USE OF COMPLEMENTARY AND ALTERNATIVE MEDICINE IN PATIENTS WITH RHEUMATOID ARTHRITIS

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1 Chiang Mai Med Bull 2003;42(3): Original article USE OF COMPLEMENTARY AND ALTERNATIVE MEDICINE IN PATIENTS WITH RHEUMATOID ARTHRITIS Waraporn Sukitawut, B.Sc., Ramjai Wichainun, B.Sc., Nuntana Kasitanon, M.D., Worawit Louthrenoo, M.D. Division of Rheumatology, Department of Medicine, Faculty of Medicine, Chiang Mai University Objective Complementary and alternative medicine (CAM) is commonly used by patients with joint symptoms. Its effect on the disease progression is by Thai patients with rheumatoid arthritis (RA). Methods Fifty-three consecutive RA patients, seen during January-May 2002, were interviewed. Types of CAM used were assessed, and their uses were correlated with medical, socioeconomic and educational status. Results Thirty-four patients (64.1%) had used at least one kind of CAM before they were seen by us. The forms of CAM used by these patients were massage (with or without herbs) in 55.9%, oral Thai herbs in 29.4%, oral Chinese herbs in 23.5%, sauna with herbs in 23.5% and others in 35.3%. Forty-one percent had used more than one modality of CAM, with an average of 1.9 modalities/patients. Fifty-nine percent were advised to use CAM by their relatives or neighbors. Regarding their belief in this remedy, 47.1% of the users wanted to try it, 29.4% partially believed that CAM was effective, and 20.6% totally believed in its effectiveness. There was no significant difference among users and non users in age, sex, duration of RA, functional class, number of joint swellings, number of tender joints, health assessment questionnaire (HAQ) score, pain (visual analogue scale), education and economic status. Conclusion The use of CAM was common among RA patients, and it was usually recommended by their relatives and friends. Clinicians should be aware of these therapies, particularly those with oral treatment, as many of them might contain corticosteroids. Thus, a prolonged use of them without medical supervision might be harmful. Chiang Mai Med Bull 2003;42(3): Key words: alternative medicine, complementary medicine, herbs, massage, rheumatoid arthritis, arthritis Address requests for reprints: Waraporn Sukitawut, B.Sc., Division of Rheumatology, Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand. Tel: ; Received 21 May 2002, and in revised form 2 July 2003.

2 106 Sukitawut W, et al. Rheumatoid arthritis (RA) is a chronic polyarthritic disease of unknown etiology affecting approximately 1% of the people in the United States (1) and 0.12% in Thailand. (2) The disease is characterized by symmetric painful joint swellings, which run a progressive course, and result in debility and deformity. Conventional therapies of RA have included nonsteroidal antiinflammatory drugs and disease modifying agents. (3) These therapies can reduce pain, improve function, and enhance well being. Unfortunately, a certain number of patients do not respond to these forms of treatment, and they still suffer from chronic pain. Complementary and alternative medicine (CAM) has been used in clinical medicine for a long time. Complementary medicine refers to the use of nonconventional, in conjuction with regular treatment, while alternative medicine refers to the use of non-conventional treatment. CAM comprises over 100 forms of treatment. (4) It has been estimated that 60-90% of persons with arthritis use CAM, (5) with herbal therapy and chiropractic being the two most common forms used. In a telephone interview by Eisenberg, (6) 18% of 246 patients who had a history of arthritis used CAM, in which 7% had used it for more than 12 months. In Australia, 82% of 90 RA patients in a teaching hospital had used more than one CAM modality, with an average of 4 modalities per patient. (7) The difference in the number of responders depends on the methods of retrieving information from the patients. Although there have been no good controlled studies that prove alternative therapy stops the progression of the disease, many RA patients get some form of CAM therapy in addition to their conventional treatment. To improve our understanding of the use of CAM in RA, we performed this study to determine the pattern and extent of its use and the socio-demographic status in our patients. Moreover, we compared functional disability among the user and non-users. Patients and methods Fifty-three consecutive RA patients, who were treated at the Division of Rheumatology, Department of Medicine, Faculty of Medicine, Chiang Mai University during January May 2002, were asked to participate in this study. All patients were asked to answer questionnaires, which contained socio-demographic information. These included age, sex, area of residence, education, marital status, occupation and income. They were also asked about the use of CAM, its type and pattern and those people who suggested in to them. A Health Assessment Questionnaire (HAQ) and self-reporting joint pain with visual analog scale (VAS) were used to determine the disability of the patients. Statistical analysis Demographic characteristics of users and non-users were compared using the non-paired T-test and Chi-square test, where applicable. Continuous data were described as mean and standard deviation (SD). Categorical variables were described

3 CAM in rheumatoid arthritis 107 Table 1. Demographic characteristics in 53 patients with rheumatoid arthritis Characteristics User (n = 34) Non-user (n = 19) p-value Age (years) ± ± Sex (female:male) 33:1 16: Marital status (Single:Married:Divorced) 3:25:6 4:13: Income 6,000 Bath/month (%) Employment status (Retired: currently employed) 11:23 8: Educational level (Secondary school or higher: lower) 23:11 9: as percentages. A p-value of < 0.05 was considered clinically significant. Result There were 53 patients (49 females and 4 males), who participated in the study. Their average age was 50.0±10.7 years, and their mean duration of disease was 7.9±6.1 years. Thirty-four patients (64.15%) had used CAM before they received conventional RA treatment at the rheumatology clinic. Details of clinical characteristics among users and nonusers are shown in Table 1. There was no significant difference among users and non-users in age, sex, marital status, employment and income, and educational level. Table 2 shows the form of therapy among users. Massage (with or without herbs) was the most common form of CAM used, and was found in 55.9% of patients. Herbal medicine (both Thai and Chinese) was found in 52.9%. Thirtyfive percent used other forms of therapy, which included taking nutritional supplement in 6 (17.6%), acupuncture in 5 (14.7%), using transcutaneous electrical nerve (TEN) stimulation in 2 (5.9%), a magnetic bed in 1 (2.9%) and body waxing in 1 (2.9%). Fourteen patients (41.2%) had used more than one type of CAM, with an average of 1.9 modalities/ patients. Regarding their belief in the effect of CAM on their RA, 47.1% patients wanted to try it, 29.4% partially believed that would give some benefit, and 20.6% totally believed that CAM was effective. More than half of the patients used CAM on suggestion from their neighbors or relatives (Table 3). Table 2. CAM used in 34 patients with rheumatoid arthritis Type of CAM Number (%) Massage (with or without herbs) 19 (55.9) Oral Thai herbs 10 (29.4) Oral Chinese herbs 8 (23.5) Sauna with herbs 8 (23.5) Others 15 (35.3) Table 3. People who influenced RA patients to use CAM Source Number (%) Neighborhood 20 (58.8) Relatives 9 (26.5) Colleagues 3 (8.8) Medical personal 1 (2.9) Self-study 1 (2.9)

4 108 Sukitawut W, et al. There was no statistically significant difference in disease activity among users and non-users (Table 4). Although joint tenderness seemed to be less in non-user groups, this did not show a statistical significance. After being treated at the rheumatology clinic, 4 patients still used CAM in addition to conventional treatment. They were taking nutritional supplement in 3 cases, and using Thai traditional massage in 1 case. Discussion In this study, we found that 64.15% of our RA patients had used at least one kind of alternative medicine, in addition to conventional medical treatment. Massage (with or without herbs) was the most common form of alternative medicine used, followed by oral herbal medicine. These findings were similar to Rao s study. (5) This study found that there was no significant difference in clinical characteristics, educational background, income, or RA disease activity among CAM users and non-users. These findings were also similar to the results found by Jacobs in the Netherlands. (8) However, Jacobs found that the CAM users had less RA-related complaints than the non-users, although both groups had the same disease activity. He suggested that CAM could not substitute conventional treatment, but it might have some psychological benefits. Unfortunately, we did not evaluate this aspect in our patients. The reason for using CAM in RA patients has not been clearly studied. Many used CAM along with their conventional therapy, (6, 9) although many did not disclose this fact to their physicians. Some patients perceived that their physician would disapprove of CAM use. (9) The lack of a cure for this illness leads to a sense of helplessness in some patients, who then seek forms of treatment. (10-11) Although herbal preparations have been used widely, good clinically controlled studies are limited. (12-13) However, herbal therapy seems to have a low incidence of minor adverse events. In a recent systematic review, only gamma linolenic acid (GLA), which is contained in many seed oils, has shown a medium to moderate effect in reducing pain and tender joint count in RA. (12) Its effect in the ability to stop progression of the disease could not be demonstrated. Table 4. Compare alternative medicine user and non-user User (n = 34) Non-user (n = 19) p-value ACR functional class (I:II:III) 2:29:3 5:13: Duration of disease (years) 7.91 ± ± Joint swelling 9.94 ± ± Joint tenderness ± ± HAQ score 0.62 ± ± VAS score ± ± Data are expressed in mean ± standard deviation

5 CAM in rheumatoid arthritis 109 However, the effect of GLA can be seen only when taker in a high dosage ( gm of GLA/day). Tripterygium wilfodii Hook F (TWH), a herbal plant that grows mainly in South China, has been used for the treatment of joint pain. But this therapy has been associated with gastrointestinal disturbances, skin rashes, leukopenia and thrombocytopenia. (14) A limitation in this study was no analysis of the composition in the herbal medicine that the patients received. If these herbal medicines contained a highdose of corticosteroids, and the patient took them for a long period of time, they might be harmful. In an analysis of 429 samples of so called Thai or Chinese herbal medicine, which patients usually bought from non-physicians or nonpharmacists in their villages in the northern part of Thailand, 108 samples or 25.17% contained corticosteroids. (15) Moreover, some of these Thai or Chinese herbal medicines might contain non-steroid antiinflammatory drugs (NSAIDs), arsenic, and heavy metals that could be dangerous for long-term use. Therefore the chance of our patients receiving corticosteroids from oral Thai or Chinese herbal medicine was high. Long term use of corticosteroids in these patients would be harmful, as they would be risk from the side effects. Therefore, physicians should be aware of the possibility of self-administered corticosteroids in patients who take so called oral Thai or Chinese herbal medicine. Non-oral CAM therapy is also not totally safe. Massage, if improperly used, can be harmful. Stretching and bending joints could aggravate joint subluxation or cause dislocation. This could pose a serious problem if being applied to patients who have cervical spine subluxation. Lastly, those who prefer to use CAM might delay convertional, therapy which could result in progressive joint destruction, and make the condition more difficult to manage. Conclusion CAM use among RA patients was common. There was no single factor that predicted the outcome of CAM use. Clinicians should be aware of these therapies, particularly those with oral treatment, as many of them might contain corticosteroids. Thus, prolonged use of them without medical supervision might be harmful. References 1. Wolfe AM. The epidemiology of rheumatoid arthritis. A review. I. Survey. Bull Rheum Dis 1968;19: Chaimanuay P, Darmawan J, Muirden KD, Assawatanabodee P. Epidemiology of rheumatic disease in rural Thailand: a WHO- ILAR COPCORD study. Community Oriented Programme for the Control of Rheumatic Disease. J Rheumatol 1998;25: American College of Rheumatology. Ad Hoc Committee on Clinical Guidelines. Guide lines for the management of rheumatoid arthritis. Arthritis Rheum 1996;39: BMA. Complementary medicine. New approaches to good practice. United Kingdom: Oxford University Press; Rao JK, Mihaliak K, Kroenke K, Bradley J, Tierney WM, Weinberger M. Use of complementary therapies for arthritis among patients of rheumatologists. Ann Intern Med 1999;131:

6 110 Sukitawut W, et al. 6. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med 1993;328: Kestin M, Miller L, Littlejohn G, et al. The use of unproved remedies for rheumatoid arthritis in Australia. Med J Aust 1985;143: Jacobs JWG, Kraaimaat FW, Bijilsma JW. Why do patients with rheumatoid arthritis use alternative treatments? Clin Rheumatol 2001;20: Visser GJ, Peters L, Rasker JJ. Rheumatologists and their patients who seek alternative care; an agreement to disagree. Br J Rheumatol 1992;31: Wasner CK. The art of unproven remedies. Rheum Dis Clin North Am 1991;17: Kaptchuk TJ, Eisenberg DM. The persuasive appeal of alternative medicine. Ann Intern Med 1998;129: Soeken KL, Miller SA, Ernst E. Herbal medicines for the treatment of rheumatoid arthritis: a systematic review. Rheumatology 2003;42: Little C, Parsons T. Herbal therapy for treating rheumatoid arthritis (Cochrane Review). In: The Cochrane Library, Issue 2, Oxford: Update Software. 14. Tao SL, Ying S, Dong Y, et al. A prospective, controlled, double-blind, cross-over study of Tripterygium wilfordii hook F in treatment of rheumatoid arthritis. Chin Med J 1989;102: Narongchai S. Glucocorticoid abuse. In: Louthrenoo W, Akrapol N, Deesomchok A. editors. Annual meeting of Faculty of Medicine, Chiang Mai University. Chiang Mai, Tanabun Press; p

7 CAM in rheumatoid arthritis 111 การศ กษาการใช การแพทย ทางเล อกในผ ป วยโรคข ออ กเสบร มาตอยด วราพร ส ข ตาว ธ, วท.บ., แรมใจ ว ช ยน นท, วท.บ., น นทนา กส ตานนท, พ.บ., วรว ทย เลาห เรณ, พ.บ. หน วยโรคข อและร มาต สซ ม ภาคว ชาอาย รศาสตร คณะแพทยศาสตร มหาว ทยาล ยเช ยงใหม จ ดประสงค การแพทย ทางเล อกได ถ กน ามาใช ในการผ ป วยท ม อาการทางระบบข อและกล ามเน อ อย างแพร หลาย แต ผลการศ กษาย งไม สามารถสร ปได ช ดเจน การศ กษาน ท าเพ อศ กษาการใช แพทย ทางเล อกในผ ป วยโรคข ออ กเสบร มาตอยด ว ธ การ ได ท าการส มภาษณ ผ ป วยโรคข ออ กเสบร มาตอยด จ านวน 53 รายท ได ร บการด แลท หน วย โรคข อและร มาต สซ ม ภาคว ชาอาย รศาสตร คณะแพทยศาสตร มหาว ทยาล ยเช ยงใหม ระหว าง เด อนมกราคม ถ งเด อนม ถ นายน พ.ศ ถ งการใช การแพทย ทางเล อกและหาความส มพ นธ ระหว างการเล อกใช แพทย ทางเล อกก บความร นแรงของโรค ผลการศ กษา ผ ป วย 34 รายจาก 53 ราย (ร อยละ 64.1) ร บว าเคยใช การแพทย ทางเล อกร วมในการ ร กษามาก อน การแพทย ทางเล อกท ใช บ อยได แก การนวด (ร วมก บการใช สม นไพรหร อไม ใช ) ร อยละ 55.9, ร บประทานสม นไพรไทย ร อยละ 29.4, ร บประทานสม นไพรจ น ร อยละ 23.5, การ อบไอน าร วมก บสม นไพร ร อยละ 23.5 และการร กษาด วยว ธ อ นๆ อ กร อยละ 35.3 พบว าผ ป วย ร อยละ 41 ใช การร กษาด วยแพทย ทางเล อกมากกว า 1 ว ธ (เฉล ย 1.9 ว ธ /ราย) ร อยละ 59 ของผ ป วย ใช การแพทย ทางเล อกตามค าแนะน าของญาต พ น องและเพ อนบ าน เหต ผลในการใช แพทย ทาง เล อกเน องจากอยากลองร อยละ 47.1, เช อว าอาจจะได ผลบ าง ร อยละ 29.4 และเช อม นเต มท ว าจะ ได ผลร อยละ 20.6 ไม พบความแตกต างในอาย เพศ ระยะเวลาการเป นโรค จ านวนข อท ปวดหร อ บวม อาการปวด หร อคะแนนการประเม นส ขภาพ ระด บการศ กษา และเศรษฐฐานะ ระหว างกล ม ท ใช และกล มท ไม ใช สร ป ผ ป วยโรคข ออ กเสบร มาตอยด จ านวนไม น อยม กจะได ร บการร กษาด วยการแพทย ทางเล อก ร วมไปก บการร กษาด วยว ธ ปกต แพทย ควรให ความสนใจในการร กษาเหล าน โดยเฉพาะการร บ ประทานสม นไพรเน องจากสารท ผ ป วยได ร บเหล าน อาจม ยาคอร ต คอร สเต ยรอยด ซ งการใช เป น ระยะเวลานานโดยปราศจากการควบค มของแพทย อาจก อให เก ดอ นตรายได เช ยงใหม เวชสาร 2546;42(3): ค าส าค ญ: การแพทย ทางเล อก สม นไพร การนวด โรคข ออ กเสบร มาตอยด โรคข ออ กเสบ

8 112 Sukitawut W, et al.