alternative remedies in rheumatic disorders
“All who drink of this remedy are cured, except those that die. Thus, it’s effective for almost the incurable.” Galen.
What is the role, if any, for “complementary” and “alternative” remedies within the routine therapy of patients with rheumatic diseases? Despite considerable interest in these therapies , I don’t consider that anything truly clinically important has emerged in rheumatology .
“Alternative” or “complementary” therapies in medicine have gained public attention and implied endorsement by the u. s. government:
• A survey of patients followed privately and university-based rheumatology practices found that roughly two-thirds had used some type of complementary or alternative therapy .
• A subsequent survey of 232 consecutive patients in both private and university rheumatology practices found that one-third were actively using one or more of those therapies during the course of 1 year .
• In 1992, Congress established an Office of different Medicine, now renamed the National Center for Complementary and medicine, at the National Institutes of Health (NIH), with an annual budget now in way over $100 million.
It therefore behooves clinicians to be aware of a number of these “complementary” and “alternative” remedies available for rheumatological patients so as to be able to effectively communicate with patients and colleagues.
The American College of Rheumatology (ACR) established a committee in 1993 to handle pertinent issues originally surrounding the efficacy of those remedies.
At that point, the committee deliberately selected the term “questionable,” following the approaches of other groups.
This permitted the avoidance of other terms that euphemized questionable remedies.
to evolve to current trends, the ACR later adopted the terms “complementary” and “alternative.”
There are three forms of therapies:
• Genuine, defined as those proven acceptably safe and effective
I have come to prefer the terms “mainstream” and “nonmainstream” to best categorize how therapies are conceived.
These names are preferable to other terms for possible remedies, like “unapproved” (eg, by the Federal Drug Administration), “false” (disproven), “unproven” (experimental), “dubious” (very doubtful), “non-standard” (falling wanting practice standards), “irregular” (not employed by mainstream medicine), or perhaps “alternative” or “complementary” (reflecting various questionable or conventional treatment options) .
Many patients with rheumatic disease suffer physically and emotionally.
they need to learn to address the illness, the constraints imposed by the restrictions of medication, and therefore the considerable uncertainty concerning outcome. These adjustments don’t seem to be always easy.
Patients want hope for a cure or for relief.
Nonmainstream approaches offer hope.
Patients may therefore turn from science and seek understanding and relief (and empowerment) from questionable sources .
we will understand this quest and sympathize since we’ve got undoubtedly also sought and used questionable remedies (such as soup for a chilly or a rub for an ache).
Increasingly, many seek “complementary” and “alternative” remedies as a way of life choice .
Recent observations suggest that a lot of patients seeking “complementary” and “alternative” therapies do so in response to psychosocial distress, not necessarily thanks to severe or unresponsive illness .
The medical response to “complementary” and “alternative” remedies therefore remains problematic.
Our different options include:
• We can inform ourselves, which is that the intent of this section.
• We can dismiss them.
• We can establish repositories of data about them, which the American College of Rheumatology and Arthritis Foundation has done .
• We can try and communicate with patients and also the public through the media. However, “Doctor’s diet cures arthritis” makes instant headlines within the lay press; by comparison, “Doctor’s diet doesn’t cure arthritis” takes years of research, writing, and revision before appearing within the rheumatology literature, and has limited impact upon physician and patient practices .
• We can aggressively combat public perceptions within the press and within the courts, as does the National Council Against Health Fraud.
• Although this is often a worthy effort, its success is additionally limited .
Education and communication must suffice until our science improves .
Many physicians have a too frequent impulse to disdain and sometimes to ridicule “complementary” and “alternative” remedies.
we’ve got a conventional intellectual view of science and also the concept that human problems will be understood and solved by the suitable application of science. However, science isn’t proof against superstition, fraud, errors, conservatism, pigheadedness, fashion, and trends (eg, tonsillectomies, adenoidectomies, irradiation for acne or autoimmune disease, and iced saline lavage for GI bleeds).
There are several possible explanations for our dismissal of “complementary” and “alternative” remedies from legitimate study.
Arguably, we not dismiss CAM.
First, non-mainstream approaches evoke discomfort and prejudice, and appear to defy rational explanation.
Second, quackery is purveyed by practitioners whom we sometimes consider unsavory and our intellectual inferiors since we don’t share their belief system, are offended by their audacity, or may feel demeaned if we condescend to contemplate their notions.
It may once have seemed absurd to propose that diet, antibiotics, or red peppers might sometimes help arthritis or that antibiotics would help ulceration disease. However, the outright rejection of “complementary” and “alternative” remedies risks missing potentially beneficial therapies .
Although some may argue that patients should be permitted to do “complementary” and “alternative” therapies because they’re often a minimum of innocuous, I argue that it’s not responsible to use therapies generally not considered acceptably safe and effective.
As examples, some “complementary” and “alternative” therapies aren’t innocuous and are occasionally harmful:
• There are documented instances of patients who received therapies apart from those promised and suffered from adverse results, including marrow aplasia, serious infections from contaminants, and death.
• Patients seeking “complementary” and “alternative” remedies may inappropriately neglect their illness .
• Expenditures on “complementary” and “alternative” remedies may divert scarce health-care resources from more appropriate areas.
I will next consider selective and representative samples of “complementary” and “alternative” remedies.
a close discussion of those remedies is beyond the scope of this presentation, but has been reviewed elsewhere .
SELECTED “COMPLEMENTARY” AND “ALTERNATIVE” REMEDIES
Prominent “complementary” and “alternative” remedies for rheumatic disorders include
• Vitamins and minerals
• Nutritional supplements
• Fish oils
• Antimicrobials (nitroimidazole, rifamycin, ceftriaxone , tetracyclines, ampicillin , and amantadine )
• Biologic therapy (thymopoietin, transfer factor, placenta-derived factors, venoms, and herbal remedies)
• Other pharmacologic agents (cis-retinoic acid, isoprinoside, amiprolose, thalidomide , and dapsone )
• Topical agents ( dimethyl sulfoxide [DMSO])
• Mechanical/instrumental therapies (hyperbaric oxygen, laser irradiation, acupuncture, photopheresis, electromagnetic radiation), chiropractic manipulation, homeopathy, biofeedback, exercise, yoga, et al. (eg, sitting in abandoned uranium mines)
A microbial etiology for autoimmune disease (RA) has long been a horny but unproven hypothesis.
However, antimicrobials may well be useful if this hypothesis were true.
The following are instructive clinical experiences concerning therapy using antimicrobial agents for patients with rheumatic disorders .
However, the subsequent reflect largely isolated and unconfirmed observations.
• Nitroimidazole antimicrobial drugs are tried for the treatment of RA due to the efficacy of levamisole, another imidazole derivative, and since of claims that RA was caused by Amoeba limax. Results, however, haven’t been impressive .
• Rifamycin, an antibiotic that blocks DNA-dependent RNA polymerase and inhibits cellular protein synthesis, was promising for the treatment of rheumatoid knee synovitis in preliminary observations .
• Tetracycline therapy has also been tried based upon a putative mycoplasma etiology for RA.
• Such therapy was considered ineffective for several years. This issue has been revisited, however, since later scientific work found that tetracyclines, particularly minocycline , may have significant physiologic effects, including reduced collagenase activity, lessening of bone resorption, and perturbation of T-cell and neutrophil function. additionally, these drugs were found to be antiproliferative, antiinflammatory, and antiarthritic in animal and possibly human arthritis. Thus, tetracycline therapy is not any longer considered “complementary” or “alternative”.
• Patients with chronic inflammatory arthritis and antibody titers to Lime disease spirochete of 1:64 or greater have had encouraging responses to ceftriaxone .
• Ampicillin was reported to be beneficial under certain conditions for patients with RA .
• Amantadine , an medicine, was useful for a gaggle of patients with teenage-onset juvenile idiopathic arthritis who had elevated antibody titers to influenza A and were born during an influenza epidemic .
If observations suggesting a take pleasure in antimicrobial and/or antiviral therapy are consistently confirmed, either chronic arthritis in some patients results from bacterial, spirochete, or infection, or such therapy could also be antirheumatic.
Foods, diet and nutritional supplements
For years, special diets for patients with arthritis were relegated to quackery. it had been shortly ago that the Arthritis Foundation presented “The Truth about Diet and Arthritis,” stating “if there was a relationship between diet and arthritis it’d are discovered way back.
the easy fact is that there’s no scientific evidence that any food has anything to try to to with causing arthritis and no evidence that any food is effective in treating or ‘curing’ it .
We et al have now reexamined this notion.
• How might food affect arthritis? First, some patients with rheumatic disease could also be allergic to certain foods and have symptoms that may be a manifestation of allergy.
• Second, certain sorts of diets with particular amounts of calories, protein, and fatty acids may affect the immunologically-mediated inflammation that happens with arthritis .
• Is there a diet for arthritis? there’s no compelling evidence at this time that any diet aside from a healthy, balanced one is consistently helpful to patients with arthritis.
• One study of a well-liked diet (the elimination of beef, additives, preservatives, fruit, dairy products, herbs, spices, and alcohol) for patients with arthritis found no consistent salutary effect on disease activity .
• Is arthritis caused by food hypersensitivity in some patients? Physicians and patients remain intrigued that arthritis may occasionally be the results of hypersensitivity to foods.
• As examples: palindromic rheumatism has been related to sodium nitrate; Behçet’s syndrome with black walnuts; systemic LE (SLE) with canavanine in alfalfa (which may cross-react with native DNA or activate B lymphocytes) and with hydrazine, and RA allegedly with many substances including house dust, tobacco, smoke, petrochemicals, tartrazine, dairy products, wheat, corn, and beef.
• In addition, rheumatoid-like synovitis in rabbits has been induced by dietary milk .
Careful, prospective, placebo-controlled, double-blind studies confirmed (for selected patients) that inflammatory arthritis can be related to foods.
• One patient, for instance, had half-hour of morning stiffness, nine tender joints, and three swollen joints on her regular diet .
• Virtually all of those findings disappeared after a 3 day fast.
• they may then be reproduced by milk challenge but not with other foods.
• The role of fish or plant oils or diets? Nutritional status exerts a profound influence on immune responsiveness and disease expression.
• As an example, mice with SLE or rats with arthritis that are fed diets rich in omega-3 (a present, substituted, polyunsaturated carboxylic acid analog) fared better than did control animals.
Clinical trials of fish oils and plant seed oils have suggested a modest decrease in certain symptoms with therapy in patients with RA but not SLE .
• Beneficial effects of animal oil supplementation could also be enhanced by limiting the dietary intake of polyunsaturated oils (eg, corn, soybean, safflower, sunflower) to 10 grams or less per day .
• Although capsules of animal oil are convenient, the quantity of omega-3 contained in each capsule is corresponding to that found in one mL of cod liver oil; thus, a 20 mL dose of cod liver oil, which is that the usual daily dose, provides roughly the identical amount of such fatty acids as that found in 20 capsules of animal oil.
In comparison to a typical “Western” diet, a Mediterranean diet generally derives fewer calories from animal material and more from cereals and vegetable oils, particularly vegetable oil.
• Liberal intake of fresh fruits and beans yet as a moderate daily consumption of wine is additionally typical of this kind of diet. The possible effects of a Mediterranean diet (MD) was the topic of a study within which 51 patients with RA were randomly assigned to a MD or to an omnivorous cuisine for 12 weeks .
• While those subjects who ate a MD had more improvement in some measures of disease activity, other indicators were unchanged.
• There was little change noted in patient global-assessments within the omnivorous subjects nor in their disease activity scores.
• Since the intervention and assessment weren’t “blinded” in any fashion, a big issue within the group assigned to the Mediterranean diet can not be excluded.
These observations suggest that dietary factors that modify arachidonic acid-derived prostaglandin or leukotriene generation affect inflammatory and immunologic responses and should therefore ameliorate symptoms of rheumatic diseases.
• The role of nutritional supplements? variety of drugs, including copper, zinc, and vitamin B, are reported to be helpful for patients with arthritis. In general, however, the evidence in support of such claims is scant
• As an example, although copper salts are antirheumatic in clinical trials, their use was related to many adverse effects; as a result, copper salts haven’t evolved as a very important therapeutic agent.
• In another study, some patients with RA benefited from oral zinc; however, the development was modest and inconsistent, and wasn’t confirmed in other studies.
• In addition, although the administration of L-histidine has helped atiny low set of patients with RA, it’s not emerged as a crucial agent. Evidence to support the efficacy of ascorbic acid for arthritis patients is additionally lacking.
While concentrations of pyridoxal are reduced within the serum of patients with RA and levels of pyridoxal 5′ phosphate, the active metabolite of B6, are inversely correlated with disease activity ; there’s at the present no convincing evidence that supplementing the diet with vitamin B has any beneficial effect on disease activity or associated disorders.
A general overview of dietary supplements is provided elsewhere.
Various herbal preparations are undergoing investigation for possible benefit for arthritis.
A good example may be a Chinese herbal remedy (an alcohol extract of Tripterygium wilfordii Hook F, TwHF) for autoimmune disease (RA), with suggestive immunosuppressive properties .
A handy study randomly assigned 35 patients with RA to placebo or one in all two doses (180 or 360 mg/day) of an alcohol/ethyl acetate extract of the herb.
A dose-response relation was noted with ACR 20 responses of 80, 40, and 0 percent within the high-dose, low-dose, and placebo groups, respectively; ACR 50 responses were note in 50, 10, and 0 percent.
Self-limited diarrhea developed more often during active treatment than with placebo (in approximately one-third and none, respectively).
Another randomized trial compared TwHF with sulfasalazine in 121 patients with RA; only 62 and 41 percent of these receiving TwHF (60 mg three times/day) and sulfasalazine (1 gm twice/day), respectively, completed the study .
Among those that completed the study, an ACR20 response was achieved significantly more often after 24 weeks of treatment by patients receiving TwHF (68 versus 36 percent).
HAQ scores and IL-6 levels improved more with TwHF, but there was no difference in ESR and CRP.
There was a 2.4 point improvement within the DAS28 with TwHF. Adverse event rates were similar within the two groups.
Additional clinical study and further investigation into the mechanism of the beneficial antiinflammatory effects of this herbal preparation are valuable.
Additional herbs and dietary supplements that are studied in patients with RA include the following;
• Those that showed some promising results: two Ayurvedic mixtures, borage, garlic, Phytodolor, Uncaria tomentosa, fish oil, and selenium
• Others that weren’t related to any clinical improvement, including blackcurrant (Ribes nigrum), Boswellia serrat, herb (eg, from common evening primrose and Oenothera lamarckiana), feverfew (Tanacetum parthenium), and green-lipped mussels.
However, all the studies were small, the results were modest at the best, and wish confirmation in standardized trials.
Other herbal preparations are promoted as treatments for osteoarthritis. One systematic review concluded that there was so far no evidence of a major benefit with Eazmov, Gitadyl, or ginger extract; by comparison, there was some evidence of efficacy (decreased pain) for Reumalex (a combination of willow bark, guaiacum resin, rattle-top, sarsaparilla, and poplar bark), willow bark alone, nettle, Articulin F (a proprietary combination of salai [Indian frankincense], Withania somnifera [winter cherry], turmuric and zinc), devils claw, extract of soybean and avocado unsaponifiables (ASU), Phytodolor (a combination of poplar bark, ash bark, and goldenrod), and capsaicin cream.
These would require rigorous well controlled randomized study to verify putative salutary effects.
A general overview of herbal medicine is provided elsewhere.
Some of the newer biologic agents, like monoclonal antibodies, interleukins, cytokines, and similar products, are exciting due to their potential, and for a few, their established clinical value.
Even those biologic agents whose therapeutic roles are still being evaluated, don’t seem to be usually considered “alternative” remedies .
Additional “complementary” and “alternative” remedies and their possible efficacy include the following:
• Although venoms affect inflammatory and immune responses in vitro, they need no documented clinical utility.
• Indeed, a “beekeepers” arthritis has been reported .
• New pharmacologic approaches are of interest; some (such as dapsone ) may receive further attention.
• Dimethyl sulfoxide (DMSO) and hyperbaric oxygen aren’t of proven value.
• Laser therapy, utilizing low power light sources, has been evaluated for both arthritis and osteoarthritis.
• a scientific review of reported clinical trials reported that laser treatment of the hands of patients with autoimmune disorder provided significant benefits .
• By comparison, consistent trends haven’t been observed in those with osteoarthritis.
• It is difficult to supply any specific recommendations regarding low level laser therapy due to variations in protocols, including laser intensity, duration, wavelength, and frequency of treatments.
• Homeopathy and biofeedback have shown varying degrees of benefit in certain situations; however, these studies haven’t been confirmed.
• The subject of homeopathy is reviewed well elsewhere.
• Acupuncture has not been found effective in patients with RA, and isn’t a risk-free procedure.
• A review of reported complications included two deaths thanks to needle injuries to the center and 90 pneumothoraces, of which two were fatal.
• Although popular, permanent magnets appear to be without benefit in patients with chronic low back pain as demonstrated during a pilot randomized trial of 20 patients .
• They also appear to be no better than placebo in relieving wrist pain in patients with carpal tunnel syndrome .
• Improvement in pain and performance are reported in some studies of patients with osteoarthritis of the knee or hip .
• Blinding could be a problem, as subjects can often discern the difference between magnetic devices and nonmagnetic or weakly magnetic (placebo) controls.
• Pulsed magnetic fields weren’t simpler than a sham treatment for patients with osteoarthritis of the knee .
• Reports have evaluated the possible efficacy sure enough patients with rheumatoid or osteoarthritis of multiple different therapies, including thalidomide , manipulation , electromagnetic wave , photo- (chemo-) pheresis , yoga , mud , prayer or distant healing , Ayurvedic medicine , and maybe soup .
As an example, glucosamine hydrochloride and chondroitin sulfate have undergone vigorous long-term evaluation in an exceedingly study sponsored by the NIH. Although generally safe, these remedies should be considered questionable (or investigational) approaches.
• I am also not awake to appropriate evidence-based observations to support recommendations for the employment of methonyl-sulfonyl-methane (MSM) , cetyl myristoleate , ginger , or zinaxin .
• Suggestive observations are available for s-adenosylmethionine (SAM-E) ; however, its use should be considered with caution in patients with RA on methotrexate .
• Pain relief from the appliance of leeches was reported in an exceedingly study of 51 patients with osteoarthritis who were randomly assigned to own leeches (Hirudo medicinalis) or topical diclofenac applied to an affected knee .
• Significantly more pain relief was reported with leeching than with diclofenac when assessed at seven days.
• The benefit persisted for up to twenty-eight days and was related to improvements in stiffness and performance.
• the shortage of blinding of patients and assessors could be a major potential source of bias and diminishes confidence within the results .
• Use of leeches also carries a risk of cellulitis and septicemia thanks to Aeromonas hydrophilia that colonize medicinal leeches.
• A small beneficial effect of whole-body massage employing a Swedish technique was suggested during a pilot study in comparison to wait-listed controls.
It should be noted when reading reports of “complementary” and “alternative” remedies that the consequence may be quite powerful in patients with arthritis. In one preliminary report, for instance, clinical improvement of the maximum amount as 50 percent occurred in up to 45 percent of patients .
At present, I don’t consider that diet or other “complementary” or “alternative” therapies have a job within the routine management of rheumatic diseases.
Nevertheless, examination of the role of diet and other questionable remedies in arthritis reminds us that it’s occasionally salutary to critically reevaluate prevailing notions about therapies.
For antimicrobials, diet, exercise, and maybe others, this reexamination has led to new insights about the pathogenesis and therapy of rheumatic diseases.
We therefore have to balance a healthy skepticism with a willingness to contemplate nontraditional concepts
It is important that we recognize this limitations of science in enabling us to grasp diseases and treat patients.
we should always therefore use caution about being dogmatic in interpreting those notions not thoughtfully scrutinized; however, we should always even be resolute against those ideas we are confident to be false and not questionable, and that we should recognize that the flexibility to differentiate among these possibilities is also difficult. i think that reason will ultimately overcome superstition; as logician wrote, “what science cannot tell us mankind cannot know.”
ACR POSITION STATEMENT
The following position has been taken by the American College of Rheumatology (ACR) concerning “complementary” and “alternative” therapies (CAM) for rheumatic diseases:
”The ACR recognizes the interest in CAM modalities.
The ACR supports rigorous scientific evaluation of all modalities that improve the treatment of rheumatic diseases.
The ACR understands that certain characteristics of some CAMs and a few conventional medical interventions make it difficult or impossible to conduct standard randomized controlled trials.
For these modalities, innovative methods of evaluation are needed, as are measures and standards for the generation and interpretation of evidence.
The ACR supports the combination of these modalities proven to be safe and effective by scientifically rigorous clinical trials published within the biomedical review literature.
The ACR advises caution for those not studied scientifically.
The ACR believes healthcare providers should learn about the more common CAM modalities, based upon appropriate scientific evaluation as described above, and may be able to discuss them knowledgeably with patients” .
SUMMARY and proposals
• Clinicians should be aware of the common complementary and alternative remedies available for arthritis to facilitate effective communication with patients and colleagues.
• Therapies are often separated into those which are genuine (ie, those proven acceptably safe and effective), questionable, or ineffective.
• We distinguish between remedies that are mainstream and nonmainstream within the context of usual practice.
• Various factors contribute to the appeal of complementary and alternative remedies.
• These include seeking hope for understanding and a cure or relief from physical and emotional suffering because of the consequences of the medical illness; as a response to psychosocial distress independent of illness severity; as a way of life choice; thanks to difficulty addressing the constraints of medication, and uncertainty concerning outcome.
• The clinician’s response to use of complementary and alternative remedies should include education of the patient and general public, and maintaining communication with the patient regarding these issues.
• We recommend that clinicians mustn’t support the employment of therapies that are generally not considered acceptably safe and effective.
• Potential harms of such therapies include adverse effects, failure to use accepted effective interventions, and financial cost.
• There are a large style of complementary and alternative remedies for rheumatic disorders
Among the more common are:
• Antimicrobial agents
• Special diets or dietary supplements
• Herbal remedies
• Homeopathy, magnets, acupuncture, Ayurvedic medicine, and others
• Special diets or other “complementary” or “alternative” therapies don’t have a job within the routine management of rheumatic diseases.