Alternative/Complementary Treatments and RA: Facts, Fads, and Fiction

To "Thunder God Vine" from China, add fish oil and gluten-free diets as alternative remedies for rheumatoid arthritis. What is the evidence? Here, a review plus commentary from an expert.

Odds are very good that someone with rheumatoid arthritis (RA) has asked you whether an herb, a supplement, or acupuncture would help. Maybe they haven't even bothered to inquire. An estimated 60-90% of arthritis patients use some form of complementary and alternative medicine (CAM).¹

There’s evidence to support a few CAM approaches, notably a traditional Chinese herb² and omega-3 fats,³ especially in conjunction with conventional RA therapies. But there’s also a powerful placebo effect for most CAM remedies.⁴

A number of approaches touted by integrative practitioners for RA (such as detoxification and gluten-free diets) are regarded as fads without basis in fact. Others have been frankly debunked as fiction. (Remember copper bracelets and magnets?)

To help you sort it out, here are some of the latest studies on CAM and RA, with commentary from Cong-Qiu Chu MD PhD, assistant professor and director of the Early Arthritis Clinic at the Oregon Health Science University in Portland:

Thunder God Vine (Tripterygium wilfordiiHook F, TwHF). Used as an anti-inflammatory in traditional Chinese medicine, its evidence now challenges methotrexate (MTX) and sulfasalazine.

• A 207-patient open-label randomized trial from China found a standardized 20 mg extract of TwHF three times a day as effective as 12.5âmg of MTX once a week for short-term treatment of RA. Combined with MTX, its results were even better.² More than three-fourths of patients (76.8%) taking TwHF plus MTX achieved a 50% response by American College of Rheumatology criteria (ACR50) after six months, compared to less than half (46.4%) on MTX alone.

Diarrhea and other gastrointestinal problems were the most common adverse effects. Irregular periods developed in 15 women. It can also cause hair loss.

No standardized extracts of TwHF are available in the US.

TWF "does have unwanted effects on the reproductive system and can reduce fertility in men and women,” Chu cautions. “Because of this, it’s is best used in women who have passed their childbearing years.”

In the current study, 15 women developed irregular menstrual periods. It can also cause hair loss.

• In a 2009 study of 121 RA patients by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), more patients achieved an ACR20 response with 60 mg of TwHF extract three times a day (65%) than with 1 g of sulfasalazine (Azulfidine) twice a day (32.8%).⁵

• The National Center for Complementary and Alternative Medicine (NCCAM) conducted a small study that found TwHF extract applied to the skin reduced joint pain in RA.⁶Fish Oil contains the omega-3 polyunsaturated fats (PUFAS) eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). The omega-3s in fish oil supplements have anti-inflammatory properties that have been shown to reduce joint pain, swelling, and morning stiffness in RA.

• In a randomized, controlled trial (RCT) of 140 early RA patients in Australia, mostly women in their mid-50s, around 40% of those who took high-dose fish oil along with their conventional disease modifying antirheumatic drugs (DMARDs) were in remission after a year.³ As Rheumatology Network reported in October, combining omega-3s and DMARDS also reduced the chance of treatment failure.⁷

• A prospective study of women reported last year suggests that omega-3s may even help prevent RA.⁸

• In 2013, the British National Health Service (NHS) surveyed 17 studies of supplements and herbs. Fish oil scored highest for effectiveness and safety.⁹Acupuncture needles placed at specific spots along the skin (acupoints) are said to stimulate the flow of energy (or qi) to treat pain and other conditions.

The problem with quantifying the efficacy of acupuncture in RA has been a lack of well-designed randomized, placebo controlled clinical trials.¹⁰ “Sham therapy,” using needling at acupoints, has been used in some studies as an active control.

• Twosystematicsreview of active-controlled trials, both published in 2008. One found 6 trials showing a decrease in

“The effectiveness of acupuncture depends on the skill and qualifications of the acupuncturist. There’s no standardized practice,” Chu comments. “But if a patient wants to try it, it will do no harm and it certainly may help.”

pain, 4 finding a reduction in morning stiffness, and 8 that found significant decreases in inflammatory markers (erythrocyte sedimentation rates or C-reactive protein).¹¹ The other cited one RCT that found acupuncture reduced pain better than indomethacin.⁹

• Other studies of acupuncture are mixed or show no effect.

Anti-Inflammatory Foods

A number of individual foods are said to have anti-inflammatory effects, reducing pain, joint swelling, and other symptoms of RA, as well as some effects on the immune system.

These include cold-water fatty fish rich in omega-3s such as salmon, mackerel, and sardines, fresh fruits such as cherries and raspberries high in antioxidants called anthocyanins,¹² vegetables containing flavonoids like onions and garlic, as well as the curry spice curcumin (tumeric), said to regulate expression of key inflammatory enzymes.¹³

• The best evidence so far is for omega-3s in fish. A 2013 prospective study of more than 32,000 older Swedish women found that eating one or more servings of fatty fish a week was associated with a 29% lower risk of RA. Long-term intake of high-dose fish oil, more than 0.21 g a day, decreased the risk of RA by 52%.¹⁴

• A recent British review found that eating more fish high in omega-3s modestly reduced joint swelling, pain and morning stiffness in RA, leading to less use of NSAIDs.¹⁵

“A lot more research needs to be done to prove which can truly be called ‘anti-inflammatory diets,’” concludes Chu. “Patients come to me and say I eliminated gluten or beef from my diet and I feel much better. I tell them, if you feel better it will not do any harm. But we really have no proof.”

• In a small randomized controlled trial from Sweden, RA patients who followed a Mediterranean diet (whole grains, fish, vegetables, and olive oil) showed reduced inflammatory activity and increased in physical function compared to those given a “Western” diet high in saturated fats and meat.¹⁶

A number of integrative practitioners also advise patients to go gluten-free, cut back on red meat, along with saturated and hydrogenated fats, sugar, potatoes, and white flour.¹⁷

References:

1.   Soeken KL, S. A. Miller SA, and Ernst E. Herbal medicines for the treatment of rheumatoid arthritis: a systematic review. Rheumatology (2003) 42:652–659. doi:10.1093/rheumatology/keg183.
2.   Lv Q-w, Zhang X, Shi Q, et al. Comparison of Tripterygium wilfordii Hook F with methotrexate in the treatment of active rheumatoid arthritis (TRIFRA): a randomised, controlled clinical trial. Ann Rheum Dis. (2014) DOI: 10.1136/annrheumdis-2013-204807 [Published online 14 April 2014].
3.   Proudman SM, James MJ, Spargo LD, et al. Fish oil in recent onset rheumatoid arthritis: a randomised, double-blind controlled trial within algorithm-based drug use. Ann Rheum Dis. (2013) doi: 10.1136/annrheumdis-2013-204145 [published online September 30, 2013].
4.   Panush RS. Patient information: Complementary and alternative therapies for rheumatoid arthritis (Beyond the Basics). UpToDate, December 2013.
5.   Goldbach-Mansky R, Wilson M, Fleischmann R, et al. Comparison of Tripterygium wilfordii Hook F versus sulfasalazine in the treatment of rheumatoid arthritis: a randomized trial. Annals of Internal Medicine (2009) 151:229–240, W49–51.
6.   Tao X, Younger J, Fan FZ, et al. Benefit of an extract of Tripterygium Wilfordii Hook F in patients with rheumatoid arthritis: a double-blind, placebo-controlled study. Arthritis Rheum. (2002) 46:1735-1743.
7.   Baron-Faust, R. Fish Oil May Boost Remission Chances in Early RA. Rheumatology Network. (2013) October 11.
8.   Di Giuseppe D, Wallin A, Bottai M, et al., Long-term intake of dietary long-chain n-3 polyunsaturated fatty acids and risk of rheumatoid arthritis: a prospective cohort study of women. Ann Rheum Dis. (2013) doi:10.1136/annrheumdis-2013-203338 [published on line August 12, 2013]
9.    UK: National Health Service: Alternative Medicine for Rheumatoid Arthritis, 2013. http://www.arthritisresearchuk.org/arthritis-information/complementary-and-alternative-medicines/complementary-therapies/herbal-medicine.aspx#sthash.yAqf4DSc.dpuf Accessed April 14, 2014.
10.   Lee MS, Shin B.-C, Ernst E. Acupuncture for rheumatoid arthritis: a systematic review. Rheumatology (2008) 47 :1747-1753. doi:10.1093/rheumatology/ken330.
11.   Wang C1, de Pablo P, Chen X, et al. Acupuncture for pain relief in patients with rheumatoid arthritis: a systematic review. Arthritis Rheum. (2008) Sep 15;59:1249-56. doi: 10.1002/art.24009.
12.   Jean-Gilles D, Li L, Ma H, et al. Anti-inflammatory Effects of Polyphenolic-Enriched Red Raspberry Extract in an Antigen-Induced Arthritis Rat Model.J Agric Food Chem. (2011) Dec [Epub ahead of print].
13.   Goel A, Kunnumakkara AB, Aggarwal BB. Curcumin as "Curecumin": from kitchen to clinic.Biochem Pharmacol. (2008) Feb 15. 75:787-809. Aug 19, 2008.
14.    Di Giuseppe D, Wallin A, Bottai M, et al., Long-term intake of dietary long-chain n-3 polyunsaturated fatty acids and risk of rheumatoid arthritis: a prospective cohort study of women.Ann Rheum Dis. (2013) [published online August 12, 2013] doi:10.1136/annrheumdis-2013-203338.
15.    Miles EA, Calder PC. Influence of marine n-3 polyunsaturated fatty acids on immune function and a systematic review of their effects on clinical outcomes in rheumatoid arthritis. Br J Nutr. (2012) Jun;107 Suppl 2:S171-84. doi: 10.1017/S0007114512001560.
16.    SkÃ¶ldstam L, Hagfors L, Johansson G. An experimental study of a Mediterranean diet intervention for patients with rheumatoid arthritis. Ann Rheum Dis. (2003) 62:208–214.
17.    Blum S, Bender M. The Immune System Recovery Plan. (2013) Scribner/Simon & Shuster, New York