Prevalence of cannabidiol use in persons with cystic fibrosis

To the Editor,

In the past decade, the use of cannabidiol (CBD) has greatly increased in the United States. The Agricultural Improvement Act of 2018 legalized hemp‐derived products in all 50 states, contributing to the continued growth of cannabidiol use and the first FDA approved cannabidiol product, Epidiolex. ¹ , ² Cannabidiol is used to treat a variety of symptoms including anxiety, depression, chronic pain, insomnia, and poor appetite; and is commonly used in people with cystic fibrosis (PwCF). ³ Approximately 10%–15% of PwCF taking elexacaftor/tezacaftor/ivacaftor (ETI) have experienced neuropsychiatric AEs. ⁴ PwCF may consider treatment with cannabidiol to lessen these ETI related ADRs. As the use of cannabidiol has increased, several studies have shown that cannabinoids have significant interactions with the cytochrome P‐450 (CYP) enzyme systems including CYP2C19, CYP3A4, CYP1A1, CYP1A2, CYP2C9, and CYP2D6. ⁵ Variability or lack of EMR documentation and reluctance of PwCF to disclose CBD use may prevent clinicians from identifying potential drug–drug interactions (DDIs) and risks of treatment failure. This is important in PwCF as cystic fibrosis transmembrane conductance regulator (CFTR) modulators have CYP3A dependent metabolism. The aim of this study was to determine the prevalence of CBD use in PwCF.

This was a two‐part study that used a retrospective audit of the EMR and a prospective survey of PwCF attending scheduled CF clinic appointments in the Adult Cystic Fibrosis Clinic at Indiana University, Indianapolis, IN. The Institutional Review Board provided an exempt approval and retrospective data was collected in January 2024 from the EMR of adult patients with CF treated at our institution. An EMR search was conducted for each patient using the terms “cannabis” and “marijuana” ('CBD' was not a recognized term in the EMR and not used to search). The chart search function was able to locate mention of the key term in orders, medication history, and clinical notes. Patients were considered previous CBD users if any historical record was found indicating use. Patients were considered current users when documented in their 2023 or 2024 annual CF clinic social work or clinical progress note in the EMR.

The Institutional Review Board approved this prospective survey. The survey was administered to patients at their routine CF appointment following informed consent. Participants were asked to describe their experience with CBD exclusively or as part of a marijuana product, and route of consumption (oral, inhalation, topical). A Likert scale was used to determine use (currently using, never used/do not plan to, never used but interested, used in the past). Participants optionally self‐reported on reason for use or interest in use. Responses were categorized into anxiety, appetite, pain, sleep, and wellness/mood support. Use of marijuana was not included on this survey as in Indiana marijuana is not currently legal and there are mandatory reporting regulations for social workers if a patient self‐reports use of marijuana and they are a parent of a minor.

We identified 373 PwCF that are currently or have previously been followed by our CF clinic. The EMRs of these 373 were reviewed for historical and current CBD use. Of those, 14.2% (n = 53) patients reported previous cannabis or marijuana use and 15.0% (n = 56) patients reported current cannabis or marijuana use.

The prospective survey was administered to 96 PwCF (Figure 1). Across all routes of consumption (oral, inhalation, and/or topical), 11.5% (n = 11) of patients were current CBD users, 20.8% (n = 20) had used in the past, 21.9% (n = 21) had never used but were interested in using, and 44.8% (n = 43) had never used and do not plan to use CBD (Figure 2). Thirty‐four percent (n = 33) of patients self‐reported their reason for use or interest in use and responses were recorded. Of those reporting reason for using CBD or interest in use of CBD, the most common reasons were sleep, anxiety, and pain reported by 33%, 30%, and 30% of respondents respectively. In addition to these top three reported reasons, recreation, mood, appetite, and general health advantages. Respondents were allowed to report multiple indications for use and 46 indications were reported from the 33 participants that provided a reason.

Figure 1.

Survey.

Figure 2.

Reported use and interest in using cannabidiol.

Our study found that PwCF are using or are interested in using CBD, with 54% of PwCF surveyed reporting use, interest in future use, or past use. These results are like other published reports where approximately 15‐10% of adolescents and young adults with CF have reported using cannabidiol and 46% reported interest in future use. ³ Yet, in contrast to patient interest in CBD, in a survey of 282 CF clinicians, 72% responded that they were under‐prepared to answer questions regarding use of cannabidiol with CF. ⁶

The expansion of cannabidiol use by PwCF combined with the lack of evidence on its use in this population, potential drug‐drug interactions, and drug‐disease interactions leave clinicians unprepared to provide advice on cannabidiol use to their patients. It is important for clinicians to ask about CBD and for researchers to continue to study potential DDIs with CBD. This is especially important in PwCF as modulators have CYP3A dependent metabolism and this DDI could result in treatment failure or increased adverse drug reactions.

Our retrospective review of the EMR found documentation of cannabis and/or marijuana in less than 30% of PwCF. In our prospective survey, 31% reported previous or current use of CBD. These numbers are somewhat encouraging that reported use is consistent from prospective survey and retrospective review of EMR documentation. Review of EMR was limited at our institution as CBD is not easily categorized to be added to the medication list. Improving ease of reporting and documentation could ultimately improve attention to potential drug‐drug interactions and unwanted adverse events.

As CBD use becomes more widespread, it is important for clinicians to be aware of use in PwCF. Studies evaluating DDI with CF pharmacotherapy and CBD should be prioritized to ensure appropriate clinicians and PwCF can make informed risk vs benefit decisions about CBD use.

AUTHOR CONTRIBUTIONS

Emma M Tillman: Conceptualization; investigation; writing—original draft; methodology; validation; writing—review and editing; formal analysis; project administration; supervision. Katherine A Gallaway: Investigation; methodology; data curation; project administration; writing—review and editing. Abi Colwell: Investigation; writing—review and editing; validation; formal analysis; data curation. Colleen Sakon: Data curation; writing—review and editing; conceptualization. Cynthia D Brown: Conceptualization; writing—review and editing.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

Tillman EM, Gallaway KA, Colwell A, Sakon C, Brown CD. Prevalence of cannabidiol use in persons with cystic fibrosis. Pediatr Pulmonol. 2024;59:3790‐3792. 10.1002/ppul.27244

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.