Complimentary and alternative
medications (CAMs) in RA
Brad Butt
Managing partner
Cooleman Court Pharmacy
• Which CAMs are our patients seeking
information on
• What evidence is there for their use
• Possible interactions – disease
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
– EPA/DHA leads to reduced conversion of AA
– Decreases leukocyte chemotaxis  reduced proinflammatory 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
• Meta analysis – 15 randomised, double blind, placebo
controlled trials (916 patients) at doses up to 2200mg
EPA/DHA per day concluded effective against primary
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
• 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
• 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
Curcumin pathway
Curcumin precautions
Bile duct obstruction
Anti coagulants
Can reduce BGL – hypoglycaema risk
May increase stomach acid secretion
• 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
• 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
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modulation of infammatory cytokines and bioactive lipid mediators: their potential role in
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Nutr 2006;83(Suppl):1505S-1519S
Galarraga B, Ho M, Youssef HM, et al. Cod liver oil (n-3 fatty acids) as an non-steroidal antiinfammatory drug sparing agent in rheumatoid arthritis. Rheumatology 2008;47(5):665-669.
Sublette ME, Ellis SP, Geant AL, et al. Meta-analysis of the effects of eicosapentaenoic acid (EPA)
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