Complimentary and alternative medications (CAMs) in RA
Brad Butt Managing partner
Cooleman Court Pharmacy WESTON
Objectives
• Which CAMs are our patients seeking information on
• What evidence is there for their use• Possible interactions – disease
state/medication
CAMs in RA
• Fish oils– Trend towards Krill oil
• Tumeric/curcumin• Others…
Fish Oils
• EPH/DHA is the key – polyunsaturated 3 fatty acids.
• Flaxseed oil – ALA 5-10% EPA and 1-5% DHA only1&2
• Quality – TGA v GOED (global organisation for EPA and DHA 3)
Inflammatory cascade
TGA v GOED table
Fish oils benefits
• Anti-inflammatory effect – complex!– PG/TXA/LT – signalling molecules in inflammation• Arachidonic acid (AA) is the major substrate for their
synthesis3-5
– EPA/DHA leads to reduced conversion of AA– Decreases leukocyte chemotaxis reduced pro-
inflammatory cytokines (TNF and IL subtypes) 6-7
– 3.8g EPA + 2g DHA 10 capsules daily
Fish oil benefits
• Anti depressant effect– Evidence for EPA/DHA in major depressive
episodes• Meta analysis – 15 randomised, double blind, placebo
controlled trials (916 patients) at doses up to 2200mg EPA/DHA per day concluded effective against primary depression8
Fish oil precautions
• Recent clinical studies show no increase in bleed risk; even in patients on aspirin and warfarin with doses up to 7g/day of EPA/DHA9
– Should be done under medical supervision1
• Doses <12g/day need medical supervision1
• Hypomania can occur with fish oil in bipolar patients10
• Seafood allergy theoretically problematic
Krill oil – fad or not?
• Krill oil has been hugely popular– Comprehensively out sells fish oil– There is a lack of good clinical evidence– Doses need to be in excess of 1500mg daily• 1500mg krill oil 226mg EPA 122mg DHA
– General feel is that evidence is for fish oils so recommend fish oil at appropriate dose first for best results
Curcumin/Tumeric
• May assist with the down regulation of inflammatory mediators
• Reduces joint inflammation in RA• Symptomatically works quickly• Lack of large clinical trials– COX2 inhibition believed to be MOA– Less GIT/BP issues associated with curcumin (v
NSAID)
Curcumin pathway
Curcumin precautions
• Bile duct obstruction• Anti coagulants• Can reduce BGL – hypoglycaema risk• May increase stomach acid secretion
Others
• Glucosaime– Minimum 4 week time to effect– Shell fish allergy precaution– 1500mg daily required– +/- condroitin/MSN
• Green lipped muscle extract– Anti-inflammatory effect– Small evidence for use
Others
• St Johns Wart– Used for depression– Effect similar to a SSRI– Variability between brands/batches as plant
derived – numerous environmental factors may affect outcome of dose
– Many interactions with other Rx medications– Reasonable evidence for its use/effect
References1. McCusker MM, Grant-Kels JM. Healing fats of the skin: the structural and immunologic roles of the
omega-6 and omega-3 fatty acids. Clin Dermatol 2010;28(4):440-451. 2. Braun L, Cohen M. Herbs and natural supplements: an evidence-based guide, 3rd ed. Sydney: Churchill
Livingstone Elsevier, 2010.3. Silva V, Barazzoni R, Singer P. Biomarkers of fsh oil omega-3 polyunsaturated fatty acids intake in humans.
Nutr Clin Pract 2014;29(1):63-72.4. Calviello G, Su HM, Weylandt KH, et al. Experimental evidence of w-3 polyunsaturated fatty acid
modulation of infammatory cytokines and bioactive lipid mediators: their potential role in infammatory, neurodegenerative, and neoplastic diseases. Biomed Res Int 2013;2013:743171.
5. Calder PC. n-3 fatty acids, infammation and immunity: new mechanisms to explain old actions. Proc Nutr Soc 2013;72(3):326-336
6. Calder PC. n-3 polyunsaturated fatty acids, infammation, and infammatory diseases. Am J Clin Nutr 2006;83(Suppl):1505S-1519S
7. Galarraga B, Ho M, Youssef HM, et al. Cod liver oil (n-3 fatty acids) as an non-steroidal anti-infammatory drug sparing agent in rheumatoid arthritis. Rheumatology 2008;47(5):665-669.
8. Sublette ME, Ellis SP, Geant AL, et al. Meta-analysis of the effects of eicosapentaenoic acid (EPA) in clinical trials in depression. J Clin Psychiatry 2011;72(12):1577-1584.
9. Harris WS. Expert opinion: omega-3 fatty acids and bleeding-cause for concern? Am J Cardiol 2007;99(6A):44C-46C.
10. Bays HE. Safety considerations with omega-3 fatty acid therapy. Am J Cardiol 2007;99(6A):35C-43C.