COMPLEMENTARY AND ALTERNATIVE THERAPIES FOR RHEUMATIC DISEASES
SHARON L. KOLASINSKI
UNIVERSITY OF PENNSYLVANIA
HOSPITAL PRACTICE . APRIL 15, 2001
Many of these therapies have a long history of apparent safety and efficacy but have not been adequately tested in controlled trials. The article reviews the most frequently used products and practices.
GLUCOSAMINE AND CHONDROITIN
Two of the complex building blocks of normal connective tissue,
GLUCOSAMINE sulfate and Chondroitin sulfate have been used for
osteoarthritis relief for decades in Europe.
GLUCOSAMINE, a constituent of glycoproteins,
proteoglycans, and glycosaminoglycans, is known to reduce osteoarthritis
cartilage. It may also have anti-inflammatory effects. Most of
the studies suggest benefit in terms of pain relief. The magnitude
of improvements was comparable to that obtained with NSAIDs. Radiographic
follow-up suggests a slowing of osteoarthritis progression.
Chondroitin sulfate is available
in over-the-counter formulations. Trials have shown positive trends
for analgesic effects in patients with osteoarthritis of the knee
and hip. Longer-term studies are needed to clarify its place in
the clinical armamentarium.
DIET
Early literature links certain foods to arthritis flares. Medical
history is rich with description of how foods or drinks contribute
to the onset and perpetuation of gout.
Fasting appears to have a
beneficial effect on pain, stiffness, inflammation. The mechanism
is obscure but could be related to reduced immunologic activity
that comes from decreased food intake.
Benefits may also be derived from
fish oil, fish oil fatty acid derivatives, and certain plant oil
supplements. Eicosapentaenoic acid and decosahexaenoic acid preparations
from cold-water fish are widely available in capsule form. Plant
oils from borage (Borage officinalis), evening primrose (Oenothera
biennia), and flaxseed (Linus usitatissimum) may provide similar
benefits. The optimal use of these agents remains to be defined.
VITAMINS
Studies suggest that those with the lowest intake and serum levels
of 25-hydroxyvitamin Do were three times more likely than those
with highest intake and serum levels of the vitamin to experience
progression of their disease.
High vitamin C intake was also associated
with a threefold reduction in osteoarthritis progression. A positive
but weaker association was demonstrated with b-carotene. No association
was found for vitamin E, Be, Be, niacin or foliate.
HERBAL PREPARATIONS
WILLOW BARK
Willow bark tea has been used since antiquity for the treatment
of pain, fever, and gout. The powdered bark remains a popular
ingredient in over-the-counter anti rheumatic preparations because
of its salicin content, a source of salicylic acid. It efficacy
in relieving pain in osteoarthritis of the knee and hip has been
demonstrated in randomized, double-blind, placebo-controlled trials.
DEVIL'S CLAW
Studies have shown that osteoarthritis pain can be significantly
alleviated with iridoid glycoside harpagoside, the presumed active
ingredient in devil's claw (Harpagophytum procumbens) remedies.
Double-blind trials with subjects taking 2.0 to 2.4 gm/day of
powdered Harpagophytum extract, containing 0.3 to 0.7 gm of harpagoside,
for one to two months showed a reduction in pain score and an
increase in mobility. Short-term tolerability was high, but long-term
efficacy and side effects remain unknown.
FEVERFEW
Fever few (Tanacetum parthenium), another traditional arthritis
remedy long used in Europe and North America, is believed to
have antipyretic as well as anti-inflammatory activity. However,
in the single clinical trial conducted thus far in 41 women with
rheumatoid arthritis treated with powdered extract of T. parthenium
leaves, none showed any improvement in pain, stiffness, or number
of swollen or tender joints.
CHINESE THUNDER GOD VINE
The roots, leaves, and flowers of the Chinese thunder god vine
(Tripterygium wilfordii) have been in use in Chinese medicine
in the 1500s. It fell into disfavor (perhaps because of toxicity)
and for the next four centuries was used only as an agricultural
insecticide. Medical interest was revived during the Cultural
Revolution. Since then, it has been used for a host of rheumatologic
disorders, including rheumatoid arthritis, SLE, Henoch-Schonlein
purpura, Sweet syndrome, scleroderma, Behcet's disease, and psoriatic
arthritis.
Its therapeutic activity probably
derives from diterpenoid components with epoxide structures. T2,
a chloroform-methanol extract, and EA, an ethyl acetate extract
of Tripterygium roots, have a anti-inflammatory and immunosuppressive
effects. The active ingredients in these extracts, triptolide
and tripdiolide, inhibit production of cytokines and other inflammatory
mediators.
Most of the information on the
medical uses of Tripterygium comes from uncontrolled clinical
trials and retrospective studies. In actively treated patients,
ESR and rheumatoid factor decreased. However, considerable toxicity
has been documented. Many women experienced amenorrhea; men may
experience azoospermia. Treatment-related deaths have also occurred
as a result of myocardial damage, renal failure, and hypotensive
episodes related to severe gastrointestinal side effects.
ACUPUNCTURE
Arthritis patients use acupuncture primarily for its analgesic
effects. After a 1998 consensus conference review of available
data, the National Institute of Health concluded that acupuncture
is promising for control of postoperative pain and chemotherapy-associated
nausea and vomiting. The NIH also approved its use as primary
or adjunctive therapy for such disorders as tennis elbow, fibromyalgia,
myofascial pain, osteoarthritis, low back pain, and carpal tunnel
syndrome.
