Bloody diarrhoea
Blood, mucus or frequent diarrhoea indicate disease activity and need to be assessed by a gastroenterologist.
Cureal treatment spectrum
Medical cannabis for ulcerative colitis
Ulcerative colitis belongs in gastroenterological care. Medical cannabis does not replace flare treatment, maintenance of remission or biologics. At most, Cureal assesses it medically as a complementary option for symptoms when abdominal pain, urgency, loss of appetite or sleep problems remain a burden despite standard therapy.
- Chronic inflammatory bowel disease
- Only alongside gastroenterology
- Practice or video
Context
What is ulcerative colitis?
Ulcerative colitis is a chronic inflammatory bowel disease (IBD) that affects only the large intestine. The inflammation attacks only the superficial mucosa, begins in the rectum and spreads continuously, that is without unaffected sections, towards the small intestine. Around 160,000 people in Germany live with ulcerative colitis, and the disease often first appears between the ages of 20 and 35.
Depending on its extent, a distinction is made between proctitis, left-sided colitis and pancolitis. The disease typically runs in flares with intervening phases of relative freedom from symptoms. Complications such as severe flares, toxic megacolon or an increased risk of colorectal cancer after many years make close gastroenterological care necessary.
Basic therapy depends on the extent, severity and flare activity and includes, among others, 5-aminosalicylic acid, cortisone, immunosuppressants, biologics, JAK inhibitors or surgery. Medical cannabis does not replace this treatment.
Symptom areas
How ulcerative colitis appears
Symptoms vary depending on the extent of inflammation and flare activity. These points do not replace a diagnosis but help with an initial assessment.
Bowel urgency
Urgency, tenesmus and frequent trips to the toilet can shape everyday life even outside severe flares.
Abdominal pain
Cramps and pain must be distinguished from an acute flare, infection, side effects and functional symptom burden.
Tiredness
Inflammation, blood loss, sleep problems, iron deficiency or medication can cause exhaustion.
Sleep and stress
Urgency, pain and worry about the next flare can considerably disturb sleep and resilience.
Red flags
Fever, heavy bleeding, weight loss, dehydration or severe pain are not an indication for online cannabis treatment.
Diagnostic work-up
Diagnosing ulcerative colitis
Ulcerative colitis is not identified by a blood test but confirmed through endoscopy, laboratory tests and exclusion diagnostics.
The diagnosis is made by a gastroenterology practice or a hospital with a gastroenterology department. It is based on the German S3 guideline on ulcerative colitis, the medical history, physical examination, laboratory values such as blood count, CRP and faecal calprotectin, and endoscopic procedures. Ileocolonoscopy with step biopsies is the diagnostic gold standard.
Histologically there are continuous, superficial changes in the mucosa, while the transmural inflammation with granulomas typical of Crohn's disease is absent. In the area of chronic inflammatory bowel disease, Cureal works exclusively on the basis of an existing gastroenterological diagnosis and in coordination with the treating practice.
How the diagnostic work-up works
- Medical history interview about symptoms, course of flares and previous history
- Laboratory values such as blood count, CRP and faecal calprotectin
- Ileocolonoscopy with step biopsies as the diagnostic gold standard
Conventional treatment
Therapy: treating ulcerative colitis
Treatment follows the S3 guideline and has several layers, from basic therapy to surgery. At most, medical cannabis complements these building blocks for persistent accompanying symptoms but does not replace them.
Basic drug therapy
First-line and remission-maintaining substances for mild to moderate cases:
- 5-aminosalicylic acid (mesalazine), by mouth or as an enema/foam when the rectum is affected
- Glucocorticoids such as budesonide or prednisolone in an acute flare
- Immunosuppressants such as azathioprine or 6-mercaptopurine to maintain remission
Biologics, JAK inhibitors and surgery
Targeted therapy for moderate to severe cases:
- TNF-alpha blockers (infliximab, adalimumab, golimumab), vedolizumab, ustekinumab
- JAK inhibitors such as tofacitinib or upadacitinib, the S1P modulator ozanimod
- Proctocolectomy with an ileoanal pouch in treatment-refractory cases
Cannabinoid system
Why cannabis is only considered for symptoms in colitis
The endocannabinoid system is also active in the gastrointestinal tract and is involved in motility, pain perception, appetite and stress processing. That is why cannabis compounds are discussed for symptoms accompanying colitis. THC is associated with pain-relieving and antispasmodic effects, while CBD is not intoxicating and may be considered above all during the day for stress and pain.
These substances do not provide reliable control of the bowel inflammation. Gastroenterological disease control remains decisive; at most, cannabis may be considered as a symptomatic complement for abdominal pain, urgency, sleep and quality of life, with clear medical dosing and follow-up monitoring.
Evidence
Ulcerative colitis and cannabis: the research
Compared with Crohn's disease the research is somewhat narrower, but it provides consistent indications of clinical improvement in symptoms. A Cochrane review (Kafil et al. 2018) and a bibliometric analysis (Kafil et al. 2020) summarise the available evidence on cannabinoids in chronic inflammatory bowel disease and identify the need for further long-term studies.
A randomised, placebo-controlled pilot study over ten weeks: a CBD-rich botanical extract in ulcerative colitis showed an improvement in patient-reported symptom scores and quality of life, with moderate tolerability.
THC-containing cannabis in moderate to severe ulcerative colitis showed a significant reduction in the clinical Disease Activity Index compared with placebo, without clear endoscopic mucosal healing.
Legal situation
Legal situation in Germany (as of 2026)
Medical cannabis has been available on prescription in Germany since 2017, and the change in the law in 2024 made access easier still for patients. There is no approved finished cannabinoid medicine for ulcerative colitis; it is used exclusively outside its approved indication (off-label), based on an individual medical decision.
Cost coverage by German statutory health insurance is assessed case by case. With documented treatment resistance or intolerance to 5-ASA, biologics and glucocorticoids, the chances are higher than with well-adjusted standard therapy. Most patients pay for cannabis therapy privately.
Milestones
2017 Cannabis as medicine available on prescription
2024 Cannabis Act eases access
Process
How the route to a prescription works for ulcerative colitis
The decision should fit in with gastroenterological treatment and is always made by the treating doctor in the individual appointment.
1
Diagnosis
Diagnosis, extent, flare activity, laboratory values and existing gastroenterological therapy are discussed.
2
Target symptoms
Abdominal pain, urgency, appetite, sleep, stress and limitations in everyday life are recorded in a structured way.
3
Medication check
Mesalazine, cortisone, biologics, JAK inhibitors, immunosuppressants and other medicines are checked for interactions. If the indication is suitable, the doctor issues a private prescription.
4
Adjustment
Treatment starts following the principle "start low, go slow" and is adjusted according to effect and tolerability.
5
Monitoring
After two to four weeks, symptom burden, side effects, signs of a flare and feedback from the gastroenterologist are reviewed.
Context
THC, CBD and choice of therapy
There is no standardised cannabis medication for ulcerative colitis as a routine therapy. The active substance, dose and time of intake are aligned with the symptom goal, flare activity and accompanying medication.
- Acute flares, fever, heavy bleeding or dehydration call for gastroenterological or hospital assessment, not a cannabis consultation.
- CBD-dominant medications may be considered during the day for stress and pain, and THC-containing medications are usually used at a low dose in the evening.
- Mesalazine, cortisone, biologics, JAK inhibitors and immunosuppressants must be taken into account in the medication check.
Frequently asked questions
Questions about cannabis and ulcerative colitis
These answers give you initial orientation. The specific assessment for your situation is made by the treating doctor in coordination with your gastroenterologist.
Does cannabis help with ulcerative colitis?
Medical cannabis does not replace standard colitis therapy and does not treat an acute flare. In some patients it can, in individual cases, ease abdominal pain, reduce urgency and support calmer sleep during flare phases, above all when 5-ASA and biologics are already well adjusted and persistent accompanying symptoms remain.
Which cannabis for ulcerative colitis?
The choice is made individually in the initial consultation. CBD-dominant medications may be considered during the day and in the evening because they are not psychoactive and are easy to adjust, above all for inner restlessness. THC-containing medications are usually started at a low dose in the evening. Combination products with a fixed THC-CBD ratio are in many cases the practical solution.
Is cannabis a treatment for colitis flares?
No. Reducing inflammation, endoscopic remission and controlling flares are not the job of cannabis. Disease control remains the job of mesalazine, cortisone, biologics, JAK inhibitors or other gastroenterological therapies. According to current research, cannabis mainly eases symptoms such as pain, urgency and impairments to sleep and quality of life; direct endoscopic healing of the mucosa has not been clearly shown in the available randomised studies.
Can cannabis be combined with biologics or JAK inhibitors?
A combination is possible in many cases but requires careful medical supervision. CBD and THC can affect how certain medicines are broken down by the liver, which can change their effects and side effects. With JAK inhibitors, particular attention to interactions is needed. Any adjustment of existing medication is made exclusively in coordination with the gastroenterology practice.
What side effects can the cannabis therapy have?
Possible side effects are a dry mouth, tiredness the next day, mild dizziness, a temporarily faster heartbeat or a temporary change in bowel habits during the adjustment phase. In patients with colitis, interactions with biologics, JAK inhibitors and immunosuppressants must also be considered. That is exactly what medical supervision is for: a low starting dose, regular monitoring and adjustment if a dose is not right.
Is medical cannabis addictive?
Compared with opioids, the potential for physical dependence is low. A psychological habit can develop, especially with permanently high doses of THC. Within a therapeutic framework with medical dose control, the risk is considerably reduced. Anyone stopping therapy should do so gradually and in consultation with the treating doctor.
What does cannabis therapy cost without cover from a health insurer?
The total costs consist of the initial consultation, repeat prescriptions and the cannabis medications from the pharmacy. At Cureal the initial consultation costs €39, a follow-up appointment €29 and a repeat prescription €19. The monthly pharmacy costs depend on the medication and dosage and are discussed individually in the initial consultation.
Related topics
Further indications in the treatment spectrum
Ulcerative colitis often occurs together with other conditions. These topics are closely linked.
Crohn's disease
The second major chronic inflammatory bowel disease. Despite different patterns of progression, the range of cannabis use overlaps when it comes to pain and symptom burden.
Go to pageChronic pain
Persistent abdominal pain can become a burden in its own right in stable phases outside an acute flare. Cannabis therapy led by pain medicine can be considered here as a complement.
Go to pageSleep disorders
Urgency, pain and stress in ulcerative colitis regularly disturb sleep. Cannabis in the evening can stabilise sleep.
Go to pageHave accompanying colitis symptoms assessed by a doctor
If pain, urgency, loss of appetite or sleep problems are a burden despite gastroenterological treatment, a medical consultation can clarify whether medical cannabis is justifiable for your situation.