1. Cannabis & Autoimmune Disorders
Dr. Nick Salamie PharmD, RPh

2. Autoimmune Disorders Inappropriate Immune Response Multiple Sclerosis
Rheumatoid Arthritis
Lupus
Sjogren’s syndrome
Myasthenia Gravis
Qualifies for Medical Cannabis
Type 1 diabetes
Psoriatic Arthritis
IBD
Addison’s disease
Graves’ disease
Hashimoto’s
Autoimmune vasculitis
Pernicious anemia
Celiac disease
Non-Qualifying
Autoimmune Disorders
Autoimmune disorders are conditions that results in an immune response inappropriately targeting healthy tissue.
The immune systems job is to guard against foreign invaders and parasites. In most people the immune system can distinguish the difference between your own native cells and foreign cells.
With autoimmune disorders, the immune system mistakes a certain part of the body or multiple parts of the body as foreign.
The cause is unknown, but autoimmune disorders happen in women at a rate of 2 to 1 compared to men.

3. Symptoms Fatigue Muscle aches Swelling Low fever Difficulty Focusing
Numbness in hands and feet
Alopeica
Rashes
Early Generalized Symptoms
Each disease will have own set of unique symptoms
- Early symptoms of all autoimmune disorders may include: fatigue, muscle aches, swelling, low fever, difficulty focusing, numbness in hands and feet, alopecia and/or rashes.
- Each condition listed on the previous page will have its own set of unique symptoms as the condition progresses.

4. Traditional Treatments
NSAIDs
Aleve
Advil
Immunosuppressant Drugs
Corticosteroids
Janus kinase inhibitors
Calcineurin inhibitors
mTOR inhibitors
IMDH inhibitors
Biologics
Monoclonal antibodies
-Traditional treatments for Autoimmune Disorders include non steroidal anti inflammatory drugs like aleve and advil.
-The other big class of drugs used are immune-suppressing drugs. These drugs weaken the immune system, hence the name, and suppress the immune system’s inappropriate response to the body’s own tissue.
-Here’s a list of categories of immunosuppressant drugs. We don’t have time to go over all these drugs, but lets take a look at humira. You have probably all seen the humira commercials where is everybody is having fun and living their best life.

5. These are the major risks with taking humira
These are the major risks with taking humira. People have died from serious infections that occurred while taking the drug. If a serious infection wasn’t enough to worry about, Cancer including a rare type of cancer called hepatosplenic T-Cell lymphoma that often results in death is a risk.
Medical Cannabis does not have these serious risks associated with it.

6. Endocannabinoid System
Complex Regulatory System
Regulates Immune Response
CB1 and CB2 Receptors
Immune Cells Express Both
Endocannabinoid and Phytocannabinoids
Immunosuppressive Properties
Cell death
Inhibition of Cell Growth
Inhibition of signaling and regulatory proteins
Inhibition of white blood cell attraction
THC modulates T-helper cells
-So briefly a little bit about the science of how cannabis helps autoimmune disorders.
-The endocannabinoid system is a complex regulatory system found in all mammals. It regulates many functions in the body. For today we are focused on how it regulates immune response.
The CB1 and CB2 receptors are the main receptors in this system that we currently know about. Immune cells in the body actually have both of these receptors.
Both endocannabinoids, like anandamide and 2-AG, and phytocannabinoids, like THC and CBD, interact with these receptors.
Cannabinoids exhibit immunosuppressive properties through these cannabinoid receptors via the 4 main pathways listed on the slide. I won’t go in depth on these mechanisms since it is complex and in all honesty boring for most people.

7. Multiple Sclerosis Cannabis useful for symptom relief
Spasticity
Pain
Sleep
May reduce progression in early MS
Cannabis Strategies
Day: CBD/THC
Night: THC
Inhalation, Oral and Sublingual
Dosing based on patients cannabis experience
Advanced Consideration: Beta-Caryophyllene
-Multiple Sclerosis probably has the most evidence of all the autoimmune disorders for cannabis as a treatment for symptomatic relief. Spasticity symptoms like stiffness, muscle spasms, and tremor are for are easily treated with Cannabis.
- Improvements in Pain levels and Sleep have also been seen in MS patients.
Cannabis may reduce the progression of MS that’s in earlier stages, but there is no evidence that is slows down advanced MS.
Cannabis strategies will differ from patient to patient, but as a general rule patients should consume CBD and THC orally during the day for symptom relief and for possible reduction in disease progression. Inhalation or sublingual dosage forms should be used as needed for fast acting relief.
Nighttime strategies are similar, but THC rich products and strains should be used.
Dosing will be based on the patients cannabis experience since THC may produce unwanted effects in newer or sensitive patients.
If at all possible picking products higher in Beta-Carophyllene is recommended since Beta-Caryophllene has neuroprotective, antioxidant, anti-inflammatory and immune-modulation action.

8. Rheumatoid Arthritis Symptom Relief Inflammation Pain Fatigue Mood THC
CBD
THCa
CBC
Beta-Caryophyllene
- Rheumatoid arthritis is one of the qualifying autoimmune diseases that qualifies for a medical cannabis card. Rheumatoid arthritis can cause significant inflammatory issues of a joint’s interior lining. RA can cause chronic severe pain, irreversible joint damage and disability.
When we look at rheumatoid arthritis we know for sure that THC can reduce arthritic pain as studies have shown this.
Inflammation in the joints is the big underlying issue with Rheumatoid arthritis. We can utilize a pool of phytocannabinoids to try to reduce this inflammation.
THC is a very valuable anti-inflammatory agent. It has 20x the anti inflammatory power of aspirin and twice as much as hydrocortisone.
CBD is also a potent anti-inflammatory agent. When combined with THC you may get synergistic anti-inflammatory actions.
THCa, which is the raw form of THC, may prove to be valuable for rheumatoid arthritis. It is non psychoactive in most people and has anti-inflammatory and immunomodulatory properties. Its also more bioavailable than the neutral form of THC.
CBC, which is short for cannabinchromene, also has anti inflammatory properties.
And finally beta caryophyllene, which is a terpene and cannabinoid has anti-inflammatory applications as well.
Ideally, you want to find an oral cannabis product that includes all these cannabinoids I just mentioned and consume it at least twice a day. Rick Simpson Oil is currently the best cannabis product for this because you can find all these cannabinoids in a handful of RSOs out there.
Consistency is key with utilizing cannabis’ anti-inflammatory properties. Using cannabis as needed for inflammatory issues is not very efficient.
Treatment strategies for Rheumatoid arthritis and Lupus will be similar to ones I discussed used in Multiple Sclerosis.
This Photo by Unknown Author is licensed under CC BY-NC-ND

9. First PDI Visit Goals Increase Quality of Life Drug Interactions
Assess Patients Cannabis Experience
No or little cannabis experience
Intermediate cannabis experience
Advanced Cannabis Experience
Tapering Strategy if Necessary
Product selection and initial strategy
Minimum Effective Dose
Follow Up
When a patient first comes into PDI ideally they will have a brief conversation with me or another healthcare professional to devise a game plan. PDI is the only dispensary in Illinois to have a health care professional available at most times.
The goals differ from patient to patient, but the universal goal always is to increase the quality of life. And to be clear getting the patient “stoned” is never a goal with just about every patient.
We do drug cannabis interactions to make sure there are no significant interactions between the patients pharmaceuticals and cannabis. For example, we have to be careful when a patient is on warfarin due to a cannabis-drug interaction that could potentially increase the risk of bleeding.
Initial Dosing Strategies with patients are typically based off the patients experience and comfort with cannabis.
Patients with no or little cannabis experience I will take a way different approach than someone with Advanced Cannabis Experience. Patients with no or little cannabis experience I typically recommend starting out with CBD Rich cannabis products and/or microdosing of a THC rich product. This conservative approach reduces the chances of any unwanted side effects and allows patients to find their sweet spot in a comfortable fashion.
A patient with intermediate cannabis experience can be defined as someone who is familiar with the effects of THC on their body and have somewhat of an idea how well they tolerate cannabis. I typically will recommend either a 1:1 cbd to thc product and/or thc rich products at low to moderate doses for these types of patients.
A patient with advanced cannabis experience can be defined as someone who has been self medicating for quite some time and knows exactly how well and the amount of cannabis they can tolerate. These patients are the easiest to dose since you don’t have to worry as much about adverse effects.
If the patient is currently coming off of opioids a sound tapering strategy should be discussed. Each tapering approach will be unique from patient to patient. A patient who has been on extended release and intermediate release oxycontin for years may have a completely different approach than a patient who has been taking norco twice a day for 1 month.
-Initial product selection and strategy is going to be based on the patients current cannabis use and any limitations, like if the patient cant inhale and so forth.
The idea is to get the patient to the minimum effective dose, also known as the sweet spot, which is the dose where they are getting sufficient relief without any adverse effects.
Following up is important because it may take multiple visits to find the best possible regimen.

10. Dosage Forms Inhalation Ingestible Sublingual/Buccal/Oromucosal
Combustion
Vaporization
Ingestible
Edibles
Oils (RSO)
Tablets/Capsules
Sublingual/Buccal/Oromucosal
Topical
Transdermal
We have quite a few dosage forms to work with in the state of Illinois to achieve this “sweet spot.”
Starting with inhalation we have a couple of different methods we can use. We have the old tried and true combustion method with either a pipe, joint, bong, or steamroller just name a few different ways. We prefer patients to inhale using vaporization over combustion to avoid any possible harmful by products. Every cannabis patient should have some sort of inhalation product unless they have some limitation that deters them from inhalation. The reasoning behind that is that inhalation is the fastest way to get the medicine into the body and is superior for acute pain or flare ups. You can think of inhalation as your rapid or break through cannabis medicine.
The downside to inhalation is that it wears off very quickly with relief really lasting only 1 to 3 hours. That’s were other dosage forms come into play like ingestible products as these products can last anywhere from 4-8 hours. But the downside is that there is a high variability as far as the onset of effect goes, anywhere from 30 minutes to 2 hours. I am a big proponent of rick simpson oil, also known as RSO, when it comes to addressing any type of pain with cannabis. I recommend patients to take at least one to two doses of a CBD rich cannabis oil daily. RSOs are a good way to keep a constant baseline of cannabinoids in the body.
Sublingual forms like tinctures are excellent for new patients when we want to take a microdosing approach. Tinctures allow us to go drop by drop if need be in patients who are more comfortable with a conservative approach. RSOs can also be taking sublingually.
Topicals are a nice add on to any cannabis regimen when one part of the body is hurting more than another. We get localized action with topicals so patients don’t have to worry about any psychoactivity. I recommend patients who experience pain in localized areas to give a topical a shot.
Transdermal dosage forms such as a patch are very convenient, but are by far the most expensive dosage form per dose.

11. Cannabis Oils/RSOs Best medical dosage form
Whole Plant/Full Spectrum Extract/Herbal Shotgun
Varying Cannabinoid Profiles
Different CBD:THC ratios
Acidic Cannabinoids: THCa, CBDa, CBGa
“Varin” Cannabinoids: THCV, CBDV
Less abundant Cannabinoids: CBN, CBG, CBC
Terpenes Captured
Beta-Caryophyllene
Lets discuss Cannabis Oils also known as Rick Simpson Oils, RSO for short, even though Rick Simpson doesn’t like his name being used in commericialized cannabis products. And that’s Rick Simpson in the picture.
In my opinion Rick Simpson Oils are the best medical cannabis dosage form currently available.
The way the extract process works is that it literally extracts everything from the plant including the cholorphyll when ethanol is used as the main solvent.
Luckily medical cannabis patients in Illinois have access to a wide variety of RSOs ranging from all THC to nearly all CBD and everything in between. There are some with very unique cannabinoid profiles you can find offered from Shelby county. For instance when the traditional THC and CBD rich medicines don’t provide much relief we may look at using a RSO that’s rich in acidic cannabinoids since THCa shows promise in neurological problems. Or we can find one with a decent amount of the varin cannabinoids like CBDV. Typically the varin cannabinoids are found more in Oils that use Carbon dioxide as a solvent like Shelby uses. Also, you will find the less abundant cannabinoids listed here in some of these RSOs. RSOs are the best way to get as many cannabinoids and terpenes into the body as possible per dose size and we may be getting a better synergistic effect than just a typical thc dominant edible.
RSOs are typically rich in terpenes as well. The specific terpene profile or entourage will really be dependent on the strain. It best to look for Oils rich in Beta-Caryophyllene since this particular terpene also acts as an anti-inflammatory agent.

12. Getting Your Cannabis Card
Formal Diagnosis of 1 of the 41 qualifying conditions
Completion of Physician Written Certification Form by a Licensed Physician
Fingerprint/Background Check
Completion of Online Registration and and Payment
Provisional Registration
-The actual process of getting a medical marijuana card in Illinois seems like an involved process, but its relatively simple especially with the help of PDI medicals staff.
The first step is to determine whether you have a formal diagnosis of 1 of the 41 qualifying conditions. Cancer, crohns disease, fibromyalgia and PTSD are just to name a few.
The next step and probably the most important step is to have a physician complete and sign a Physician written certification form.
The next step is to call PDI Medical and schedule an application appointment, which we do free of charge. Fingerprints and background checks are no longer required, but we will take your passport photo and we will also help you to make sure you fill out the online application correctly before you submit to the state with payment.
Provisional registration allows you to get a temporary paper cannabis card within 24 hours. This is available because it usually takes 90 days for the plastic hard card to arrive. The temporary card addressed that potential 90 day void.

13. Resources
“Autoimmune Diseases: Types, Symptoms, Causes, Diagnosis & More.” Healthline, Healthline Media, autoimmune-diseases.
Backes, Michael, et al. Cannabis Pharmacy: the Practical Guide to Medical Marijuana. Black Dog & Leventhal Publishers, 2017.
“Health: Autoimmune Disorders and Cannabis.” Performance by Michele Ross, Green Flower Media, disorders-and-cannabis.
“Immunosuppressant Drugs: A Complete Overview.” Healthline, Healthline Media,
Russo, Ethan B., and Jahan Marcu. “Cannabis Pharmacology: The Usual Suspects and a Few Promising Leads.” Cannabinoid Pharmacology Advances in Pharmacology, 2017, pp. 67–134., doi: /bs.apha

14. Questions