third of the intended dose, resulting in inadequate exposure. Remission rates at the end of 10 weeks were 28% for the CBD group and 26% for the placebo group. However, patients in the CBD group endorsed significantly better quality of life than those in the placebo group. This study highlights that while cannabis might improve UC symptoms, additional research is needed to determine which dose achieves benefits and minimizes adverse effects.

Naftali et al. [19] also performed a randomized controlled trial of 20 patients with CD to further explore what dose might achieve a clinical benefit and still avoid side effects. Patients who had failed to respond to standard treatment and had a CDAI of greater than 200 were randomized to receive 10 mg of CBD or placebo twice daily. Patient’s hemoglobin, albumin, creatinine, and liver enzymes were checked throughout the study. This study ultimately concluded that although safe, 10 mg of cannabis twice daily for 8 weeks did not produce a significant difference in average CDAI between cannabis and placebo groups. One possible weakness of this study is that 10 mg twice daily is a relatively small dose of CBD in the first place.

More recently, a double-blind, randomized, and placebo-controlled trial involving 32 patients with UC observed that those in the cannabis group achieved clinical remission and reported better quality of life. Patients were given either cigarettes containing 0.5 g of dried cannabis flowers with 80 mg of THC or placebo cigarettes. The study determined that smoking cannabis did not contribute to an improvement in Mayo endoscopic score or a reduction in serum inflammatory markers, like CRP and calprotectin [20].

Another study from 2021 by Naftali et al. [21] that examined the relationship between CBD oil and CD reached similar conclusions. This study was also a double-blind, randomized, and placebo-controlled trial. It consisted of 56 patients with CD consuming CBD oil or placebo orally for 8 weeks. As seen in the prior study, patients in the cannabis group had a significant improvement in quality of life metrics and CDAI scores but did not exhibit less inflammation as evidenced by endoscopic appearance, CRP, or calprotectin.

Case 2

A 23-year-old male graduate student with ileocolonic CD in clinical but not endoscopic remission currently requires 5 mg of prednisone daily to decrease his diarrhea symptoms. He says that he would like to try cannabis. His job is an NIH-funded position, for which he has to complete annual drug testing.

It is possible that this patient would benefit from cannabis from both the perspectives of symptom management and a reliance on steroids. Cannabis could decrease gut motility and in doing so would likely result in fewer episodes of diarrhea. Diarrhea was one of the most common symptoms that patients cited improved with cannabis use in population studies [10].

Additionally, in the Naftali et al. [15] study involving 30 patients with CD, it was found that after cannabis use, patients with CD needed fewer medications overall, particularly corticosteroids. For this reason, there may be some role for steroid sparing with cannabis supplementation in this patient.

However, these proposed benefits would have to be weighed within the greater context of what is at stake for this patient professionally. Regardless of individual state laws, cannabis remains federally illegal, and this patient is routinely drug tested. Failure to pass an annual drug test might result in the patient losing his government funding if found to be in violation of a federal law.

Concerns for Clinicians Whose Patients Use Cannabis

Storr et al. [10] reported that more than a third of patients with IBD who were not cannabis users were worried about the possible side effects of the substance. Furthermore, even for patients who achieve a reduction in IBD symptoms with cannabis, there are still concerns among clinicians regarding the long-term consumption of it. One issue that must be viewed within the larger context of needing more standardized dosing is that of toxicity. When inhaled in doses of 2–3 mg or ingested in doses of 5–20 mg, THC has been found to impair attention, concentration, short-term memory, and executive functioning, which consists of more advanced cognitive tasks like planning and emotional self-regulation. Severe adverse effects are typically not seen until concentrations of higher than 7.5 mg/m 2 , and include nausea, postural hypotension, delirium, panic attacks, anxiety, and myoclonic jerking. Given that cannabis is delivered through a multitude of means and formulations, it is challenging to ensure therapeutic dosing that entirely avoids toxic effects for individuals with varying levels of prior exposure [22].

Cannabis dependence and addiction potential are other facets that may limit the practicality and widespread use of cannabis. It was initially disputed whether or not cannabis possesses addictive properties. However, recent studies have proven that frequent cannabis users are at high risk of dependence. A prospective cohort study of 600 frequent cannabis users (ages 18–30) determined that 3 years later, the incidence of dependence was 37.2% (95% CI = 30.7–43.8). Living alone, total number, and type of recent negative life events were all predictive of developing a dependence [23]. A 2012 National Survey on Drug Use and Health revealed that a total of 2.7 million people above the age of 12 met diagnostic criteria for cannabis dependence as defined by the DSM-IV [24]. Thus, the impact of daily cannabis use on the potential for addiction cannot be underestimated. For those dependent on cannabis, withdrawal symptoms commonly include irritability, poor sleep quality, dysphoria, craving, and anxiety [22].

The cannabis consumed today is thought to be between 6–7 times more potent that than used in the 1970s. Among adolescent use, blunts, which contain purely cannabis, have become more popular than joints, which contain a combination of cannabis and tobacco, suggesting the amount of THC consumed overall per instance is much higher today than in past decades. Patients with IBD who are pregnant must be explicitly counseled to avoid the use of cannabis while pregnant. Although the research is limited, prenatal use of marijuana in particular has been connected to infertility, placental complications, and fetal growth restriction as well as long-term offspring effects on executive function and learning [25].

Additionally, for patients with psychiatric disease, cannabis is not an ideal adjuvant therapy for symptom control. Cannabinoid agonists have been shown to exacerbate the symptoms of patients with schizophrenia, for example, regardless of if being treated with an antipsychotic. This is not surprising given the connections between THC and psychosis. Laboratory studies have largely disproved the notion of cannabis as self-medication for those with schizophrenia, failing to identify any significant clinical benefit of cannabis in this patient population [26].

Chronic heavy use of cannabis can also predispose patients to cannabinoid hyperemesis syndrome (CHS), which only resolves with abstinence from cannabis. CHS is described as a cyclical vomiting illness that occurs within the context of regular cannabis use. The regular cannabis use typically predates the recurrent episodes of nausea and vomiting. Further complicating this picture, the symptoms of CHS are similar to those of a CD flare with a partial small bowel obstruction [27]. However, one pathognomonic feature that distinguishes CHS is the fact that symptoms improve or temporarily resolve with hot showers or baths. Allen et al. [28] found that 9/10 patients with CHS took multiple hot showers or baths a day. They also found that of this group, only those who abstained from cannabis achieved resolution of symptoms, and once it was resumed, patients again suffered from CHS. This study illustrates that CHS symptomatology is disruptive to daily life and must be taken into account when considering long-term use of cannabis for medical purposes.

Lastly, patients contemplating cannabis use must be counseled on the need to avoid operating heavy machinery, as marijuana is the illicit drug most commonly associated with impaired driving and fatal accidents. The exact relationship between chronic cannabis use, lung cancer, and airway disease is less apparent. It is reasonable to conclude that patients who inhale cannabis long-term are more likely than non-users to incur lung damage. At the same time, cigarette smoking is known to be more carcinogenic than cannabis smoking [29].

It must be emphasized that one of the primary means by which cannabis is consumed is smoking, which alone poses inherent health risks. Smoking cannabis results in more rapid effects compared to oral ingestion. With smoking, a peak plasma concentration of THC can be reached in minutes versus with oral ingestion it may take hours [30]. A cohort study of young adults found that those who were cannabis-dependent exhibited respiratory symptoms at a similar rate as those who smoked between 1 and 10 cigarettes a day. Some of these symptoms included wheezing, exercised-induced shortness of breath, nocturnal wakening with chest tightness, and increased sputum production. This study concluded that as early as 21 years of age, those who smoke cannabis heavily may experience respiratory symptoms and changes in spirometry [31]. Overall, cannabis is a treatment modality that requires thoughtful evaluation of these potentially negative attributes prior to recommending it for patients with IBD.

Case 3

An 18-year-old woman with a past medical history of well-controlled schizophrenia, intermittent alcohol binging, and Crohn’s colitis, who is maintained on vedolizumab, lives in Tennessee, a state where cannabis remains fully illegal. She plans to cross state lines to obtain recreational cannabis and wishes to stop medical therapy, opting for “natural” remedies instead.

For multiple reasons, this patient should be advised to continue with her current treatment regimen, rather than stop it in favor of pursuing cannabis exclusively as therapy for Crohn’s colitis. Although well-controlled, this patient’s history of schizophrenia suggests that she would be a poor candidate for cannabis, as she might be more vulnerable to THC and its psychoactive properties than a patient without underlying psychiatric illness. Her history of binge drinking and desire to engage in risky behavior by traveling to a different state in pursuit of cannabis because it is illegal in her home state also raises concerns for cannabis dependence. In this particular scenario, it would be important to assess if she has been using cannabis, and if so, how much and how often. It is also essential to stress that cannabis should not be used in conjunction with alcohol, especially when consumed in large quantities.

Even aside from this issue of addiction potential in a patient who already engages in alcohol binging, cannabis should never serve as a replacement for standard maintenance therapy. Although cannabis might assist with symptom management, traditional therapy in the form of vedolizumab will provide greater benefit in terms of inflammation for this patient. Currently, there is no compelling evidence to suggest that cannabis alone would result in disease treatment.

Conclusion

In the USA, cannabis is classified as a Schedule I substance, which severely limits the scientific research that can be conducted on it. As cannabis gains popularity, both amongst patients and clinicians, governments will likely continue to pass laws at the state level approving its use, despite limited evidence of its clinical utility. By November of 2020, a total of 36 US states and four territories have already approved cannabis for medical use.

Patients with IBD often experience pain, nausea, and decreased appetite. As described here, in multiple studies, patients with IBD reported a significant improvement in symptoms and quality of life metrics with the use of cannabis. While initially promising, additional double-blind, placebo-controlled studies have found that even though CBD may improve perceived symptoms, it does not reduce inflammation or address underlying disease activity. These studies failed to demonstrate that when given cannabis, patients with IBD had an improvement in inflammatory markers or mucosal healing on endoscopy compared to patients with IBD in placebo conditions. Thus, in many circumstances, patients with IBD would benefit more from maintenance therapy optimization than from the initiation of cannabis as adjuvant therapy.

These studies also suggest that additional investigations are warranted to further elucidate the role of cannabis in the treatment of IBD. Changing the current classification of this substance would be the first step to facilitating more comprehensive studies on IBD and cannabis within the USA specifically. Overall though, from what is known, cannabis is a medication that offers benefits but also comes with appreciable legal considerations and potential side effects. When recommending it to patients for symptom relief, it is imperative to reflect on how issues of toxicity, dependence, and adverse effects from chronic use might impact a patient. As cannabis continues to become more widespread in consumption, it is essential for providers to ask patients about their cannabis use and have informed, non-judgmental conversations about risks and benefits of it.

Acknowledgements

Funding

No funding or sponsorship was received for publication of this article.

Authorship

All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published.

Authorship Contributions

Megan C. Buckley, Anand Kumar, and Arun Swaminath all contributed to the writing and editing of this review paper.

Disclosures

Megan C. Buckley, Anand Kumar, and Arun Swaminath have nothing to disclose.

Compliance with Ethics Guidelines

This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors. We thank the patients who inspired some of the clinical vignettes we shared in this article.

Coronavirus (COVID-19) information for patients with inflammatory bowel disease

[MUSIC PLAYING] Patients who are infected with the novel coronavirus, called SARS-CoV-2 may develop a disease called COVID-19. The symptoms of COVID-19 are most frequently fever, cough, and other respiratory symptoms, which might progress to shortness of breath. Other symptoms people commonly have include a fatigue or muscle aches. More recently, colleagues have described that you can have digestive symptoms associated with the infection with the SARS-CoV-2 development of COVID-19. The digestive symptoms most often described include a loss of appetite, but also a loss of smell or taste and abdominal discomfort or more frequent bowel movements or loose stools.

In patients who have inflammatory bowel disease, where the primary problem with their underlying condition affects the intestines, having digestive symptoms can be confusing, and it could be confused for activation of the inflammatory bowel disease. We haven’t seen enough patients who have IBD who’ve developed COVID-19 to know whether the patients have different types of symptoms, but the unique concern here is to distinguish between someone who is having a relapse of their Crohn’s disease or colitis, compared to someone who might be having symptoms of an infection. And to make it even more complicated is the infection actually triggering a relapse. So we’re working hard with our patients and with additional research to try and figure some of this out.

Patients who have Crohn’s disease and ulcerative colitis have a chronic condition in which the immune system of the intestines, which exists to protect us from getting infected or having other problems, is overactive. So what happens in patients with Crohn’s and colitis is that the immune system the intestine continues to be activated and cause symptoms or problems. Because of this and because we haven’t yet found the cause of these conditions, the primary treatment for many patients is to use immune modifying or immune-suppressive therapies. It makes sense then to be concerned that if you’re on a therapy that’s modifying your immune system, are you at increased risk for infection?

Some of the therapies we use have been associated with increased risks of viral infections, including influenza, the common viral infection we talk about, as well as other viral infections, like Epstein-Barr virus or even viruses that can cause warts on your hands or other things. Because of this, we’ve had a particular interest in whether our patients with IBD and the therapies they’re on might increase their risk for infection with the novel coronavirus that causes the COVID-19 pandemic.

So far, we haven’t seen that and in fact, quite the contrary. We believe some of these therapies may actually prevent progression of COVID-19, and some of them are actively being studied for patients who are suffering from COVID-19 to control the disease. It’s important to understand that the goal of treatment for Crohn’s disease and ulcerative colitis is not to immune suppress the patient. It’s to modify that overactive immune system so that it’s under better control. So in general, we don’t think of our IBD patients at baseline as being immune suppressed. In fact, it’s the opposite.

Their immune system is a bit overactive. And when we treat them effectively, our general strategy is to just turn down the immune system enough, so their body takes over. And we minimize the risk that they’re going to have any infections.

So our general message to patients right now has been stay on your existing therapies and stay in remission. And obviously, for concerns about this, we encourage them to call their doctors and have conversations about whether there might be any adjustments to be made.

Patients with inflammatory bowel disease who develop COVID-19 will have the same symptoms as the general population of patients who don’t have inflammatory bowel disease. These symptoms include fever or cough or shortness of breath or other congestion in the upper airways. It can also be that it presents with digestive symptoms, abdominal discomfort, loss of appetite, or change in your bowel habits.

Because patients with inflammatory bowel disease are often on immune therapies, it’s important that you let your doctor and your doctor’s team know right away if you develop some of these symptoms or if you’re worried that you might have developed COVID-19. We can test you for that, and now we have reliable testing and results that come back quite quickly. And then we can make some modifications.

Based on the treatments you’re on, we might have you hold your therapy for a couple weeks to let this pass. And most patients will recover uneventfully from this problem. We know so far, based on an international registry of inflammatory bowel disease patients and patients who developed COVID-19, that there does not appear to be an increased risk overall in patients with IBD developing COVID-19 or having a different set of outcomes from COVID-19.

What that means is that most people recover uneventfully, regardless of what treatments they’re on. We’re obviously studying this carefully, so we understand it more. But the most important thing to know is that you should be calling and having a conversation with your doctor, with your doctor’s team of nurses and nurse practitioners, and have a good sense for when it would be important to be tested and when we might have you hold your therapies for a couple of weeks.

I don’t recommend that you do that on your own and stop your medicines without talking to us because we really do want to make sure we have a good handle on this for you. Most people who have this won’t require hospitalization, but if you get sicker or develop more shortness of breath, it is important to know that we’re here for you. We’re available, and we can take care of this together. Please be in touch with us.

University of Chicago Medicine section chief of Gastroenterology, Hepatology and Nutrition, David T. Rubin, MD, answers common questions about coronavirus (COVID-19) and inflammatory bowel disease, which includes Crohn’s disease and ulcerative colitis.

What are the symptoms of COVID-19 and are they different for inflammatory bowel disease patients?

Patients who are infected with the novel coronavirus called SARS-CoV-2 may develop a disease called COVID-19. The symptoms of COVID-19 are most frequently fever, cough and other respiratory symptoms, which might progress to shortness of breath. Other common symptoms include fatigue or muscle aches. Some digestive symptoms have been associated with COVID-19 as well, including a loss of appetite, a loss of smell or taste, abdominal discomfort, more frequent bowel movements or loose stools.

We haven’t seen enough IBD patients who’ve developed COVID-19 to know whether these patients have different types of symptoms but for patients with IBD, having digestive symptoms could be confused for activation of IBD. The unique concern here is to distinguish between someone who is having a relapse of their IBD, compared to someone who might be having symptoms of an infection. We’re working hard with our patients and performing additional research to figure this out.

Are inflammatory bowel disease patients considered immunosuppressed? Do they have a higher risk of contracting COVID-19?

Patients who have Crohn’s disease and ulcerative colitis have a chronic condition in which the immune system of the intestines is overactive. The goal of IBD treatment is not to immune suppress the patient, but rather to modify their overactive immune system so it’s under better control. We don’t think of our IBD patients at baseline as being immune suppressed. In fact, it’s the opposite. When we treat them effectively, we turn down the overactive immune system just enough so their body takes over, and we minimize their risk for infections.

Being on immune therapies for inflammatory bowel disease may increase the risk for some viral infections, but based on the information we have so far, we have not seen an increased risk of contracting COVID-19 in patients who are on the standard IBD therapies. Of the Crohn’s and ulcerative colitis patients we have seen who developed COVID-19, their course and recovery is exactly like what we’re seeing in the general population. Our general message to patients right now is to stay on your existing therapies and stay in remission. If you have any concerns, please make an appointment or video visit with your doctor and have a conversation about whether there might be any adjustments to be made. Learn about our online second opinion service.

What should I do if I have Crohn’s disease or ulcerative colitis and develop COVID-19 symptoms?

Patients with inflammatory bowel disease who develop COVID-19 will have the same symptoms as the general population of patients who don’t have IBD: fever, cough, respiratory symptoms (shortness of breath) or new onset diarrhea. Let your doctor know right away if you develop some of these symptoms or if you’re worried that you might have developed COVID-19.

If you have been diagnosed with COVID-19, based on the treatments you’re on, you may need to stop your therapy for a couple weeks. I don’t recommend that you stop your medicines without talking to your doctor first. Based on an international registry of IBD patients who developed COVID-19, there does not appear to be an increased risk overall in patients with IBD developing COVID-19 or having a different set of outcomes. Most IBD patients who develop COVID-19 won’t require hospitalization, but if they get sicker or develop more shortness of breath, it is important to know that we’re here to help.

Managing Crohn’s disease and Ulcerative Colitis During COVID-19 Pandemic

Video Transcript

You should keep your appointments, but they are going to be in a different form than you might be used to. Most of our patients are having their appointments by telephone, by MyChart, or even now by video visits. So we’ve been able to shift many of our stable patients to those types of visits and we can handle many of your concerns and questions as well as your routine healthy follow up visits doing it this way.

What you should also know is that if you get sick, we are completely available, and we can still see you. And we would work hard to figure out what the best way to do that is. It is safe to come see us in the clinic if you need it, but we’ll work with you to figure out how and when that should be done. We have, on the other hand, rescheduled or deferred most of the elective procedures of colonoscopies or other endoscopic procedures. Most of these procedures that we do to look for precancerous changes or for other indications we feel can be delayed until we’re done with the pandemic and we can move forward safely.

If you need a procedure because of something that’s time sensitive or essential in other ways for your management, we certainly are still offering that and doing it. The best thing to do is to call your doctor or to call your doctor’s team so that you know what options are available for you. But don’t cancel your appointments and certainly don’t stop your medicines.

Some of our patients who receive therapies for inflammatory bowel disease are receiving those therapies by intravenous infusions. And that means they go to an infusion center either at the University of Chicago Medicine or some of the outlying centers that we work with those centers are safe. It’s important to stay on schedule with your infusions. But we have specifically asked and really required that all the infusion centers have a protocol in place to keep our patients safe and also, to keep the nurses who work there safe.

The protocol needs to include screening the patient for any known contacts with COVID-19, screening the patient for any symptoms to suggest COVID-19, including fevers or respiratory symptoms, or as I mentioned, digestive symptoms can sometimes be a clue. And the other things that the infusion centers need to do is to space patients apart at least six feet, to have a single provider working with the patient, meaning one nurse to patient ratio, so that there are not multiple people exposed to the patient. And the provider should all be wearing masks and gloves and offering those to the patient if they don’t already show up with them.

The final part of keeping infusion centers safe is to make sure that after a patient has received their infusion, the chair and the surrounding area is appropriately cleansed and cleaned. If you know that your infusion center is doing that– and I can tell you that the University of Chicago Medicine is doing it and the infusion centers that we work with in the Chicago land and Northwest Indiana areas are doing it– then you should keep your appointments, make sure you get your treatments, and stay in remission. Delaying the infeasible therapies or for that matter, many of our other treatments, can lead to relapse and loss of response to the drugs. We definitely don’t want to deal with that as a consequence of COVID-19. We want to keep you healthy.

The medications we used to treat inflammatory bowel disease include a variety of therapies that work by different mechanisms or target different parts of our immune system. We fortunately, have many options that we’ve been using to treat patients with Crohn’s disease and ulcerative colitis. Some of them are older, like the medicines that are immune modulator therapies called thiopurines or azathioprine and 6MP, or another medicine called methotrexate. And more recently, we have a variety of biological therapies which target different components of the immune system.

The goal of these therapies is not to suppress the immune system so patients are more susceptible to infections, and that would include this particular coronavirus infection, but rather, to control the overactive inflammation of the bowel and let the body heal itself and catch up. We don’t always know how to do this perfectly, but we’ve gotten much better at it. Our biological therapies, for example, aim at specific directed components of the immune system. A whole class of therapies called anti-TNF treatments focus on an inflammatory protein called TNF or tumor necrosis factor. The TNF protein is elevated whenever somebody has an infection or overactive immune response, and therefore, targeting it works quite well for many people with Crohn’s and colitis.

The treatments that are used in the anti-TNF class include drugs that you may have heard of called Remicade or Humira or Cimzia or Simponi. And these therapies are recommended to be continued at the current time even with the pandemic occurring. The other therapy we talk about is a drug that targets the white blood cells that might be on their way to your bowel. That therapy is known as Entyvio. And Entyvio works by actually blocking those white blood cells from getting out of the blood vessels into your intestines. So it’s a more selective therapy in that it only works on the intestinal immune system. And therefore, it may have a different profile and it’s something that we think of in a different way when we talk about risks for infections. The risk for infection might be lower than our anti-TNF and other treatments.

And lastly, we have a treatment that’s known as Stelara, which targets two other inflammatory proteins that go up. And they tend to be proteins that are elevated just where there’s inflammation in your body. So it’s a bit more selective, but it still works on the entire body. So that therapy we also think of a bit differently. The general message regarding all of these therapies is that if you are in remission and the treatment you’re on is working for your Crohn’s and your colitis, you should be staying on that therapy, and you should be communicating with your health care team about any additional thoughts or changes that might be necessary.

For most patients, we are not recommending that they stop treatments, and we are recommending that they adhere to the social distancing and stay at home recommendations. And obviously continue to be very careful about washing their hands and not touching their face. Remember that these treatments are keeping your inflammatory bowel disease under control. If the IBD becomes active the problem then is that you might need to be on corticosteroids like prednisone, which we worry can actually make things worse for you and definitely have a higher risk of infections. So it’s best to stay in remission and to do the best you can to be at home, keep your hands clean, and to follow the other recommendations as they’re coming out.

Many patients have asked whether they should stockpile their medications or whether there is going to be a national shortage of their therapies. The good news is that the answer to that question is, no. We have assurances from the pharmaceutical companies that there’s plenty of medicine available and that they can stay on their schedule, refilling them appropriately, and not worry about this.

Related to that, I would also advise you not to be taking additional supplements at this time. Some patients have asked whether they should be taking extra vitamins or zinc or other things to prevent a viral infection. There’s no data to support that and we don’t want you to start taking new things now that might have a whole other set of side effects or problems that would confuse us during this important time.

Part of an international collaboration to develop guidance for inflammatory bowel disease patients who develop COVID-19 is the important distinction between having symptoms from the infection and having an activation of IBD. So if you have a flare of your IBD, remember that this could be part of the COVID-19 presentation. It might also just be that your IBD is flaring. There are many reasons people flare from their inflammatory bowel disease. One of them that patients often tell us is stress, and of course, we’re all under stress right now.

The other would be if you had stopped your medicines or if your routine in some other way has changed. You might not be exercising like you used to do. Your diet might have changed because you’re staying at home or doing other things. And so there are many different reasons to think that you might actually be relapsing. The good news is that we have ways to sort this out that don’t require you to necessarily come to the clinic or have any procedures done. And with some simple tests, we can often distinguish between what is a flare of your inflammatory bowel disease and what might be due to an infection. Or in some cases, what might be due to stress, but not an activation of your inflammatory bowel disease.

Then we do have good treatments available. And many of these treatments are quite safe to start even when we’re worried about the pandemic going on. There’s guidance that we’ve now developed and we’re publishing that will give people some more information about which treatments to use and when to use them.

But the international group of experts said that if a patient has more severe inflammatory bowel disease, even during this pandemic, the usual treatments we use for IBD are safe and appropriate to be used in this setting. So it’s important to know that you shouldn’t ignore your IBD symptoms or any of your other digestive symptoms. You should be in touch with us so we can work together and get it back under control quickly. The last thing we want is for you to be living with these symptoms and afraid to notify us or afraid to come to the clinic if we need you to when, in fact, we could take care of you and get you better.

We know that there are a lot of inflammatory bowel disease patients who are working as essential workers right now and can’t be working from home, despite the recommendations for people to try to do so. It’s an important question to know whether these individuals should be taking time off of work or whether they should be doing other things to protect themselves above and beyond the usual recommendations. The way to think about this important question is first to know what the likelihood of exposure and contact with people who have COVID-19 is.

For example, those who are working as paramedics or some of the health care professionals doctors, nurses, technicians, respiratory therapists, pharmacists who are interacting with patients are right in front of many people who have COVID-19. They’re a high risk of exposure. And then there are others who are working but are not necessarily as exposed as often.

And the second question is the availability of personal protective equipment if there’s a shortage of PPEs such that the person who is going to be exposed to these patients can’t protect themselves, it is appropriate for them to ask for a leave or to get support from their doctor’s office to do so. It’s also important to know that if you have active and appropriate personal protective equipment, you can be working with patients, you can be doing a lot of your job as long as you’re also thoughtful about not touching your face, washing your hands very carefully, and making sure that you’re talking to your doctor and your doctor’s team to know that you’re in remission, and that your medications are being managed properly.

I know that this is stressful for many people who are in these situations, and it ends up being a case by case basis. But for many of them, we reassure them. We, of course, thank them for their vital role in helping us through this difficult time. And then we work with them so they understand how they can modify their risk or protect themselves better.

We’ve learned a bit about the coronavirus and COVID-19 in pregnant women. And it applies to pregnant patients who have IBD, as well. What we’ve learned so far is that when women who are pregnant develop COVID-19, they recover similar to the general population. And although their babies might be born a bit early or a little underweight, for the most part, the babies seem to do well. And in the early experiences that were reported, the babies did not have the coronavirus infection.

What we haven’t studied enough yet because of the timing of all this is, what happens if a woman who’s pregnant becomes infected with the coronavirus in the first trimester. The data we have from prior coronavirus epidemics and other types of infections suggests it might be OK. But because this is a novel coronavirus and it’s the first time we’ve seen this, we still need to be extra careful.

What we recommend to our patients who have IBD and are pregnant is that first, they make sure they’re staying in remission from their IBD. We definitely don’t want them to relapse because they stop their IBD therapies and then they need to be in a health care system or hospitalized and increase their risk. We also know that when IBD is in remission, the baby does well and the mother does well, so that’s important to keep in mind.

But we’re also recommending that our IBD patients who are pregnant take extra precautions for what we call strict social isolation. That might mean that in addition to staying home, you’re also restricting visitors in specific ways. And even when you need to go out to the grocery store, you wear a mask, you wear gloves, you take extra precautions, and wash your hands, as we’re recommending to everybody. But in this particular case, we’d like you to be extra careful. We don’t have data yet to say that there’s more to worry about, but we don’t want to find out later that we were wrong about this. So I think it’s completely reasonable to be on alert and to take those precautions.

I don’t say this to make people more stressed than they already are. I’m just trying to provide people with knowledge so that they can be empowered to take good care of themselves and to prevent any problems from happening.

Should I keep my IBD appointments at this time?

Yes, you should keep your appointments, but do so virtually, if possible. Most of our IBD patients are having their appointments by telephone, MyChart, or video visits. We can handle many of your concerns and questions as well as your routine healthy follow up visits this way. If your IBD symptoms worsen and you are feeling sick, it is safe to come to an appointment at the clinic. We will work with you to find the best way to make an appointment happen. We have deferred most elective colonoscopies or other endoscopic procedures at this time. If you need a procedure because of something that’s time sensitive or essential in other ways for your management, we certainly are able to do that. The best thing to do is to call your doctor to find out what options are available for you.

If I am currently receiving infusion treatment for IBD, is it safe to go to an infusion center?

If you know that your infusion center is following proper safety protocols, then you should keep your appointments and get treatment. The University of Chicago Medicine is following safety protocols including screening patients for any known contacts with COVID-19 and any COVID-19 symptoms, spacing patients at least six feet apart and having a single provider working with each patient to limit exposure. All providers are wearing masks and gloves and offering those to the patient if they don’t already have them. After a patient has received their infusion, the chair and the surrounding area is appropriately cleaned.

Delaying infusible therapies or other treatments can lead to relapse and loss of response to the drugs.

Which IBD medications suppress the immune system? Is it safe to take these medications?

The medications we used to treat inflammatory bowel disease include a variety of therapies that work by different mechanisms or target different parts of our immune system. Sometimes we recommend immune modulator therapies called thiopurines or azathioprine and 6MP, or another medicine called methotrexate.

More recently, we have a variety of biological therapies which target different components of the immune system. A class of therapies called anti-TNF treatments focus on an inflammatory protein called TNF or tumor necrosis factor, which is elevated whenever somebody has an infection or overactive immune response. Anti-TNF drugs such as Remicade, Humira, Cimzia or Simponi are recommended to be continued at the current time.

Another drug called Entyvio targets the white blood cells that might be on their way to the bowel, blocking them from getting out of the blood vessels into the intestines. This is a more selective therapy in that it only works on the intestinal immune system, and therefore, the risk for infection might be lower than with anti-TNF and other treatments.

Lastly, we use a treatment known as Stelara, which targets two other inflammatory proteins that tend to be elevated only where there is inflammation in your body. This is a more selective treatment, but it still works on the entire body.

The goal of these therapies is not to suppress the immune system so patients are more susceptible to infections, but rather, to control the overactive inflammation of the bowel and let the body heal itself.

The general message regarding all of these therapies is that if you are in remission and the treatment you’re on is working for your Crohn’s disease and ulcerative colitis, you should stay on that therapy during the COVID-19 pandemic. We recommend that you continue to communicate with your health care team about any additional changes that might be necessary. For most patients, we are not recommending that they stop treatments. It is important to remember that these treatments are keeping your IBD under control. If the IBD becomes active, we may recommend corticosteroids like prednisone, however they can increase your risk of infections. This is why we want our patients to do their best to stay in remission. We recommend patients stay home as much as possible, wash hands frequently and follow any guidelines from our public health officials, such as the Centers for Disease Control and Prevention (CDC).

For your convenience and safety, our inflammatory bowel disease specialists are offering online second opinions and video visits for new and existing patients.

Should I be concerned about a supply shortage of IBD medications?

No. We have assurances from the pharmaceutical companies that there is a sufficient supply of medicine available. We recommend that patients with Crohn’s disease or ulcerative colitis stay on their medication schedule and refill their prescriptions appropriately.

Should I take supplements like vitamin c or zinc to help prevent coronavirus?

At this time, I would advise against taking additional supplements, such as extra vitamins or zinc to prevent a viral infection. There is no data to support their effectiveness and starting a new supplement might cause other side effects.

How do I know the difference between an IBD flare-up vs. COVID-19?

It may be hard to tell the difference between a flare up and COVID-19 infection because their symptoms can be similar. Loss of appetite, abdominal discomfort, more frequent bowel movements or loose stools are symptoms of both conditions.

We have testing options that do not require an in-person visit. These simple tests can help identify the cause of your symptoms.

What should I do if I think I’m having an IBD flare-up?

We have treatments available that are safe to start even while this pandemic is going on. There’s guidance that we’ve developed and published that will give people more information about which treatments to use and when to use them. If a patient has more severe inflammatory bowel disease, the usual treatments we use for IBD are safe and appropriate to be used in this setting. Patients shouldn’t ignore their IBD symptoms or any other digestive symptoms. Keep in touch with your physician to get it back under control quickly. The last thing we want is for patients to be living with these symptoms and afraid to notify their doctor or come to the clinic.

Any advice for essential workers with IBD who are unable to work from home?

We know that there are a lot of IBD patients who are essential workers right now and can’t work from home. It is important for these patients to recognize their likelihood of exposure and increased chance of contact with COVID-19-positive patients. For example, paramedics, doctors, nurses, technicians, respiratory therapists and pharmacists who are interacting with patients with COVID-19 have a high risk of exposure and should make sure they protect themselves as much as possible.

The advice we’ve been giving the general public should be followed the same by IBD patients. This includes social distancing, washing hands, cleaning surfaces and staying at home when possible. We also recommend keeping in touch with your doctor to know you are in remission and making sure your medications are being managed properly.

Are there extra precautions that pregnant women with IBD should be taking during the COVID-19 pandemic?

We’ve learned some information about COVID-19 in pregnant women, which applies to pregnant patients with Crohn’s disease or ulcerative colitis as well. We have seen that women who are pregnant and develop COVID-19 recover similarly to the general population. Although their babies might be born a bit early or a little underweight, for the most part, the babies seem to do well.

At this time, we have not seen cases of pregnant women becoming infected with COVID-19 in the first trimester. The data we have from prior coronavirus epidemics and other types of infections suggest patients may be fine. Because this is a novel coronavirus, we still need to monitor those patients carefully.

We recommend that our pregnant patients with inflammatory bowel disease make sure they’re staying in remission from their IBD. Stopping their IBD therapies could cause a relapse and would require hospitalization which may increase their risk of exposure to COVID-19. We also know that when IBD is in remission, the baby and mother both stay healthy. It is important that our IBD patients who are pregnant take extra precautions and follow strict social isolation. That means in addition to staying home, they should also restrict visitors from entering the home. If pregnant patients with IBD need to go out to the grocery store, they should wear a mask and gloves, and carefully wash their hands, as we’re recommending to everybody. We don’t have data yet to say that pregnant patients with IDB have more to worry about, but we want them to be extra careful.

David T. Rubin, MD

Dr. Rubin specializes in the treatment of digestive diseases. His expertise includes inflammatory bowel diseases (Crohn’s disease and ulcerative colitis) and high-risk cancer syndromes.

Inflammatory Bowel Disease Center

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Whether you are facing a complex health issue or difficult treatment decision, getting a second opinion can help you make an informed decision about your care. Get an online second opinion from one of our experts without having to leave home.

‘Patients Are Being Duped’: What’s Inside Some CBD Products

Although CBD, short for cannabidiol, comes from the cannabis plant, it does not get you high. As long as it’s derived from hemp, it’s legal to buy over the counter.

By Shyang Puri • Published February 18, 2019 • Updated on April 11, 2019 at 3:42 pm

On a recent night in Hartford’s Parkville neighborhood, curious shoppers stopped by a social hour to try out drinks, treats, and more that the vendors said contained CBD, the chemical found in marijuana and hemp plants that’s surging in popularity thanks to claims it can help with a litany of medical issues.

Although CBD, short for cannabidiol, comes from the cannabis plant, it does not get you high. As long as it’s derived from hemp, it’s legal to buy over the counter.

People tell NBC Connecticut that they’re using CBD as a natural remedy for all kinds of health issues, ranging from pain and inflammation to anxiety and depression.

Jocelyn Cerda started the “So Chill CBD Social Hour” after she started using CBD herself.

“I have Crohn’s and colitis, so I use it on a regular basis just to keep my symptoms under control,” Cerda said.

Hemp products became easier to buy and sell after a change to federal law last year, but they’re also unregulated. Yet public demand for CBD is growing and companies are cashing in. The industry is projected to hit the billion dollar mark this year.

Chris Martinez, the president and co-founder of Evio Labs, said his laboratory has tested CBD products for more than 400 companies.

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“There’s a lot of inconsistencies in the market right now,” Martinez said.

To see if you’re getting what you pay for, NBC stations in Miami and New York partnered with Martinez to blind-test three brands of CBD oil and four brands of candy gummies that were purchased over the counter in stores and online.

The results showed that a product’s contents sometimes did not match its label. More than half of the samples contained less CBD than advertised.

“They were significantly lower – sometimes three times less than what was stated on the label,” Martinez said of the results.

The lab rejected samples from two brands of oils for not meeting California standards for quality control.

Evio Labs flagged one of our five samples, labeled as a Lazarus Naturals product, for containing lead.

NBC 4 New York purchased the sample from an independent seller on Groupon. Lazarus Naturals said they could not verify that the sample was actually their product because the product did not have a batch number and they have experienced a problem with counterfeit products sold on unapproved marketplaces.

Another sample purchased from CBDistillery contained an amount of a pesticide that exceeds California’s acceptable standards. A company spokesperson told NBC 4 New York that they had the batch in question tested by “an accredited third party lab,” and that the amounts of the pesticides detected passed that laboratory standards.

NBC 4 New York also purchased several vials of Jolly Green CBD oil online and in a store.

Every sample contained less than half of the advertised amount on the packaging, according to the lab results. The company did not respond to NBC 4 New York’s requests for comment.

Only one brand of gummies, Green Roads, contained the amount of CBD advertised on the packaging. Of the other three brands, one brand contained zero CBD.

Gummies purchased from a surgery recovery website called, “Dani’s Doll House,” were marketed as the “strongest” CBD gummies.

“All five of those samples had zero CBD in them,” Martinez said.

The website’s owner told NBC 6 Miami that they purchase the gummies from a distributor and apply their own label for resale, adding in an email follow up that she is “going to try to get to the bottom of this.”

Samples of gummies from Hemp Bombs and Gold Line had less than the amount of CBD advertised, according to the lab results.

Hemp Bombs told NBC 6 Miami that they couldn’t verify those results. A spokesperson said the gummies were made using an older manufacturing process that involved “sprinkling CBD on them.” They said the company now “infuses the CBD hemp extract into the gummies.”

Test results for Gold Line brand gummies, which were purchased online, had less than half the amount of CBD advertised on their website at the time of purchase. The company told NBC 6 Miami that they put the “wrong photo” online and called it an “innocent mistake.” They removed the product from their website.

“Until there is some type of regulation that levels off the playing field, patients are being duped. Patients are buying products that aren’t really going to benefit them,” Martinez said.

Before making any purchases, Martinez suggested asking sellers for lab results from within the last 30 days. Industry experts also advise making sure products are tested for heavy metals, pesticides and toxins.

Some companies put QR codes on their labels for buyers to scan and pull up results right on their phones.

“I tell the vendors, ‘Hey, bring those lab results,’” Cerda said. The goal of her monthly social hour is to connect people with local vendors making their own CBD, she said.

We did not test any of the products available there.

CBD products for sale at dispensaries to medical marijuana patients are different from the hemp products available over the counter, and the only FDA-approved use for CBD is in a treatment for severe forms of epilepsy.

Cerda said she now uses a CBD product that is only available at medical marijuana dispensaries, but she said access to CBD is necessary for people who do not have health conditions that qualify them to use medical marijuana in Connecticut.

With some caution, and a little trial and error, she said CBD’s pros can outweigh the cons.

“It’s a gray area. These are uncharted waters. You just gotta go out there and give it a shot,” Cerda said.