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Complimentary and alternative medications (CAMs) in RA

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.

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Complimentary and alternative medications (CAMs) in RA

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  1. Complimentary and alternative medications (CAMs) in RA Brad Butt Managing partner Cooleman Court Pharmacy WESTON

  2. Objectives • Which CAMs are our patients seeking information on • What evidence is there for their use • Possible interactions – disease state/medication

  3. CAMs in RA • Fish oils • Trend towards Krill oil • Tumeric/curcumin • Others…

  4. 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)

  5. Inflammatory cascade

  6. TGA v GOED table

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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)

  12. Curcumin pathway

  13. Curcumin precautions • Bile duct obstruction • Anti coagulants • Can reduce BGL – hypoglycaema risk • May increase stomach acid secretion

  14. 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

  15. 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

  16. References • McCusker MM, Grant-Kels JM. Healing fats of the skin: the structural and immunologic roles of the omega-6 and omega-3 fatty acids. ClinDermatol 2010;28(4):440-451. • Braun L, Cohen M. Herbs and natural supplements: an evidence-based guide, 3rd ed. Sydney: Churchill Livingstone Elsevier, 2010. • Silva V, Barazzoni R, Singer P. Biomarkers of fsh oil omega-3 polyunsaturated fatty acids intake in humans. NutrClinPract 2014;29(1):63-72. • 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. • Calder PC. n-3 fatty acids, infammation and immunity: new mechanisms to explain old actions. Proc Nutr Soc 2013;72(3):326-336 • Calder PC. n-3 polyunsaturated fatty acids, infammation, and infammatory diseases. Am J ClinNutr 2006;83(Suppl):1505S-1519S • 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. • 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. • Harris WS. Expert opinion: omega-3 fatty acids and bleeding-cause for concern? Am J Cardiol 2007;99(6A):44C-46C. • Bays HE. Safety considerations with omega-3 fatty acid therapy. Am J Cardiol 2007;99(6A):35C-43C.

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