What to Know About Cannabis Use and Diabetes, with Halis Akturk, MD

Despite medical cannabis in the US dating back more than 3 decades, the legalization movement in the last decade means millions and millions of US adults now have access to cannabis, for both medical and recreational purposes.

However, with this boom in use, concerns regarding the health effects of cannabis use have become a greater focal point of discussion among medical circles. According to a 2023 study in JAMA Network Open, 17% of a 175,000-patient cohort of adults reported cannabis use in the previous 3 months and 34.7% of those individuals met the criteria for moderate to high risk for cannabis use disorder.¹

At the 84th American Diabetes Association Scientific Sessions, Halis Akturk, MD, associate professor of medicine and pediatrics at the Barbara Davis Center for Diabetes at the University of Colorado, led a session titled “The Highs and Lows of Cannabis Use in Diabetes—Behavioral and Psychosocial Considerations”. Based in Colorado, Akturk has a unique view from the frontlines of research and real-world practice as Colorado was among the first states to allow for both medical and nonmedical cannabis use.

Diagnostic Criteria for HK-CHS

Venous Blood Glucose at 250 mg/dL or greater
Anion Gap greater than 10
Serum β-hydroxybutyrate greater than 0.6 mmol/L
pH at 7.4 or greater
Bicarbonate at 15 or greater

In the past 5 years, Akturk has published numerous studies detailing the effects of cannabis use with type 1 diabetes. In 2019, a study from Akturk in JAMA Internal Medicine evidenced the elevated risk of diabetic ketoacidosis among adults with type 1 diabetes using cannabis receiving care at the Barbara Davis Center for Diabetes. Building o this research, a similar study published in Diabetes Care in 2020 confirmed a similar trend using data from the T1D Exchange clinical registry. In 2022, Akturk led an additional study providing clinicians with an overview of the differences in presentation between diabetic ketoacidosis and hyperglycemic ketosis due to cannabis hyperemesis syndrome.^2,3,4

At ADA 2024, we sat down with Akturk to learn more about this emerging space, what additional risks are associated with cannabis use in adults with and without type 1 diabetes, and what questions hears most often from his colleague regarding the topic.

HCPLive: What is the prevalence of cannabis use among people with type 1 diabetes and what are the primary reasons cited for use?

Akturk: In Colorado, we have the one of the highest rates of cannabis users with type one diabetes. So, we did a survey study a couple years ago and we asked the adults with type one diabetes: "Have you been using the cannabis or have you ever used the cannabis in the last 12 months?". In the results, there were about 30% of the patients in the adult clinic with type 1 diabetes that were at least used once cannabis in the last one year. The reasons for use were multiple, with about 75% of the people were using recreational reasons and 25% of the people were using medicinal reasons. In some states, you can just get a medicinal card for different indications. This was relatively a high use in our community for type 1 diabetes.

HCPLive: What are some of the chief concerns about how the effects of cannabis use manifest among patients with type 1 diabetes?

Akturk: Our previous research showed that the people who are using cannabis have an increased risk for diabetic ketoacidosis when they have type 1 diabetes. This was a local study we did a couple of years ago in JAMA, where we were trying to find out the reasons for that. Then we went to the T1D Exchange data and we looked to see if we can confirm our study results. We confirmed that the people who are using cannabis, after adjustment for the other things like pump use, age, diabetes, duration and other confounders, were at an increased for diabetic ketoacidosis.

As a next step, we realized that these people have a different the metabolic profile when they present to ER with the diabetic ketoacidosis symptoms. In other research, what we did is we looked at their metabolic profiles and their labs to compared people who are using cannabis and not using it. So, we did an objective study, and we looked at their urine drug screen use. If somebody's urine drug screen is positive for cannabis, we consider this person is using and, if it's not that, we consider that as not using it.

We found very significant differences in terms of the labs at presentation. We showed that these same people are also getting hyperglycemia, they are getting ketosis, and they have an onion gap. They also present to the ER with nausea and vomiting. But the main difference was the pH and the bicarb. So, their pH was more than 7.4 and their bicarb was more than 15. So, in DKA, there should be pH should be less than 7.3 and bicarb should be less than 15. So, we call them as a different entity, as hyperglycemic ketosis related to the cannabis hyperemesis syndrome.

HCPLive: When should providers approach discussions around cannabis use among patients with type 1 diabetes?

Akturk: I think we should educate people about cannabis at the type 1 diabetes diagnosis. We have a structured plan for the sick day management for alcohol and we added structures for cannabis education in the type 1 diabetes care program at the Barbara Davis Center. If there is a new patient, I suggest the providers, especially the endocrinologist, to discuss the cannabis with them at their first visit. If they have some frequent visits related to the ER visits and there are some frequent diabetic ketosis episodes, I suggest asking them if they use cannabis or not.

Disclosures of interest for Akturk include REMD, Dexcom, Senseonics, and Eli Lilly and Company.