Many patients with RA turn to alternative, traditional or complementary medicines because of lack of efficacy or fear of traditional medicines. There is also the sometimes mistaken notion that alternative medications are safer than traditional medicines. This chapter attempts to examine the efficacy and safety of some of these treatments.
In a study of patients with rheumatoid arthritis at our Center, it was found that 66% of patients had tried some form of alternative medicine. The most commonly preferred were acupuncture, Ayurveda, herbs, and homeopathy.
- Always discuss your use of alternative medications, herbs, etc with your rheumatologist/ doctor
- Always use only licensed and well-qualified practitioners
- Remember that even herbs can have side effects and interact with medications you take
- Remember that often not enough research has been done into ‘natural’ therapies and hence all their side effects are not known.
- Traditional medicines which your doctor gives you have known side effects and are usually safe to take under proper supervison
- There is no evidence that any of the alternative forms of medicine can prevent joint damage such as has been proven with drugs like methotrexate
- Acupuncture or Acupressure
What is alternative therapy?
A traditional Chinese system of medicine. In needle acupuncture fine metal needles are inserted to manipulate life energy. In ancient China it was believed that our life energy called qi (pronounced chee) runs along certain pathways in the body called meridians. Stimulation along specific points along these meridians could balance the life energy and correct illness. Acupressure stimulates these points without needles. Other types of acupuncture stimulate these points with heat and herbs (moxibustion), lasers, magnets, etc.
Does it work?
There have now been several studies which show that acupuncture can relieve the pain associated with knee osteoarthritis, back pain, and fibromyalgia. However, studies have not shown it is useful in inflammatory arthritis such as rheumatoid arthritis.
Can you try it?
- Acupuncture is generally safe.
- Make sure only sterile disposable needles are used
- Safety in pregnancy and children under 10 years is unknown
- It does relieve pain associated with osteoarthritis, back conditions and fibromyalgia.
- It is not a cure and repeated sessions are required to keep the pain levels low
Acupressure at home.
- Ayurvedic Treatment
What is it?
Ayurveda originated in India 4000 years ago and was modified to reflect an organized system of medicine. Ayurvedic practitioners believe that every creation inclusive of a human being is a model of the universe. The Ayurvedic practices (chiefly that of diet, lifestyle, and the Panchkarama) aim to maintain the Dosha, or body’s equilibrium. Despite a holistic approach aimed to cure disease, therapy is customized to the individual’s constitution (Prakruti). A combination of medicine, exercise, diet and meditation is usually prescribed.
Does it work?
Very few scientific studies have been conducted with ayurvedic treatments on patients with arthritis. In one small study a combination of ginger, turmeric, boswellia and ashwagandha reduced pain in osteoarthritis. There has been evidence that ginger reduces pain and inflammation of arthritis and can act as a painkiller. Elimination diets which are used in Ayurveda are useful in rheumatoid arthritis. However, these diets eliminate many nutrients and can usually not be sustained long-term. Many of the symptoms return when foods are added back to the diet.
However, in rheumatoid arthritis ayurvedic treatments failed to show significant benefits over placebo (Semin Arthritis Rheum. 2005 Apr;34(5):705-13).
Can you try it?
As always inform your rheumatologist and ayurvedic doctor of all medications and diseases you have. Be aware that Ayurvedic treatments have not been shown to prevent joint damage in clinical trials. In addition, more safety monitoring of ayurvedic medicines is required by a changing ecological environment, the use of insecticides, new manufacturing techniques, an as yet unregulated pharmaceutical industry, the availability of combinations of herbs over the counter and not mentioned in ancient Ayurvedic texts, and the need to look at the active principles of these medicines as potential chemotherapeutic agents. The side effect profile of these medications can vary and more large randomized trials would be needed before the clinician can recommend their use.
- Unlicensed ayurvedic doctors may not use pure forms of the medication and there is a risk of heavy metal contamination
- In very large doses ginger can irritate the stomach
- Do not use these medicines if you are on a blood thinning medication
- They can interact with traditional medicines
One teaspoon of freshly grated ginger in a glass of warm water or tea can reduce pain. Also use generously in cooking.
A study published in the November 2006 issue of Arthritis & Rheumatism examined the effect and mechanism of turmeric (a botanical supplement long thought to have anti-inflammatory properties) on arthritis.
Initial results showed that a version of turmeric extract that was free of essential oils had a significant impact on arthritis and most closely matched the composition of commercially available supplements. This version was used in subsequent experiments and was shown to prevent acute and chronic arthritis, even when it was administered after arthritis had been induced. In addition, turmeric significantly inhibited joint destruction due to arthritis and inhibited NF-κB, a protein that controls the gene expression of substances that produce an inflammatory response. Turmeric also altered the expression of hundreds of genes involved in joint swelling and destruction and prevented an increase in osteoclasts (cells that break down bone) in joints.
Before turmeric supplements can be recommended for medicinal use, clinical trials are clearly needed to verify/determine whether treatment with adequate doses of well-characterized turmeric extracts can indeed prevent/suppress disease flares in RA patients, as well as to explore any potential benefits of turmeric dietary supplements in the prevention or treatment of more common forms of arthritis in the general population.
Can you try it?
Turmeric is safe as a cooking ingredient and appears to have several medicinal values. However, further studies are needed on the concentrated forms before its safety can be established.
What is it?
Homeopathy originated in Europe and is based on the principle that ‘like cures like. It works like having a vaccine or immunization where giving people tiny amounts of a substance that causes disease can help the body fight disease.
Does it work?
It is hard to say whether homeopathy is of benefit. Very few studies have been conducted for people with arthritis and these have shown benefits but not better than placebo, which is an inactive or inert comparator. Usually you will be given tiny sugar-coated pills which you should allow to dissolve under your tongue.
Can I try it?
As always, inform your rheumatologist and homeopathic doctor of all medications and diseases you have. Be aware that homeopathic treatments have not been shown to prevent joint damage in clinical trials. They are generally not harmful and not known to interact with traditional medications.
Do not stop prescribed medicine for arthritis while on homeopathy.
- Naturopathic Medicine
What is it?
Naturopathic medicine evolved in Europe and uses healthy living, eliminating toxins, exercise, diet, herbs and dietary supplements.
Does it work?
There is evidence that a healthy lifestyle helps arthritis.
Can I try it?
As always, inform your rheumatologist and naturopathic doctor of all medications and diseases you have.
Do not stop prescribed medicine for arthritis.
The use of herbal therapies comes with potential risks that are worth noting to consumers of herbs for medicinal purposes. Active ingredients in herbal therapies or drugs may produce herb/herb or herb/drugs interactions that have undesirable side effects. For example, when combined with levodopa, kava can cause an increase in the number and duration of “off” periods; St. John’s wort taken with sertraline (Zoloft) may produce nausea, vomiting, or anxiety. Herbal therapies and drugs are often made of more than one active element. This further complicates what pharmacologic ingredient is causing the interaction or undesirable side effect.
A lack of standardization of herbal remedies also makes it challenging to understand what causes adverse interactions. Contamination, misidentification of an herbal plant, or an incorrectly substituted plant all raise issues of quality and can result potentially in an unwanted side effect. Of 400 users of complementary medicine surveyed, Abbot, White, and Ernst (1996) found 8% of those who tried herbal remedies had an adverse reaction.
- Natural Therapies
A mixture of these is available in a form called ‘piasceledine’ 300 mg once daily. It gave relief from osteoarthritis pain in small studies and there were no serious side effects.
There is some evidence that this can relieve arthritis pain in doses of 3-6 mg per day. However, it can raise hormone levels and theoretically increase the risk of breast cancer. Naturally occurring boron is plentiful in fresh fruits and vegetables.
This is a pineapple extract which is commonly used by arthritis patients. Small studies have failed to proven any benefits. It can interact with some medications such as blood thinners and antibiotics.
Glucosamine and Chondroitin:
One supplement is Glucosamine, derived from the shells of crabs and lobsters. The other is Chondroitin, usually derived from animal cartilage. These supplements are said to help relieve arthritis pain. They are also said to prevent the arthritic joint narrowing that causes one bone to grind against another. Of note, Glucosamine sulfate and Chondroitin sulfate are components of normal cartilage. In the body, they are the building blocks for cartilage
Do these supplements really work?
There are at least 50 published clinical trials on either one of these supplements or the combination, with various relevant health outcomes, such as improved joint pain, function and improved joint space. However, some studies failed to show any significant benefit. All the studies were done on Osteoarthritis patients. We have no evidence that these supplements are useful for inflammatory arthritis such as Rheumatoid arthritis.
If patients choose to take dietary supplements to control their symptoms, they should be advised to take Chondroitin sulfate with Glucosamine sulfate which may have an additive effect. Three months of treatment is a sufficient period for the evaluation of efficacy; if there is no clinically significant decrease in symptoms by this time, the supplements should be discontinued. Furthermore, there is no evidence that these agents prevent osteoarthritis in healthy persons or in persons with knee pain but normal radiographs. Also of note, these supplements will not cure arthritis — and that they are only a part of a multipronged treatment.
Some physicians advise patients to use it in three-month-on, two-month-off cycles. Some patients who use these supplements have been able to use [fewer] anti-inflammatory and pain medications. There are things that work for certain patients that don’t work for others.
Which brand of supplement should I use?
According to the results of some studies, Glucosamine sulfate is more effective than other forms of Glucosamine. Patients should be advised to use Glucosamine sulfate rather than Glucosamine hydrochloride.
There are many different brands of Glucosamine and Chondroitin, which are usually sold together in one supplement. Unfortunately, at this time, there is no government monitoring to ensure the purity of these products.
In order to assure that you get a consistent dose of the supplements, stick with a reputable manufacturer; choose products sold by large and well-established companies. If you don’t recognize a brand name, ask about the company’s reputation, how long it has been in business and how long the store has stocked the brand.
The dose is 1500 mg of glucosamine and 1200 mg of chondroitin daily.
Who should NOT take these supplements?
The supplements, which are available in pharmacies and health food stores without a prescription, are well tolerated and appear to be safe however these supplements may have a blood-thinning effect so people taking these supplements in addition to an anticoagulant may have to have their blood tested more often. People who are allergic to shellfish also should consult their doctors before using Glucosamine and Chondroitin
People with diabetes should use caution when taking Glucosamine because of concern that it might raise blood sugar, an issue which is not confirmed yet.
The effects of these supplements on a growing child or developing baby are not yet known. For that reason, Glucosamine and Chondroitin are not recommended for children, women who are pregnant and women who could become pregnant.
What are the side effects of Glucosamine and Chondroitin?
These supplements are generally well tolerated. However, side effects can occur. The most commonly reported side effects of Glucosamine and Chondroitin include:
- Diarrhea or constipation
- Increased intestinal gas
It is important to check with your doctor before starting any new treatments. Your doctor can review the other medications you are taking and help you decide whether or not these supplements are right for you. Do not take more of the supplements than is recommended.
Ginger. It’s known to have painkilling and anti-inflammatory agents. Ginger is believed to reduce joint pain and inflammation in people with OA and RA, and protect the stomach from gastrointestinal effects of NSAIDs. A clinical study showed ginger reduced knee osteoarthritis pain. High doses which are available in supplements can cause stomach irritation.
- DMSO. Once widely used to relieve joint and tissue inflammation, it fell out of favor when animal studies showed high doses damaged the lens of the eye. Don’t use it without consulting your doctor.
- Evening primrose oil. See GLA.
- Fish oil or omega oils. Studies show it relieves the pain of RA. The dose needed is 2000 mg daily
- Flaxseed. There are many good nutritional reasons to add it to your diet, but studies of its effect on arthritis have shown mixed results. Its anti-inflammatory properties work best if other vegetable-based oils are restricted.
- GLA. Gamma linolenic acid (GLA) is an omega-6 fatty acid the body uses to make anti-inflammatory agents, unlike other omega-6 fatty acids that actually increase inflammation. It’s found in evening primrose oil, black currant oil, and borage oil supplements. Several studies show it relieves the stiffness and pain of RA. In one study, some patients were able to quit taking NSAIDs.
- MSM. It’s widely touted for relief of pain and inflammation. Its safety and effectiveness have yet to be determined.
- SAM-e. Many European studies over the last 20 years show SAM-e is as effective as anti-inflammatory painkillers in treating OA but with fewer side effects. It works in conjunction with vitamin B-12, B-6, and folate. Claims that SAM-e repairs and rebuilds cartilage lack evidence, as studies have been done only in the lab and in animals.
- Shark cartilage. Ground-up cartilage from Pacific Ocean sharks is supposed to relieve the inflammation and pain of arthritis. Animal and lab studies are promising, but there are no human studies to support claims.
Stinging nettle. Taken orally or applied to the skin, stinging nettle is supposed to reduce the pain and inflammation of OA. Some studies show that patients can lower their dosages of NSAIDs by taking stinging nettle in extract form. Two small studies showed stinging nettle applied topically