When the Patient Insists on Natural Therapies
When the Patient Insists on Natural Therapies
Not every patient is a fan of modern medicine. Some try to treat their ailments with herbal supplements and special diets, but in rheumatoid arthritis, delaying treatment with proven therapeutic treatments can have a detrimental effect on health outcomes.
Still, there will probably always be a set of patients who insist on trying natural therapies after a rheumatoid arthritis diagnosis.
“To be very clear, rheumatoid arthritis is not appropriately treated by alternative therapies, supplements, or herbal products as the main therapeutic intervention,” said Sharon Kolasinski, M.D., a rheumatologist and specialist in complementary and alternative medicine at the University of Pennsylvania.
While there have been studies on the effects of glucosamine hydrochloride, chondroitin sulfate and exercise programs like tai chi and yoga, few herbal supplements, or natural therapies, have been tested and vetted through the clinical trials process. That’s not to say alternative therapies shouldn’t be used as adjuvant therapies approved by the attending physician as some have proven therapeutic effects.
How to manage the patient who insists on natural therapies.
If a patient is committed to pursuing non-traditional therapies, they should be educated about the potential consequences of this choice, Dr. Kolasinski said.
Identify the goal: Ask the patient what he or she hopes to achieve by embarking on a natural therapy and why? Do they want to improve flexibility or reduce pain?
Target symptoms: Pinpoint the specific issues he or she wants to control. Are they interested in reducing swelling or alleviating fatigue?
Explain the science: Explain to the patient how the desired supplement could interact with any prescription medications. Supplements and vitamins can impede how DMARDs or biologics act.
Establish a timeline: No natural therapy should be implemented indefinitely. Decide upon an appropriate timeframe — a week, month or several months — to test the therapy and evaluate whether it has been successful.
“Don’t make the assumption that supplements will help or won’t hurt. Some can interact negatively with prescription medications,” Dr. Kolasinski said. “If a patient’s outcomes aren’t different after the test period, then they need to stop trying it.”
Ultimately, Dr. Kolasinski said, it’s important to listen to a patient’s desire and goals with treatment plan. Avoid being judgmental about his or her choice and try to find common ground that will address their concerns and wants while effectively controlling their rheumatoid arthritis.
“I try to educate patients. They’ve received a life-long diagnosis, and they want to have some control. They think natural therapies promise that,” she said. “They’re seeking positive action to enhance their health and take charge of their disease.”
The 2015 American College of Rheumatology rheumatoid arthritis treatment guidelines addresses the use of DMARDs (Disease-Modifying Anti-Rheumatic Drugs), biologic DMARDs and glucocorticoids, but it does not address the use of natural or alternative therapies.
The guidelines are comprehensive, but in short: For patients with low, moderate or high rheumatoid arthritis disease activity — and who have never before taken a DMARD — the ACR recommends patients start with DMARD monotherapy (preferably methotrexate). If disease activity remains moderate or high — despite DMARD monotherapy (with or without glucocorticoids) — combination therapy should be introduced (a combination of DMARDs or a TNFi or a non-TNF biologic).
Should Patients Skip DMARDs or Biologics?
DMARDs and biologic treatments can be associated with adverse effects in some patients; however, it’s important they understand the consequences of delaying treatment with established and proven therapies.
“If a patient opts not to take their DMARD or biologic therapy, they will see the development of progressive, irreversible damage due to uncontrolled rheumatoid arthritis,” she said. “It can destroy their joints and limit their mobility.”
Recent studies have shown that patients have worse outcomes the longer treatment is delayed. And, at a certain point of disease progression, the joint damage can become irreversible. Generally the earlier the treatment is started, the better the chances of reaching remission.
Research on Natural and Alternative Therapies
Researchers continue to explore the benefits of alternative and complimentary therapies.
There have been a number of studies that show that tai chi and yoga are effective in improving physical function in adults with rheumatoid arthritis and fibromyalgia. Exercises like tai chi and yoga, which promote strength, flexibility, balance and positive mental health, are recommended by researchers as adjuvant treatment.
While a number of studies have shown that chondroitin sulfate and glucosamine hydrochloride supplements offer little relief from joint pain, the MOVES trial presented at 2014 annual meeting of the American College of Rheumatology, shows that a combination of the two supplements is comparable to celecoxib in reducing knee pain, but the trial was done specifically in osteoarthritis patients.
A 2015 study of 207 patients with rheumatoid arthritis showed that Tripterygium wilfordii Hook F (TwHF), an herb used in Chinese traditional medicine, was superior to methotrexate monotherapy — as either a monotherapy itself or in combination with methotrexate.
Specifically, researchers found that 76.8% of patients in the methotrexate/TwHF treatment combination group; 55.1% of patients in the TwHF monotherapy group; and, 46.4% of patients on methotrexate monotherapy group reached ACR50 at 24 weeks. The findings were published in the Annals of the Rheumatic Diseases.
1. Jasvinder A. Singh, Kenneth G. Saag, Louis Bridges Jr., et al. “2015 American College of Rheumatology Guidelines for the Treatment of Rheumatoid Arthritis,” Arthritis Care & Research. November 2015. DOI 10.1002/acr.22783
2. Qian-wen Lv, Wen Zhang, Qun Shi, et. al. “Comparison of Tripterygium wilfordii Hook F with methotrexate in the treatment of active rheumatoid arthritis (TRIFRA): a randomized, controlled clinical trial,” Annals of the Rheumatic Diseases. June 2015; DOI: 10.1136/annrheumdis-2013-204807.
3. American College of Rheumatology annual meeting abstracts: Results from various tai chi and yoga clinical trials presented at this annual meeting.
4. Marc Hochberg, Johanne Martel-Pelletier, Jordi Monfort, et. al. "Combined Chondroitin Sulfate and Glucosamine Is Comparable to Celecoxib for Painful Knee Osteoarthritis. Results from a Multicenter, Randomized, Double-Blind, PHASE IV NON-Inferiority TRIAL," ACR 2014 annual meeting. Abstract: 2231