Rheumatoid arthritis (RA) is an autoimmune disease in the general family of lupus . For reasons that are not understood, in rheumatoid arthritis the immune system goes awry and begins attacking innocent tissues, especially cartilage in the joints. Various joints become red, hot, and swollen under the onslaught. The pattern of inflammation is usually symmetrical, occurring on both sides of the body. Other symptoms include inflammation of the eyes, nodules or lumps under the skin, and a general feeling of malaise.
Rheumatoid arthritis is more common in women than in men and typically begins between the ages of 35 and 60. The diagnosis is made by matching the pattern of symptoms with certain characteristic laboratory results.
Medical treatment consists mainly of two categories of drugs: anti-inflammatory drugs in the ibuprofen family (nonsteroidal anti-inflammatory drugs, or NSAIDs) and drugs that may be able to put rheumatoid arthritis into full or partial remission, the so-called disease-modifying antirheumatic drugs (DMARDs).
Anti-inflammatory drugs relieve symptoms of rheumatoid arthritis but do not change the overall progression of the disease, whereas the DMARDs seem to affect the disease itself. A good analogy might be the various options available to "treat" a house "suffering" from a severe termite infestation. You could remove heavy furniture, tiptoe about instead of holding public dances, and put large beams under the joists. However, none of these methods would do anything to stop the gradual destruction of your house. These methods are like NSAIDs and other supportive techniques in that they treat only the symptoms.
A more definitive approach would be to hire an exterminator and kill the termites. In medical terms, this would be described as a disease-modifying treatment. Because medical treatments for chronic diseases are seldom as completely effective as this example, a closer analogy might be spraying a chemical that slows the spread of termites but does not stop them.
In rheumatoid arthritis, the drugs believed to alter the course of the disease (to slow it down or stop it) include antimalarials (hydroxychloroquine and chloroquine), sulfasalazine, TNF inhibitors (etanercept, infliximab, and adalimumab), interleukin-1 receptor antagonists, leflunomide methotrexate, gold compounds, D-penicillamine, and cytotoxic agents (azathioprine, cyclophosphamide, and cyclosporine). They are unrelated to one another but work somewhat similarly in practice.
Unfortunately, most of the drugs in this category can cause severe side effects. Because of this toxicity, for years a so-called pyramid approach was taken with people with rheumatoid arthritis. Physicians started with NSAIDs to help with the pain and inflammation, and progressed to successively stronger and more toxic medications only when the basic treatments failed. Natural treatments such as those described here might also be useful in early stages.
However, over the last few years, research has found that severe joint damage occurs very early in rheumatoid arthritis. This evidence has caused many authorities to suggest early, aggressive treatment with disease-modifying drugs to prevent joint damage. Nonetheless, this approach has not been universally adopted, and some physicians still prescribe NSAIDs for early stages of rheumatoid arthritis. The treatments described here may be reasonable alternative options.
Rheumatoid arthritis is a difficult disease, and no alternative approach solves it easily. Even if you choose to use alternative methods, you should maintain regular visits to a rheumatologist to watch for serious complications. Finally, keep in mind that medical treatment may be able to slow the progression of rheumatoid arthritis. It is not likely that any of the alternative options have the same power.
Fish oil is the only natural treatment for rheumatoid arthritis with significant documentation. According to the results of at least 13 double-blind, placebo-controlled studies involving a total of over 500 participants, supplementation with omega-3 fatty acids can significantly reduce the symptoms of rheumatoid arthritis. 1,2 In addition, at least one small study suggests that it may help rheumatoid arthritis patients lower their dose of nonsteroidal anti-inflammatory medication (eg, ibuprofen). 84
However, unlike some of the standard treatments, fish oil has not been shown to slow the progression of rheumatoid arthritis. It has been suggested that omega-3 supplementation is more effective when omega-6 intake (particularly arachidonic acid) is kept low, as occurs with a vegetarian diet. 67 The benefits of fish oil may also be enhanced by simultaneous use of olive oil. 74 A badly designed human study hints that a relative of fish oil, krill oil , might be helpful as well. 79
For more information, including dosage and safety issues, see the full Fish Oil article.
Boswellia serrata is a shrub-like tree that grows in the dry hills of the Indian subcontinent. It is the source of a resin called salai guggal, which has been used for thousands of years in Ayurvedic medicine, the traditional medicine of the region. It is very similar to a resin from a related tree, Boswellia carteri , which is also known as frankincense. Both substances have been used historically for arthritis.
Recent research has identified boswellic acids as the likely active ingredients in boswellia. In animal studies, boswellic acids have shown anti-inflammatory effects, but their mechanism of action seems to be quite different from that of standard anti-inflammatory medications. 10-13
An issue of Phytomedicine that was devoted to boswellia briefly reviewed previously unpublished studies on the herb. 14 A pair of placebo-controlled trials involving a total of 81 people with rheumatoid arthritis found significant reductions in swelling and pain over the course of 3 months. Furthermore, a comparative study of 60 participants over 6 months found the boswellia extract relieved symptoms about as well as oral gold therapy. However, keep in mind that while gold shots can induce remission in rheumatoid arthritis, we have no evidence that boswellia can do the same.
Another double-blind study found no difference between boswellia and placebo. 15 The bottom line is that we need more research to know for sure whether boswellia is an effective treatment for rheumatoid arthritis.
For more information, including dosage and safety issues, see the full Boswellia article.
The herb devil's claw may be beneficial in rheumatoid arthritis. One double-blind study followed 89 people with rheumatoid arthritis for 2 months. The group given devil's claw showed a significant decrease in pain intensity and an improvement in mobility. 16
Another double-blind study of 50 people with various types of arthritis showed that 10 days of treatment with devil's claw provided significant pain relief. 17
For more information, including dosage and safety issues, see the full Devil's Claw article.
Glucosamine is best known as a proposed treatment for osteoarthritis. However, it might be helpful for RA as well. A double-blind, placebo-controlled study of 51 people with RA found that glucosamine at a dose of 1,500 mg daily significantly improved symptoms. 77 It did not, however, alter measures of inflammation as determined through blood tests.
Some evidence, including small double-blind trials, additionally support the use of the following herbs and supplements for the treatment of rheumatoid arthritis:
Note : Tripterygium wilfordii is believed to be unsafe for pregnant or nursing women, and may present risks in other groups as well. 26,27,75
Vitamin E may reduce pain in rheumatoid arthritis, but it does not seem to reduce inflammation. 37,54,55 Some evidence suggests that adding vitamin E, or vitamin E plus other antioxidants, to standard rheumatoid arthritis therapy might improve results. 39 However, an extremely large randomized trial involving over 39,000 women found that taking 600 IU of vitamin E every other day did not reduce the risk of rheumatoid arthritis. 87
Individuals taking the drug methotrexate for treatment of rheumatoid arthritis may benefit by taking folate supplements. Folate appears to reduce methotrexate side effects, including mouth sores, nausea, and liver inflammation. 57-59 In addition, folate supplements may help reverse a more subtle methotrexate side-effect: a rise in blood levels of homocysteine . 60,61 Elevated levels of homocysteine are thought to increase risk of heart-disease.
The following treatments are also sometimes proposed as effective for rheumatoid arthritis, but there is as yet little to no scientific evidence for or against their use: adrenal extract , beta-carotene , betaine hydrochloride , boron , burdock , cayenne , chamomile , copper , feverfew , folate , ginger , L-histidine , horsetail , magnesium , manganese , molybdenum, pantothenic acid , D-phenylalanine , perilla frutescens , pregnenolone , proteolytic enzymes , sea cucumber, and vitamin C .
Zinc supplements have been evaluated as a treatment for rheumatoid arthritis, but overall the study results have not been encouraging. 34,35,49-53 Other treatments that have as yet generally failed to prove effective in small double-blind trials include selenium , collagen, 46,47-50probiotics , 72white willow , 73 and an Ayurvedic herbal mixture containing extracts of ashwagandha , boswellia , ginger , and turmeric . 45 Two studies commonly cited as evidence that turmeric alone is useful for rheumatoid arthritis actually fail to provide any meaningful supporting evidence. 20,21
A 6-month, double-blind, placebo-controlled study of 168 people with rheumatoid arthritis failed to find that elk velvet antler enhanced the effectiveness of conventional treatment for rheumatoid arthritis. 83
Two separate groups of researchers conducting detailed reviews of 8 randomized controlled trials found some beneficial effects of acupuncture for rheumatoid arthritis, but were unconvinced that it was more beneficial than sham acupuncture or other standard treatments. 85,86 Another review of 11 randomized trials did not find that mediation, progressive muscle relaxation, static magnetic therapy, acupuncture or tai chi relieved pain in patients with rheumatoid arthritis. The 11 trials included a total of 607 patients. 95
Various herbs and supplements may interact adversely with drugs used to treat rheumatoid arthritis. For more information on this potential risk, see the individual drug article in the Drug Interactions section of this database.
8. Nordstrom DC, Honkanen VE, Nasu Y, et al. Alpha-linolenic acid in the treatment of rheumatoid arthritis. A double-blind placebo-controlled and randomized study: flaxseed vs. safflower seed. Rheumatol Int . 1995;14:231-234.
11. Wildfeuer A, Neu IS, Safayhi H, et al. Effects of boswellic acids extracted from an herbal medicine on the biosynethsis of leukotrienes and the course of experimental autoimmune encephalomyelitis. Arzneimittelforschung . 1998;48:668-674.
13. Safayhi H, Boden SE, Schweizer S, et al. Concentration-dependent potentiating and inhibitory effects of Boswellia extracts on 5-lipoxygenase product formation in stimulated PMNL. Planta Med. 2000;66:110-113.
15. Sander O, Herborn G, Rau R. Is H15 (resin extract of Boswellia serrata , "incense") a useful supplement to established drug therapy of chronic polyarthritis? Results of a double-blind pilot study [in German; English abstract]. Z Rheumatol . 1998;57:11-16.
34. Peretz A, Neve J, Jeghers O, et al. Zinc distribution in blood components, inflammatory status, and clinical indexes of disease activity during zinc supplementation in inflammatory rheumatic diseases. Am J Clin Nutr . 1993;57:690-694.
37. Edmonds SE, Winyard PG, Guo R, et al. Putative analgesic activity of repeated oral doses of vitamin E in the treatment of rheumatoid arthritis. Results of a prospective placebo controlled double blind trial. Ann Rheum Dis. 1997;56:649-655.
40. Murav'ev IuV, Venikova MS, Pleskovskaia GN, et al. Effect of dimethyl sulfoxide and dimethyl sulfone on a destructive process in the joints of mice with spontaneous arthritis [in Russian]. Patol Fiziol Eksp Ter. 1991;2:37-39.
46. Cazzola M, Antivalle M, Sarzi-Puttini P, et al. Oral type II collagen in the treatment of rheumatoid arthritis. A six-month double blind placebo-controlled study. Clin Exp Rheumatol . 2000;18:571-577.
51. Dixon JS, Bird HA, Martin MF, et al. Biochemical and clinical changes occurring during the treatment of rheumatoid arthritis with novel antirheumatoid drugs. Int J Clin Pharmacol Res. 1985;5:25-33.
56. 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.
57. van Ede AE, Laan RF, Rood MJ, et al. Effect of folic or folinic acid supplementation on the toxicity and efficacy of methotrexate in rheumatoid arthritis: a forty-eight week, multicenter, randomized, double-blind, placebo-controlled study. Arthritis Rheum. 2001;44:1515-1524.
58. Griffith SM, Fisher J, Clarke S, et al. Do patients with rheumatoid arthritis established on methotrexate and folic acid 5 mg daily need to continue folic acid supplements long term? Rheumatology (Oxford). 2000;39:1102-1109.
59. Ortiz Z, Shea B, Suarez-Almazor ME, et al. The efficacy of folic acid and folinic acid in reducing methotrexate gastrointestinal toxicity in rheumatoid arthritis. A metaanalysis of randomized controlled trials. J Rheumatol. 1998;25:36-43.
61. Morgan SL, Baggott JE, Lee JY, Alarcon GS. Folic acid supplementation prevents deficient blood folate levels and hyperhomocysteinemia during longterm, low dose methotrexate therapy for rheumatoid arthritis: implications for cardiovascular disease prevention. J Rheumatol. 1998;25:441-446.
68. Mur E, Hartig F, Eibl G, et al. Randomized double blind trial of an extract from the pentacyclic alkaloid-chemotype of uncaria tomentosa for the treatment of rheumatoid arthritis. J Rheumatol . 2002;29:678-681.
69. Cibere J, Deng Z, Lin Y, et al. A randomized double blind, placebo controlled trial of topical Tripterygium wilfordii in rheumatoid arthritis: Reanalysis using logistic regression analysis. J Rheumatol . 2003;30:465-467.
70. Segal NA, Toda Y, Huston J, et al. Two configurations of static magnetic fields for treating rheumatoid arthritis of the knee: double-blind clinical trial. Arch Phys Med Rehabil . 2001;82:1453-1460.
71. David J, Townsend S, Sathanathan R, et al. The effect of acupuncture on patients with rheumatoid arthritis: a randomized, placebo-controlled cross-over study. Rheumatology (Oxford). 1999;38:864-869.
73. Biegert C, Wagner I, Ludtke R, et al. Efficacy and safety of willow bark extract in the treatment of osteoarthritis and rheumatoid arthritis: results of 2 randomized double-blind controlled trials. J Rheumatol . 2004;31:2121-2130.
76. Chiang EP, Selhub J, Bagley PJ, et al. Pyridoxine supplementation corrects vitamin B6 deficiency but does not improve inflammation in patients with rheumatoid arthritis. Arthritis Res Ther. 2005;7:R1404-1411.
82. Stenstrom CH, Arge B, Sundbom A, et al. Dynamic training versus relaxation training as home exercise for patients with inflammatory rheumatic diseases. A randomized controlled study. Scand J Rheumatol. 1996;25:28-33.
93. Brien S, Lachance L, Prescott P, McDermott C, Lewith G. Homeopathy has clinical benefits in rheumatoid arthritis patients that are attributable to the consultation process but not the homeopathic remedy: a randomized controlled clinical trial. Rheumatology (Oxford). 2010 Nov 13.
94. Macfarlane GJ, El-Metwally A, De Silva V, et al. dence for the efficacy of complementary and alternative medicines in the management of rheumatoid arthritis: a systematic review. Rheumatology (Oxford). 2011;50(9):1672-1683.
95. Macfarlane GJ, Paudyal P, et al. A systematic review of evidence for the effectiveness of practitioner-based complementary and alternative therapies in the management of rheumatic diseases: rheumatoid arthritis. Rheumatology (Oxford) .2012;51(9):1707-1713.
Last reviewed August 2013 by EBSCO CAM Review Board
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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