posted in Complementary Alternative Medicine on April 22, 2021 by
Should patients use CBD or other cannabis products for lupus? With the increasing popularity and availability of cannabis and CBD, many lupus patients ask, “How about using these for lupus?” This online chapter of The Lupus Encyclopedia covers the latest information regarding the research, use, dosing, effectiveness, and potential side effects of medical marijuana, medical cannabis, and CBD for lupus. This information will also be helpful for the health care provider who is considering whether their patients should take these products or not.
Marijuana (cannabis) and its active components (THC and CBD) have become more popular for medical treatments. As of this writing (February 2023), 23 states (including the District of Columbia) have legalized its use recreationally. Another 14 states have legalized its use for medical purposes. Many of my (Donald Thomas, MD) patients ask about using it, so I think it is important to review some information.
My goal is to present the facts based on scientific evidence without bias. If, and when, better, larger research studies are done in the future, much of this information could change.
NOTE: Make sure to read and follow my Lupus Secrets and my advice on Living Successfully with Lupus. These are practical and valuable tips.
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Medical cannabis physicians: what to look for
How to tell if CBD helps you or not
Cannabinoids and the immune system
Contraindications (when to avoid cannabinoids)
Why lupus patients should not smoke cannabinoids
Alcohol and food interactions with cannabinoids
What should be monitored while taking cannabinoids
Use during pregnancy and breastfeeding
What to do around the time of surgery
Costs of prescription strength cannabinoids
Should people use CBD for lupus? Since CBD does not cause people to be high, US federal law allows CBD-containing hemp (“industrial hemp”) to be grown as long as it contains no more than 0.3% THC when dried. Industrial hemp is used to produce CBD products that can be purchased in all 50 states.
Although not much research has been done regarding CBD for lupus, the rest of this online chapter discusses the science behind what we know.
Cannabinoids are the active compounds of the cannabis plant. There are over 140 different known cannabinoids, and each acts differently in the body. The two most studied and well-known are cannabidiol (CBD) and tetrahydrocannabinol (THC). THC is the cannabinoid responsible for the intoxicating effects sought by recreational users (the “high”). CBD does not make people “high.”
Cannabidiolic acid (CBDA) is another cannabinoid. It is found in CBD-containing hemp (also known as industrial hemp) and cannabis.
The term “medical cannabis” will be used to refer to any substance recommended for the treatment of medical conditions (such as chronic pain) that contains any of the substances derived from the cannabis plant. This includes THC, CBD, and other cannabinoids.
In January 2023, the FDA decided to work with Congress on a path to legalize the sale of CBD.
The FDA does not regulate CBD quality. A 2022 study showed that around half of CBD products did not contain the amount of CBD stated on the label. Problems with dangerous amounts of lead, mercury, and other contaminants have also been seen in unregulated products. Consider checking lab reports that measure CBD purity, such as those found at ConsumerLab.com.
Responsible producers have batches of products regularly tested for quality. If you decide to use CBD, stick to products from sellers who can produce a “Certificate of Analysis.”
Regulated dispensaries are found in the states that legalized the use of medical marijuana. Products come in many forms, with varying amounts of THC and CBD. If you decide to use medical cannabis, make sure you get it from a reputable dispensary, not homemade, so you know what you are getting.
Companies that sell high-quality products include NuLeaf, Joy Organics, Bluebird Botanicals, and Charlotte’s Web. (Note: we are not promoting or recommending these products, and other products and brands of high quality exist). They typically provide a QR code on the package to scan with a smartphone to check the third-party analysis results for the batch used to make your product. The United States Department of Agriculture (USDA) also tests and certifies high-quality products. Using a brand that is USDA-certified ensures the highest quality.
Also, make sure to use only products that list the amount of CBD per serving. If the label just says “cannabinoids,” it may not contain much CBD.
Potential dangers of homemade products include unknown THC and CBD quantities, mold, pesticides, and contamination by other drugs, such as Fentanyl.
Synthetic marijuana, or laboratory-produced cannabinoids, sold under names such as K2, Spice, and Crazy Monkey, have similar effects on the body as naturally produced cannabinoids but are unregulated and not studied. Thousands of cases of intoxication side effects from these are reported to the US regional poison control centers yearly.
Synthetic marijuana products can cause psychosis, high body temperatures, muscle and kidney damage (rhabdomyolysis), seizures, stroke, and life-threatening blood clots. Avoid synthetic marijuana.
A 2017 National Academies of Sciences, Engineering, and Medicine review of 35 randomized, controlled trials (RCTs) concluded there was enough evidence to use cannabinoids for chronic pain. Another 2017 study from Portland, Oregon, found a small amount of evidence that cannabinoids may help nerve pain but not enough proof for other pain types.
However, a 2018 Canadian evaluation of all the RCTs studying the medical uses of cannabis concluded that the evidence for its usefulness in chronic pain, including nerve pain, was low. However, the study’s analysis found that medical cannabis could be helpful for chemotherapy-induced nausea and vomiting. It recommended avoiding medical marijuana products for acute pain, headaches, and rheumatologic conditions (such as lupus).
After their full review, the authors stated that if all other standard medical therapies had failed, medical cannabis could be considered for nerve pain and to help decrease pain and suffering in dying people.
All agree that more high-quality research is needed. The problem with cannabis research in the United States is that cannabis is a Schedule I drug (illegal). Therefore, high-quality US studies are lacking. We will not thoroughly understand the proper use of medical cannabis unless the government allows research to go forward. Though studies so far do not greatly support cannabinoids for treating pain, it does not mean they are ineffective.
Most studies show that the best pain relief may come from THC-containing products. On average, they may reduce pain by around 30%. However, these research results have not proven that this amount of reduced pain is clinically effective and well-balanced with safety. These studies suggest that THC products may help “take the edge” off of pain. Yet, THC-containing products also tend to have more side effects, such as euphoria.
CBD-only products have very little proof that they help pain.
Dr. Peter Grinspoon, a Harvard Medical School (Boston, Massachusetts) physician who specializes in medical cannabis, agrees. He has stated that for severe arthritis pain, pure CBD probably has little effect but that medical cannabis containing THC could possibly help. He has also described his overall experiences with patients:
Among my patients to whom I have suggested CBD for chronic pain, a few have noticed great benefits, a few have noticed some benefits, and a lot have noticed no benefits. I have had a few patients use CBD for lupus pain but with questionable results. For those who have said they noticed a benefit, it is unclear whether that benefit was just the placebo effect.
High-quality research is greatly needed to see if cannabinoids safer than THC and may help arthritis pain and lupus pain.
Research studies up to January 2023 show that the potential for negative side effects from using medical marijuana (see below) is greater than its proven benefits. This view is supported by a Cochrane review on medical cannabis. Therefore, most experts do not recommend its use for pain until more rigorous studies are done.
However, we realize that many of our patients will use medical cannabis, often due to dissatisfaction with the results of over the counter and prescription pain therapies. Therefore, we want them to know the facts to make well-informed decisions.
If you decide to use medical cannabis, do not rely on the advice of a salesperson at a marijuana dispensary (called a budtender). Instead, seek the advice of a physician trained in medical cannabis.
Physicians who prescribe medical cannabis should do a thorough physical examination and a review of your medical history. They should then discuss the potential risks and benefits of cannabis and explain the different types available, the THC and CBD amounts, what dose to begin with, and how to adjust the dose.
A responsible physician would require “informed consent,” often in the form of a “Pain Contract” that lists the potential side effects. Close follow-up should be performed every few weeks. A drug toxicology screen (for cocaine, heroin, and so on) should also be done at these visits. If you see a doctor with a full waiting room and your visit is a hurried affair yielding a quickly written prescription, this is not quality care.
The recommendations below come from small studies. These recommended uses and doses for using cannabinoids are not proven to be the best. However, these recommendations are based on studies until January 2023, when this was written.
If you are using CBD for pain, a good habit to get into is to rate the severity of your pain on a scale of 1 to 10 before use (1 is minimal pain, 10 is the kind of severe pain you get from, say, slamming your thumb in a car door). Then, write down your level every 30–60 minutes after taking the cannabinoid to assess its effectiveness.
How quickly it works depends a lot on the form used. For example, tinctures, oils, and concentrates placed under the tongue can work within 30 minutes, while edibles (discussed below) can take several hours. If it helps, topical CBD oil can start working within 15 minutes. However, it can take up to 90 minutes in some people.
Reduced pain, nausea, and increased appetite begin within 30 to 60 minutes after ingestion and peak at 2 to 4 hours.
If you use a THC product, pain relief does not correlate with feeling “high.” In other words, if you notice a decrease in your pain but do not feel “high,” don’t increase the dose, thinking that you’ll get even more pain relief.
For insomnia, a CBD tincture under the tongue can take half an hour to work, while an edible can take an hour or longer. It is essential to also follow sleep hygiene recommendations. CBD does not appear to adversely affect sleep quality (but THC does). Dronabinol is a synthetic prescription THC. It is used to treat nausea from chemotherapy and appetite loss from AIDS. It causes euphoria and “high” responses after 2 hours, similar to what is felt 30 minutes after smoking marijuana.
Cannabinoid receptors are on the surfaces of many cells to which cannabinoids can attach. There are 2 types: cannabinoid 1 (CB1) and 2 (CB2) receptors. CBD, CBDA, THC, and other cannabinoids bind to these receptors, causing specific chemical changes within the cells. When they bind to brain and pain nerve cannabinoid receptors, they can produce desired medical effects such as less nausea, reduced pain, less seizure activity, and fewer muscle spasms.
When THC (but not CBD) binds to brain cells, it produces the intoxication and euphoria that some people seek when using it recreationally. However, as discussed below, binding to receptors on some cells can result in side effects.
Though human studies are lacking, animal studies suggest that CBDA may help reduce pain and nausea. One study also showed that it reduced COX-2 (cyclooxygenase-2) activity in mice and may have anti-inflammatory properties. COX-2 is one of the enzymes inhibited by nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, naproxen, and celecoxib.
Cannabinoids cause changes in immune system activity. CB2 receptors are on most immune system cells, especially the B-cells (types of white blood cells). When cannabinoids bind to CB2, they can lead to less inflammation. For example, when CB2 is activated on young (premature) B-cells of the bone marrow, they stay there instead of going into the blood to cause inflammation. CB2 activation on T-cells also reduces inflammation.
Lenabasum (ajulemic acid, JBT-10; formerly called anabasum and Resunab) is an experimental cannabinoid drug that binds to CB2. In 2017, it was shown to reduce the inflammatory cytokines TNF-alpha and interferons. TNF-alpha and interferon cytokines are chemical messages sent from one immune system cell to another, telling it to become more active and causing inflammation. Therefore, reducing their number can reduce inflammation.
 A phase 2 clinical trial showed that lenabasum reduced dermatomyositis (a systemic autoimmune disease that attacks skin and muscles) muscle and skin inflammation (redness and itching) within two months. Potential side effects included dry mouth, dizziness, and fatigue. Lenabasum is in clinical trials for systemic lupus erythematosus, cystic fibrosis, scleroderma, and dermatomyositis.
If cannabinoids (such as lenabasum) are shown to significantly reduce inflammation and damage, they could potentially play a role in treating autoimmune diseases such as lupus. However, they would also need to be proven safe.
There are two FDA-approved cannabinoids (as of February 2023): dronabinol and cannabidiol.
Dronabinol (Marinol, Syndros) is approved to stimulate appetite in wasting conditions, such as HIV and cancer, and to prevent nausea and vomiting from chemotherapy.
Cannabidiol (CBD, Epidiolex) is approved to treat seizures from Dravet syndrome, Lennox-Gastaut syndrome, and tuberous sclerosis. Note that this is a pure prescription-strength form of CBD, which is not intended for lupus; more studies are needed.
Other Prescription Cannabinoid Drugs Available in Other Countries
Nabilone (Cesamet) is approved to treat nausea and vomiting from chemotherapy in Canada and some other countries but not in the United States.
Nabiximols is approved to treat muscle spasms from multiple sclerosis (MS) in many countries (including Canada and the United Kingdom) but not the United States. It is an aerosol that is sprayed on the insides of the cheeks. It contains equal parts THC and CBD.
Note that the discussion below applies to both prescription and OTC cannabinoids.
Before using cannabinoids, you should consider possible reasons not to do so. The following is a general list. Specific considerations will vary from person to person.
There are many potential drug interactions. Check with your doctor before you begin taking a cannabinoid. For example, antifungal drugs used to treat thrush and other yeast infections in lupus patients can significantly increase the blood levels of cannabinoids. Cannabinoids may increase the drug levels of cyclosporin, tacrolimus, and voclosporin (Lupkynis), which are used to treat lupus nephritis.
Other drugs commonly taken by SLE patients that can have significant interactions include cholesterol-lowering medicines (statins), sildenafil (used for Raynaud’s and pulmonary hypertension), blood pressure medicines (nifedipine, metoprolol, propranolol, valsartan, diltiazem, and verapamil), proton pump inhibitors for acid reflux (such as pantoprazole and omeprazole), NSAIDs (naproxen and celecoxib), and many antidepressants.
Cannabinoids can dangerously increase warfarin (Coumadin) blood levels. Warfarin is commonly used in patients who have antiphospholipid syndrome.
Liquid dronabinol (Syndros) contains alcohol and should not be taken with disulfiram (Antabuse) or metronidazole. Otherwise, stomach cramps, nausea, headache, and flushing can occur.
Products containing THC (including dronabinol) have the potential for substance abuse. Avoid these products if you have a history of alcohol or drug abuse.
Since many lupus patients have memory problems and “lupus fog,” it is vital for them to question whether they should use CBD for lupus or not.
There are many proven dangers of smoking tobacco for lupus patients. It can lead to the onset of lupus, trigger lupus flares, decrease the effectiveness of antimalarials like hydroxychloroquine (the most important treatment for lupus), make skin lupus harder to treat, cause heart attacks and strokes, and lead to lung cancer.
Cannabis smoke contains many of the same dangerous chemicals and carcinogens (cancer-causing substances) as tobacco smoke. Cannabis smoking increases the risk of heart attacks and strokes. Since these are the most common causes of premature death in people with SLE, this is another reason for avoidance.
Medical studies show that smoking cannabis can lead to chronic bronchitis, a disease due to permanent lung damage. This condition increases the risk of infection, and infections are among the leading causes of death in people with SLE. Smoking cannabis worsens dry mouth, can cause thrush, and increases periodontal disease. All of these are already problems in SLE that could be further exacerbated by smoking cannabis.
Since smoking cannabis has not been studied in SLE patients, and its potential risks are so high, please do not smoke it.
Cannabinoids can be used in many different forms—smoked, vaped, ingested (such as “edibles,” capsules, concentrates, and tincture drops), topicals (ointments, creams), and as an aerosol spray on the insides of the cheek.Â
Marijuana edibles (“medibles”) come in many forms, including popcorn, baked goods, candies, butter and oils, mints, and beverages. Be extra careful to keep these secure and hidden from children.
Caution is needed if you consume cannabis edibles. Their absorption is slow and the effects are gradual in onset. It may be several hours before feeling anything. This can lead inexperienced users to eat an additional serving (called “stacking”), thinking it must not be working. This can easily cause an overdose with nausea, nonstop vomiting, psychotic thoughts, and heart palpitations.
Tincture (liquid) drops and concentrates are placed under the tongue (sublingual). These are absorbed and have rapid effects. These are some of the easiest forms to adjust the dose for reliable results.
Topicals (ointments, oils, salves)Â are advertised to rub over painful areas.
Smoking or vaping cannabis is hazardous to lupus patients for the reasons discussed above and should not be used.
In general, all forms of medical cannabis and CBD for lupus patients should be started at a low dose. Then, go up slowly over time until the desired effect is achieved. If any side effects occur, go back down on the amount.
Medical marijuana and edibles purchased from medical and recreational dispensaries contain an average of around 20% THC and 2% CBD. However, amounts vary widely, ranging from 0 to 45% THC and 0 to 40% CBD. The THC in most products is 2 to 3 times higher than needed for pain relief. These higher THC amounts place the person at higher risk for dangerous psychotic side effects but without additional pain relief.
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Prescription-strength CBD (Epidiolex)Â is dosed at 2.5 mg to 10 mg per kg of body weight twice daily. It is FDA-approved to prevent seizures. For a 150-pound person, this comes out to 170 mg twice daily up to a maximum of 680 mg twice daily.Â
OTC CBD dosage depends on the disorder being treated. Note, though, that dosing has not been adequately studied.
The following CBD doses were used in small research studies that suggested benefits for specific conditions. Remember that none of these were high-quality studies (such as randomized, double-blind, placebo-controlled trials using large numbers of patients).
Dosing has not been studied in CBD and lupus.
If you decide to take CBD, consider starting at a low dose, such as 5 mg to 25 mg at a time. Then, slowly increase the dose as tolerated and as needed.
Anxiety and public speaking: 150 mg to 600 mg capsules or edibles once or twice daily. For public speaking, 150 mg to 600 mg 2 hours before speaking.
Insomnia: 160 mg to 500 mg tincture oil under the tongue 30 minutes before bed or 160 mg to 500 mg capsules or edibles 1 to 2 hours before bed. Make sure to print out and abide by the sleep hygiene recommendations on The Lupus Secrets page.
Chronic noncancer and nerve pain (CBD-only products may be ineffective): THC products containing CBD may be more helpful. Ask a physician experienced in medical cannabis for proper dosing.
Acute pain: There is no evidence of effectiveness. No dosing guidelines are available.
Prescription-strength THC (dronabinol)Â is dosed at 2.1 mg once daily and up to 10 mg twice daily. It is FDA-approved for nausea and to increase appetite.
OTC THC dosing of 10 mg or less at a time is commonly recommended. Use products that are low in THC and higher in CBD for lupus.
Avoid alcohol since cannabinoids can increase the intoxication effects of alcohol.
Fatty meals increase absorption. If you use a THC product and develop side effects, try taking it on an empty stomach instead.
A responsible prescriber will ask you to read and sign a pain contract that discusses how pain medicines work and what their potential side effects are, as well as do regular drug screens (such as for cocaine and heroin). Close follow-up with your physician should occur to monitor the product’s effectiveness and tolerability. If you have thoughts of suicide, depression, anxiety, moodiness, drowsiness, or other side effects, report these to your physician as soon as possible.
Liver function tests, weight, blood counts, and kidney function should be monitored regularly.
THC causes intoxication and a “high” sensation, but CBD does not. THC products are potentially addictive and have abuse potential. That is not the case for pure CBD products. If you decide to use cannabinoids, choose a product that is lower in THC and higher in CBD.
One potential side effect of cannabinoids (primarily higher THC products) is hyperemesis syndrome. “Emesis” is the medical term for “vomit,” and hyper– comes from the Greek for “a lot of.” Fortunately, this is rare, but when it occurs, it can cause uncontrollable nausea, vomiting, and abdominal pain that can last hours to months.
Hot baths and showers can help decrease the severity of cannabinoid hyperemesis syndrome. The usual drugs to treat nausea are often of little benefit. Interestingly, topical capsaicin use may help.
People who take CBD products (including Epidiolex) for seizures should also taper off gradually to prevent withdrawal seizures.
Schizophrenia is a brain disorder where the person can hallucinate, think abnormally, and lose touch with reality. Using THC products and marijuana at an early age can increase the risk for schizophrenia.
Weekly cannabis use at least doubles the risk for testicular cancer.
THC-containing products can cause cannabis use disorder in approximately 10% of users. It occurs in around one out of three daily users. Those affected become accustomed to the effects of cannabis (tolerance), go through withdrawal symptoms if they try stopping it abruptly, and continue to use it even if it is causing them harm. Cannabis use disorder is associated with poor school functioning, a higher likelihood of requiring socioeconomic assistance (social welfare programs), low income, unemployment, criminal behavior, and lower life satisfaction.
Long-term cannabis users can develop permanent brain abnormalities, including decreased hippocampus size, lower IQ, and reduced brain nerve activity. A 2014 study of 158 cannabis users showed significantly worse memory, attention, and performance scores than nonusers. Unsurprisingly, these were worse in daily users than sporadic users. However, even those who had previously stopped using cannabis had significantly lower brain function than people who never used cannabis. This suggests that adverse brain effects can be permanent.
Research suggests that CBD may decrease some of the unwanted side effects of THC by preventing THC from attaching to CBD1 and CBD2 receptors on specific body cells. However, the research is preliminary, and more studies are needed.
If you used to smoke cannabis many years ago, consider that THC strength has increased from approximately 3% in the 1990s to around 20% today.
from the FDA-approved package insert
Stomach upset, nausea, diarrhea, weight change, loss of appetite
Rash
Elevated liver enzymes
Anemia
Drowsiness, fatigue, insomnia, difficulty thinking, moodiness, aggression/anger, suicidal thoughts
Infection and fevers
Rash, hives, angioedema
from the FDA-approved package insert
Euphoria, “high”
Abdominal pain, nausea, vomiting, weight changes, diarrhea
Facial flushing, heart palpitations, fast heart rate
Muscle weakness or pain
Increased sweating
Elevated liver enzymes
Thinking abnormalities, altered judgment, sexual indiscretion activity, drowsiness, memory loss, anxiety/depression, incoordination, confusion, “flu-like symptoms,” headaches, nightmares, speaking problems, ringing in the ears, psychiatric symptoms (hallucinations, paranoia)
Low blood pressure, lightheadedness, passing out (syncope)
Rash, hives, angioedema, mouth sores
Hyperemesis syndrome (uncontrollable vomiting)
Seizures
Do not use cannabinoids while breastfeeding or pregnant. Fetal and infant exposure to THC increases the risk of permanent brain damage, which can lead to autism, hyperactivity, lower IQ, memory problems, and psychiatric illness.
CBD for lupus and lupus pregnancy risks has not been formally studied.
Cannabis smoking decreases sperm counts by around 30% and should be avoided in men trying to have a baby.
Older individuals have a higher chance of side effects, and lower doses are usually needed. The side effects can increase the risk of falls, which can be very dangerous (bleeding in the brain and hip fractures, for example). Do not use it without discussing it with your physician. If you have osteoporosis, you should consider not taking a cannabinoid.
Cannabinoids should be avoided before surgery to prevent dangerous interactions with anesthetic medications.
Prescription cannabinoids are not covered by insurance other than for the FDA-approved indications of chemotherapy-induced nausea, appetite stimulation, rare forms of seizures, and muscle spasms from MS.
The costs, out of pocket, as per UpToDate.com, for a typical one-day supply, are as follows:
Epidiolex: $32 to $250 per day for a 150-pound adult
Generic dronabinol: $2.5 to $375 a day
For OTC CBD products, prices range from US 24 cents for 10 mg to US $2.67 for 10 mg, per ConsumerLab.com.
ConsumerLab.com also tests product quality. The least expensive product was also one of the highest-quality brands. This is a case where more expensive does not mean higher quality.
www.projectcbd.org and www.cdc.gov/marijuana/index.htm
Read chapter 39 of The Lupus Encyclopedia, edition 2
Look up your symptoms, conditions, and medications in the Index of The Lupus Encyclopedia
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Don Thomas, MD, author of The Lupus Encyclopedia and “The Lupus Secrets“
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THC gummies are $20 for 20-2mg-10MG. This last me 2-3 months. So the cost is actually extremely low. Not sure how $20 a day was calculated. In states where Cannabis is not legal, delta 8 and delta 9 is, which is low dose THC
I only use as needed for days of extreme pain or insomnia. It is a game charger, pain virtually gone in an hour, and restful sleep.
I went with the THC/CBD tinctures, starting a couple of years ago. Basically, when you get enough into your system around the clock, you can find you have less pain. Start with 5 mg of each, and watch the mg of the product. My 800 mg THC requires less of a dose. Take more if you do not get the effects you need, but be careful about increasing beyond 20mg and wait an hour or so to feel effects before taking more. I take enough to work without feeling the psychological effects, and it usually clears within twelve hours. The combination of THC with CBD is anti-inflammatory. If I have breakthrough pain, or wake suddenly at night, I take half of a 10mg THC/CBD 1:1 gummy. Dosing is difficult without physician input, but they are afraid to lose their licensing. U of Maryland has a masters program that just started to develop knowledgeable medical people, so that will be a good thing. However, many state universities are not supporting these studies, which is too bad. Buy quality brands and not from the local grocery or MLM mail order. Topical CBD often is great, too.
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