Rheumatoid Arthritis

Feeding a high-fat diet to animals who are susceptible to autoimmune disease has increased the severity of RA.1 People with RA have been reported to eat more fat, particularly animal fat, than those without RA.2 In short-term studies, diets completely free of fat have helped people with RA.3 Since at least some dietary fat is essential for humans, though, the significance of this finding is not clear.

Strictly vegetarian diets that are also very low in fat have been reported to reduce RA symptoms.4 5 In the 1950s through the 1970s, Max Warmbrand, a naturopathic doctor, used a very low-fat diet to treat people with RA. He recommended a diet free of meat, dairy, chemicals, sugar, eggs, and processed foods.6 A short-term (ten weeks) study employing a similar approach failed to produce beneficial effects.7 Long before publication of that negative report, however, Dr. Warmbrand had claimed that his diet took at least six months to achieve noticeable results. In one trial lasting 14 weeks - still significantly less than six months - a pure vegetarian, gluten-free (no wheat, rye, or barley) diet was gradually changed to permit dairy, leading to improvement in both symptoms and objective laboratory measures of disease.8 The extent to which a low-fat vegetarian diet (or one low in animal fat) would help people with RA remains unclear.

Preliminary evidence suggests that consumption of olive oil, rich in oleic acid, may decrease the risk of developing RA.9 One trial in which people with RA received either fish oil or olive oil, found that olive oil capsules providing 6.8 g of oleic acid per day for 24 weeks produced modest clinical improvement and beneficial changes in immune function. However, as there was no placebo group in that trial, the possibility of a placebo effect cannot be ruled out.10

Fasting has been shown to improve both signs and symptoms of RA, but most people have relapsed after the returning to a standard diet.11 12 When fasting was followed by a 12-month vegetarian diet, however, the benefits of fasting appeared to persist.13 14 It is not known why the combination of these dietary programs (i.e., fasting followed by a vegetarian diet) might be helpful, and the clinical trial that investigated this combination15 has been criticized both for its design and interpretation.16 17 18

Food sensitivities develop when pieces of intact protein in food are able to cross through the intestinal barrier. Many patients with RA have been noted to have increased intestinal permeability, especially when experiencing symptoms,19 and RA has been linked to allergies and food sensitivities.20 In many people, RA worsens when they eat foods to which they are allergic or sensitive and improves by avoiding these foods.21 22 23 24 In one study, the vast majority of RA patients had elevated levels of antibodies to milk, wheat, or both, suggesting a high incidence of allergy to these substances.25 English researchers have reported that one-third of people with RA may be able to control their disease completely through allergy elimination.26 Identification and elimination of symptom-triggering foods should be done with the help of a physician.

Drinking four or more cups of coffee per day has been associated with an increased risk of developing rheumatoid arthritis in preliminary research.27

Lifestyle Modification

Although exercise may initially increase pain, gentle exercises help people with RA.28 29 Women with RA taking low-dose steroid therapy can safely participate in a weight-bearing exercise program with many positive effects on physical function, activity and fitness levels, and bone mineral density, and with no aggravation of disease activity.30 Many doctors recommend swimming, stretching, or walking to people with RA.

People with RA have been reported to have an impaired antioxidant system, making them more susceptible to free radical damage.31 Vitamin E is an important antioxidant, protecting many tissues, including joints, against oxidative damage. Low vitamin E levels in the joint fluid of people with RA have been reported.32 In a double-blind trial, approximately 1,800 IU per day of vitamin E was found to reduce pain from RA.33 Two other double-blind trials (using similar high levels of vitamin E) reported that vitamin E had approximately the same effectiveness in reducing symptoms of RA as anti-inflammatory drugs.34 35 In other double-blind trials, 600 IU of vitamin E BID was significantly more effective than placebo in reducing RA, although laboratory measures of inflammation remained unchanged.36 37

Oils containing the omega-6 fatty acid gamma linolenic acid (GLA) - borage oil,38 39 40 black currant seed oil,41 and evening primrose oil (EPO)42 43 - have been reported to be effective in the treatment for people with RA. Although the best effects have been reported with use of borage oil, that may be because more GLA was used in borage oil trials (1.1-2.8 grams per day) compared with trials using black currant seed oil or EPO. The results with EPO have been mixed and confusing, possibly because the placebo used in those trials (olive oil) may have anti-inflammatory activity. In a double-blind trial, positive results were seen when EPO was used in combination with fish oil.44 GLA appears to be effective because it is converted in part to prostaglandin E1, a hormone-like substance known to have anti-inflammatory activity.

Many double-blind trials have proven that omega-3 fatty acids in fish oil, called EPA and DHA, partially relieve symptoms of RA.45 46 47 48 49 50 The effect results from the anti-inflammatory activity of fish oil.51 Many doctors recommend 3 grams per day of EPA and DHA, an amount commonly found in 10 grams of fish oil. Positive results can take three months to become evident. In contrast, a double-blind trial found flaxseed oil (source of another form of omega-3 fatty acid) not to be effective for RA patients.52

Cetyl myristoleate (CMO) has been proposed to act as a joint "lubricant" and anti-inflammatory agent. In a double-blind trial, people with various types of arthritis that had failed to respond to non-steroidal anti-inflammatory drugs received either CMO (540 mg per day orally for 30 days) or a placebo.53 These people also applied CMO or placebo topically, according to their perceived need. Sixty-four percent of those receiving CMO improved, compared with 14% of those receiving placebo. More research is needed to determine whether CMO has a legitimate place in the treatment options offered RA patients.

The use of dimethyl sulfoxide (DMSO) for therapeutic applications is controversial in part because some claims made by advocates appear to extend beyond current scientific evidence, and in part because topical use greatly increases the absorption of any substance that happens to be on the skin, including molecules that are toxic to the body. Nonetheless, there is some preliminary evidence that when applied to the skin, it has anti-inflammatory properties and alleviates pain, such as that associated with RA.54 55 DMSO appears to reduce pain by inhibiting the transmission of pain messages by nerves.56 It comes in different strengths and degrees of purity, and certain precautions must be taken when applying DMSO. For these reasons, DMSO should be used only under the supervision of a doctor.

Research suggests that people with RA may be partially deficient in pantothenic acid (vitamin B5).57 In one placebo-controlled trial, those with RA had less morning stiffness, disability, and pain when they took 2,000 mg of pantothenic acid per day for two months.58

Supplementation with New Zealand green-lipped mussel (Perna canaliculus) significantly improved RA symptoms in 68% of participants in a double-blind trial.59 Other studies have been carried out, some of which have confirmed these findings, while others have not.60 61 62 63 64 In a recent double-blind trial, use of green-lipped mussel as a lipid extract (210 mg per day) or a freeze-dried powder (1,150 mg per day) for three months led to a decrease in joint tenderness and morning stiffness, and to better overall function.65 However, members of the Australian Rheumatism Association have reported side effects, such as stomach upset, gout, and skin rashes, occurring in people taking certain New Zealand green-lipped mussel extracts. One case of hepatitis reported in association with the use of a New Zealand green-lipped mussel extract has also been reported.66

Deficient Zinc levels have been reported in people with RA.67 Some trials have found that zinc reduced RA symptoms,68 but others have not.69 70 Some suggest that zinc might only help those who are zinc-deficient71 and, although there is no universally accepted test for zinc deficiency, some doctors check white-blood-cell zinc levels.

People with RA have been found to have lower selenium levels than healthy people.72 73 One74 of two double-blind trials using at least 200 mcg of selenium per day for three to six months found that selenium supplementation led to a significant reduction in pain and joint inflammation in RA patients, but the other reported no beneficial effect.75 More controlled trials are needed to determine whether selenium reduces symptoms in people with RA.

Copper acts as an anti-inflammatory agent needed to activate superoxide dismutase (SOD), an enzyme that protects joints from inflammation. People with RA tend toward copper deficiency76 and copper supplementation has been shown to increase SOD levels in humans.77 The Journal of the American Medical Association quoted one researcher as saying that while "Regular aspirin had 6% the anti-inflammatory activity of [cortisone]. . . copper [when added to aspirin] had 130% the activity [of cortisone]."78

Several copper compounds have been used successfully in treating people with RA,79 and a controlled trial using copper bracelets reported surprisingly effective results compared with the effect of placebo bracelets.80 Under certain circumstances, however, copper can increase inflammation in rheumatoid joints.81 Moreover, the form of copper most consistently reported to be effective, copper aspirinate (a combination of copper and aspirin), is not readily available. Nonetheless, some doctors suggest a trial of 1-3 mg of copper per day for at least several months.

Boron supplementation at 3-9 mg per day may be beneficial, particularly in treating people with juvenile RA, according to very preliminary research.82 The benefit of using boron to treat people with RA remains unproven.

D-phenylalanine has been used with mixed results to treat chronic pain, including pain caused by RA.83 No research has evaluated the effectiveness of DL-phenylalanine, a related supplement, in treating people with RA. The effect of either form of phenylalanine in the treatment of people with RA remains unproven.

Many years ago, two researchers reported that some individuals with RA had inadequate stomach acid.84 Hydrochloric acid, called HCl by chemists, is known to help break down protein in the stomach before the protein can be absorbed in the intestines. Allergies generally occur when inadequately broken down protein is absorbed from the intestines. Therefore, some doctors believe that when stomach acid is low, supplementing with betaine HCl can reduce food-allergy reactions by helping to break down protein before it is absorbed. In theory such supplementation might help some people with RA, but no research has investigated whether betaine HCl actually reduces symptoms of RA.

Supplementation with betaine HCl should be limited to people who have a proven deficit in stomach acid production. Of doctors who prescribe betaine HCl, the amount used varies with the size of the meal and with the amount of protein ingested. Although typical amounts recommended by doctors range from 600 to 2,400 mg of betaine HCl per meal, use of betaine HCl needs to be monitored by a healthcare practitioner and tailored to the needs of the individual.

Bromelain has significant anti-inflammatory activity. Many years ago in a preliminary trial, people with RA who were given bromelain supplements experienced a decrease in joint swelling and improvement in joint mobility.85 The amount of bromelain used in that trial was 20-40 mg, TID or QID, in the form of enteric-coated tablets. The authors provided no information about the strength of activity in the bromelain supplements that were used. (Today, better quality bromelain supplements are listed in gelatin-dissolving units [GDU] or in milk-clotting units [MCU].) Enteric-coating protects bromelain from exposure to stomach acid. Most commercially available bromelain products today are not enteric-coated.

Propolis is the resinous substance collected by bees from the leaf buds and bark of trees, especially poplar and conifer trees. Anti-inflammatory effects from topical application of propolis extract have been noted in one animal study,86 and a preliminary controlled trial found that patients with RA treated with topical propolis extract (amount and duration not noted) had greater improvements in symptoms compared to placebo.87

Boswellia is an herb used in Ayurvedic medicine (the traditional medicine of India) to treat arthritis. Boswellia has reduced symptoms of RA in most reports.88 While some double-blind trials89 using boswellia have produced positive results, however, equivocal results90 and negative findings have also been reported.91 In some trials where boswellia has appeared ineffective, though, patients have been allowed to continue use of non-steroidal anti-inflammatory drugs (NSAIDs). Such use of NSAIDs can confound experimental results, because boswellia and NSAIDs work in a similar fashion in reducing inflammation. Some doctors suggest using 400-800 mg of gum resin extract in capsules or tablets TID.

A cream containing small amounts of capsaicin, a substance found in cayenne pepper, can help relieve pain when rubbed onto arthritic joints, according to the results of a double-blind trial.92 Capsaicin achieves this effect by depleting nerves of a pain-mediating neurotransmitter called substance P. Although application of capsaicin cream initially causes a burning feeling, the burning lessens with each application and disappears for most people in a few days. Creams containing 0.025-0.075% of capsaicin are available and may be applied to the affected joints three to five times a day. A doctor should supervise this treatment.

Devil's claw has anti-inflammatory and analgesic actions. Several open and double-blind trials have been conducted on the anti-arthritic effects of devil's claw.93 The results of these trials have been mixed, so it is unclear whether devil's claw lives up to its reputation in traditional herbal medicine as a remedy for people with RA. A typical amount used is 800 mg of encapsulated extracts TID or powder in the amount of 4.5-10 grams per day.

Turmeric is a yellow spice often used to make curry dishes. The active constituent, curcumin, is a potent anti-inflammatory compound that protects the body against free radical damage.94 A double-blind trial found curcumin to be an effective anti-inflammatory agent in RA patients.95 The amount of curcumin usually used is 400 mg TID.

Ginger is another Ayurvedic herb used to treat people with arthritis. A small number of case studies suggest that taking 6-50 grams of fresh or powdered ginger per day may reduce the symptoms of RA.96 A combination formula containing ginger, turmeric, boswellia, and ashwagandha has been shown in a double-blind trial to be slightly more effective than placebo for RA;97 the amounts of herbs used in this trial are not provided by the investigators.

The historic practice of applying nettle topically (with the intent of causing stings to relieve arthritis) has been assessed by a questionnaire study.98 The nettle stings were reported to be safe except for causing a sometimes painful, sometimes numbing rash lasting 6 to 24 hours. Further studies are required to determine whether this practice is therapeutically effective.

Yucca, a traditional remedy, is a desert plant that contains soap-like components known as saponins. Yucca tea (7 or 8 grams of the root simmered in a pint of water for 15 minutes) is often drunk for symptom relief three to five times per day. The effects of yucca in the treatment of people with RA has not been studied.

Burdock root has been used historically both internally and externally to treat painful joints. Its use in the treatment of people with RA remains unproven.

Although willow is slow acting as a pain reliever, the effect is thought to last longer than the effect of willow's synthetic cousin, aspirin. One double-blind trial found that willow bark combined with guaiac, sarsaparilla, black cohosh, and poplar (each tablet contained 100 mg of willow bark, 40 mg of guaiac, 35 mg of black cohosh, 25 mg of sarsaparilla, and 17 mg of poplar) relieved pain due to RA better than placebo over a two-month period.99 The exact amount of the herbal combination used in the trial is not given, however, and patients were allowed to continue their pain medications. Clinical trials on willow alone for RA are lacking. Some experts suggest that willow may take one to four weeks before results are noted.100

Topical applications of several botanical oils are approved by the German government for relieving symptoms of RA.101 These include primarily cajeput (Melaleuca leucodendra) oil, camphor oil, eucalyptus oil, fir (Abies alba and Picea abies) needle oil, pine (Pinus spp.) needle oil, and rosemary oil. A few drops of oil or more can be applied to painful joints several times a day PRN. Most of these topical applications are based on historical use and are lacking modern clinical trials to support their effectiveness in treating RA.

Preliminary studies conducted in India with the herb picrorhiza show a benefit for people with RA.102 Currently, this therapeutic effect remains weakly supported and therefore unproven.

Southwestern Native American and Hispanic herbalists have long recommended topical use of chaparral on joints affected by RA. The anti-inflammatory effects of chaparral found in test tube research suggests this practice might have value, though clinical trials have not yet investigated chaparral's usefulness in people with RA. Chaparral should not be used internally for this purpose.

Cat's claw has been used traditionally for RA, but no human trials have investigated this practice.

Meadowsweet was used historically for a wide variety of conditions, including treating rheumatic complaints of the joints and muscles.103