Rheumatoid arthritis and glucosamine:
Glucosamine may have some effect against rheumatoid arthritis, but research is limited with only one study located in a literature search which showed slight superiority of the compound 1-(p-chlorobenzoyl)-5-methoxy-2- methylindole- 3-acetic acid monohydrate glucosamide to indomethacin (22). This compound is a different form of glucosamine than the more commonly used glucosamine sulfate and is not available commercially. Glucosamine compounds have much more research supporting a benefit for osteoarthritis as opposed to rheumatoid arthritis.
Assessment and Plan: Rheumatoid arthritis
- The research evidence expressed supports advising rheumatoid arthritis patients to select foods that provide substantial amounts of omega-3 fatty acids (fish products, omega-3 rich seeds, and vegetables) and to avoid foods that are very rich in omega-6 fatty acids (polyunsaturated oils and animal fats). (1)
- Omega-3 oils consist of three types which include eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and α-Linolenic acid (ALA). The principal sources of EPA and DHA available include fish oil, algal oil, and krill oil. ALA is found in flax seed oil, canola oil and soybean oil.
- Daily doses of omega-3 fish oil ranged about 1 to 9 grams with an average of about 3 g taken. Treatment periods ranged from 8 weeks up to a year. In many of the trials, omega-3 fish oil was continued along with other medications. The following benefits of omega-3 cold water fish oil was supported by research:
- Omega-3 fish oil consumption in the form of oily fish may prevent rheumatoid arthritis. Compared with subjects who never or seldom consumed oily fish, individuals who consumed oily fish 1-7 times per weeks had a 20% reduced risk of developing RA (7).
- Some indicators of disease activity which did not show statistically significant improvements with the use of fish oil include erythrocyte sedimentation rates, and overall global assessment of disease severity (6).
- Grip strength in some studies was improved (1).
- Was able to allow patients to reduce their use of anti-rheumatic medication while taking 2.6 grams of omega-3 daily. (4)
- Improved the pain index (1), and the physician pain assessment score (8).
- Reduced the swelling of joints (5)
- Lowered the number of tender joints (5,6,8)
- The duration of morning stiffness was reduced (1,2,3,6,8). In one study, morning stiffness was reduced almost 70 minutes more than corn oil after 8weeks with high doses of 130 mg per kilogram (3), and another study showed that it reduced morning stiffness by 25.9 minutes after 3 months (6).
- Omega-3 fish oil adverse reactions and interactions:
- A total of 10 studies were reviewed by Villani AM et al to determine potential serious adverse effects of fish oil at a dose of under 1.86 grams per day (21 It was found that there were no serious adverse effects reported in 994 adults over 59 years of age and other non-serious adverse effects were not significantly different from placebo (21).
- Fish oil has been reported to affect platelet aggregation, reduce vitamin K dependent factors which may be associated with an increased anticoagulation (reduce blood clotting) effect. Consumption should be avoided when taking anticoagulants like aspirin, warfarin, or ticlopidine because of the potential increased risk of bleeding (20).
- A case of a 67-year old woman taking warfarin (1.5 mg/day), an increase in her fish oil intake from 1 g/day to 2 g/day was associated with an increase in time for blood to clot as measured by the international normalized ratio (INR) which went from 2.8 to 4.3 within 1month, and decreased to 1.6 after the fish oil dose was reduced (17).
- An intake of 6 grams per day of docosahexaenoic acid (DHA) found no significant difference found in blood coagulation, platelet function, or thrombotic parameters including prothrombin time, activated partial thromboplastin time, antithrombin-III levels, and platelet aggregation (19).
- Fish oil may contain harmful contaminants such as heavy metals including mercury, dioxins, and polychlorinated biphenyls (PCBs). This risk can be reduced by purchasing fish oil that has undergone a purification process speciied on the label (approved by the FDA, EPA, or US Pharmacopeia) (18).
- Kjeldsen-Kragh J performed a study on rheumatoid arthritis patients who initially fasted for 7-10 days, then ate gluten-free vegan diet for 3.5 months, followed by a 9-month lactovegetarian diet. Compared to a mixed food diet, those on the specified diet had a significant improvement in multiple clinical and laboratory variables. A year later, many of the patients had sustained benefit. (9)
- Some foods have been noted to improve the levels of inflammatory markers in the blood, but have not yet been researched well for benefits in inflammatory diseases such as rheumatoid arthritis. Yellow potato consumption was associated with lower levels of the inflammatory marker interleukin-6, and those who ate purple potatoes had lower levels of C-reactive in (CRP) (10). A legume-based diet resulted in a significantly higher reduction in the inflammatory marker, CRP (~40% vs ~5% reduction in lab values) and complement (C3) (~80% vs ~40% reduction in lab values) (11).
- A study by Hermsdorff HH et al, 45 people with rheumatoid arthritis who received 8 weeks of curcumin at a dose of 500 mg resulted in the same reduction of swelling and pain as the prescription drug diclofenac sodium at a dose of 50 mg (12).
- Adverse reactions of turmeric/curcumin include but not limited to: A theoretical increase risk of bleeding with antiplatelet effects is possible although less than that caused by aspirin was reported (13).
- One study reported the following with doses of 1-4 grams per day: gastrointestinal complaints, falls, dizziness, respiratory tract infection, delusions, edema, and hearing impairment. Sodium, potassium, urea, creatinine, protein, albumin, bilirubin, alkaline phosphatase, and alanine aminotransferase/glutamic-pyruvic transaminase were followed without evidence of toxicity (14).
- There was one case reported where transient complete atrioventricular block occurred with taking 20-30 pills containing turmeric 50% (about 75 mg), mulberry leaves 10%, garlic 10%, black soybean 20%, and arrowroot starch 10% (15).
- One study on dose escalation showed that no toxicity was observed up to 8000 mg/day (16).
- Rheumatoid arthritis and cat’s claw: Cat’s claw refers to certain types of woody vines that grow in the Amazon. Two of the most commonly used species are Uncaria tomentosa and Uncaria guianensis (Uncaria guianensis has the greater antioxidant potency). Rosenbaum CC performed a review of studies entitled “Antioxidants and anti-inflammatory dietary supplements for osteoarthritis and rheumatoid arthritis.” The author found that three studies supported cat’s claw (either alone or in combination with other supplements) for OA, but larger clinical trials need to be done to confirm benefit in rheumatoid arthritis since there was only one trial with 40 patients showing less pain but no change in swelling or stiffness (8).
- Rheumatoid arthritis and glucosamine: Glucosamine may have some effect against rheumatoid arthritis, but research is limited with only one study located in a literature search which showed slight superiority of the compound 1-(p-chlorobenzoyl)-5-methoxy-2- methylindole- 3-acetic acid monohydrate glucosamide to indomethacin (22). This compound is a different form of glucosamine than the more commonly used glucosamine sulfate and is not available commercially. Glucosamine has much more research supporting a benefit for osteoarthritis as opposed to rheumatoid arthritis.