alternative medicine is usually defined as medical interventions alternative medicine use by patients with. rheumatologic conditions and highlight …
COMMENTARY
Complementary and Alternative Medicine for Arthritis
Jaya K Rao, MD, MHS
ince the mid-1990s, the prevalence and costs associated with the use of complementary and alternative medicine have attracted the interest of health care organizations, policy makers, providers, and consumers Complementary and alternative medicine is usually defined as medical interventions that are neither taught widely in US medical schools nor generally available in US hospitals1 and includes modalities such as herbal medicine, spiritual healing, and aromatherapy It is important to remember, however, that with data from efficacy studies complementary and alternative medicine treatments have the potential to become part of mainstream medicine For example, digitalis and colchicine were once considered alternative but are now prescribed by mainstream practitioners In this commentary, I will briefly review the epidemiology of complementary and alternative medicine use by patients with rheumatologic
conditions and highlight recent data on selected complementary and alternative medicine treatments for arthritis
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for adverse interactions with prescribed treatments Complementary and alternative medicine use is particularly common among people with musculoskeletal disorders1,3 Population- and clinic-based data indicate that 28 to 90 of people with arthritis and other rheumatologic conditions use complementary and alternative medicine4-8 Studies of patients with specific rheumatologic conditions eg, fibromyalgia, osteoarthritis, systemic lupus erythematosus demonstrate a similar degree of use In general, people with a higher educational
Epidemiology
It is well documented that people with chronic conditions use complementary and alternative medicine to treat their symptoms Depending on the study population and how it is defined, the estimated prevalence of complementary and alternative medicine use by Americans ranges from 33 to 901-5 In a landmark study, Eisenberg and colleagues
reported that 33 of Americans used an alternative therapy in 19901 By 1997 the percentage of Americans reporting complementary and alternative medicine use increased to 42, and 46 reported visiting a complementary and alternative medicine practitioner2 While most individuals use complementary and alternative medicine to supplement conventionally-prescribed treatment, many do so without informing their doctor,1,2,6 raising concerns about the potential
While most individuals use complementary and alternative medicine to supplement conventionally-prescribed treatment, many do so without informing their doctor, raising concerns about the potential for adverse interactions with prescribed treatments
level, a longer duration of disease, poorer functional status, and higher levels of pain are more likely to use complementary and alternative medicine4,7 Data also indicate that use and the specific types used varies by race and ethnicity9,10
Data From North Carolina
Population-based data
document a geographic variation in complementary and alternative medicine use with higher rates
Jaya K Rao, MD, MHS, is an adjunct clinical associate professor of medicine in the Division of Rheumatology at Emory University School of Medicine She can be reached at jkrao@mindspringcom or Emory University School of Medicine, Division of Rheumatology, 49 Jesse Hill Jr Drive SE, Atlanta, GA 30303
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reported by residents of the western United States1,3 While the variation in rates may relate to the definition of complementary and alternative medicine used in the survey, it is also important to note, however, that complementary and alternative medicine use is not uncommon in the South3 Data from studies of North Carolina residents underscore this point In a study of 1059 adult residents of western North Carolina, nearly one-half 458 reported using complementary and alternative medicine to treat their chronic conditions11 Although
its use was not associated with the number of chronic conditions or health care utilization, people with less education were more likely to use honey-lemon-vinegar-whiskey combinations while people with greater education were more likely to have visited a complementary and alternative medicine practitioner In a study of 211 rural community-dwelling adults with arthritis, Arcury and colleagues reported that complementary and alternative medicine use was common and they found differences in the types used based on race and ethnicity African Americans were more likely to rely on prayer and topical treatments eg, liniments, turpentine than European Americans9 Finally, in a study of 752 arthritis patients who were seen in 16 primary practices in rural and urban North Carolina, 89 reported using at least one complementary and alternative medicine5 Interestingly, 71 of those who used at least one treatment discussed this behavior with the physician5 Given the widespread interest in
complementary and alternative medicine, it is not surprising that medical universities have developed integrative medicine programs Three medical universities in North Carolina Duke University, the University of North Carolina at Chapel Hill, and Wake Forest University have established such programs to provide selected forms of complementary and alternative medicine treatment to patients and to conduct research
Recent Data on Selected Complementary and Alternative Medicine Treatments for Arthritis
Complementary and alternative medicine is big business in the United States Since the passage of the Dietary Supplemental Health and Education Act of 1994, dietary supplements and herbal products have become widely available In 1997 an estimated 165 million adults 184 of all prescription users used herbal medicines along with conventionally prescribed medications, and they spent 51 billion dollars out-of-pocket on these remedies2 Furthermore, they made 629 million visits to alternative
practitioners, far exceeding the total number of visits made to primary care providers in 19972 An extensive review of complementary and alternative medicine therapies is beyond the scope of this commentary Instead, I will highlight data on 2 treatments used for arthritis symptoms that have been the focus of recent investigation: glucosamine/chondroitin sulfate and acupuncture Since the 1980s glucosamine and chondroitin have been used to treat osteoarthritis, primarily in European countries12
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Notably, in Europe and other countries, glucosamine sulfate is approved as a prescription treatment for osteoarthritis13 Glucosamine is a precursor to the glycosaminoglycan molecule, and chondroitin is the most abundant glycosaminoglycan found in cartilage13 Short-term 4 to 6 week controlled trials indicate that patients treated with glucosamine experience modest improvements in pain and function compared to those receiving placebo14 and experience treatment effects comparable to nonsteroidal
anti-inflammatory drugs15 Two recent meta-analyses that examined randomized trials of glucosamine and chondroitin report mixed conclusions regarding efficacy which may relate to the specific formulations of glucosamine used in the trials, methodologic concerns, and industry bias12,16 A large multicenter trial was designed to address some of these concerns: patients with symptomatic knee osteoarthritis were randomized to glucosamine, chondroitin, glucosamine plus chondroitin, celecoxib, or placebo treatment for 24 weeks17 Patients who were treated with glucosamine and chondroitin sulfate alone or in combination did not experience a significant improvement in pain compared to controls17 Unfortunately, this trial involved treatment with glucosamine hydrochloride, a formulation that other investigators have concluded is not effective compared to the glucosamine sulfate formulation16,18 At this time, patients who are considering using glucosamine for their osteoarthritis symptoms should be
advised to take glucosamine sulfate rather than glucosamine hydrochloride, and those with severe pain might consider adding chondroitin sulfate to this regimen18 Acupuncture is an important modality in traditional Chinese medicine that involves the transcutaneous placement of needles, sometimes with ancillary electrical current, heat, or moxibustion ie, incense burning, to specific sites in order to restore the persons balance of vital energy also known as qi or chi19 Acupuncture, which is often used for pain relief, has been the focus of several recent trials These trials have highlighted the methodological dilemma of finding an appropriate comparison to acupuncture Sham acupuncture may stimulate pain inhibitory fibers or endorphin release while positive comparisons to a wait list control may be due to treatment expectations or placebo effects20 Witt and colleagues reported significant improvements in outcome among those who received acupuncture compared to a wait-list control group21
These investigators also performed a 3-arm randomized trial in which one group received sham acupuncture22 Compared to the sham acupuncture or wait-list control groups, the group who received acupuncture experienced significant improvements in pain and function immediately after receiving the entire intervention 12 acupuncture sessions over 8 weeks, but these improvements declined over time22 Another study reported significant improvements in outcome when the acupuncture and sham acupuncture groups were compared to a wait list control group, but no differences when the acupuncture group was compared to the sham acupuncture group23 Given the heterogeneity of study findings and clinically minimal effects when acupuncture is compared to sham therapy, a recent meta-analysis concluded that it is premature to
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recommend this treatment as part of routine care for knee osteoarthritis and suggested that clinicians and patients might
consider acupuncture as one option in a multidisciplinary treatment approach20
Managing Patients Who Also Use Complementary and Alternative Medicine
Regardless of their particular beliefs about complementary and alternative medicine, physicians have an ethical obligation to discuss treatment alternatives with their patients Although physicians should acknowledge their level of knowledge regarding complementary and alternative medicine during these discussions, they should also make sure that the patient has received information about the safety eg, potency, drug interactions and efficacy of these treatments24 Because patients complementary and alternative medicine usage may change over time,25 physicians should periodically review their patients current regimens Since most alternative therapies are unproven, physicians may have legal concerns when they are asked to recommend specific complementary and alternative medicine treatments, provide referrals to practitioners, or tolerate
continued use of these therapies As a general rule, the mere referral to a complementary and alternative medicine practitioner does not expose the referring physician to liability unless the referral itself deprives the patient of receiving appropriate care ie, referral delays or eliminates an opportunity to receive important care26 On the other hand, the physician could be held liable if he or she
recommends a complementary and alternative medicine that is associated with serious risks or is known to be ineffective27 Thus, when recommending specific complementary and alternative medicine, physicians should review the literature to determine the level of risk for the treatment, discuss the potential risks and benefits with the patient, document this discussion, and continue to monitor the patient conventionally27 When referring patients to complementary and alternative medicine practitioners, physicians should also inquire about the practitioners credentials, competence, and
practices27
Final Thoughts
People with rheumatologic conditions often use complementary and alternative medicine to treat their symptoms To date, epidemiologic studies have focused on describing patients use of complementary and alternative medicine and identifying predictors of this behavior Given that many patients do not discuss their use of complementary and alternative medicine with their physicians, future investigations might focus on developing methods such as office-based tools to facilitate patient-provider communication regarding complementary and alternative medicine Furthermore, complementary and alternative medicine is an evolving field as results emerge from efficacy studies of specific treatments Clinicians should keep abreast of the findings of these trials because these data will be helpful in managing and advising patients who use such therapies NCMJ
REFERENCES
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United States: prevalence, costs, and patterns of use New Engl J Med 1993;3284:246-252 2 Eisenberg DM, Davis RB, Ettner SL, et al Trends in alternative medicine use in the United States, 1990-1997: Results from a national survey JAMA 1998;28018:1569-1575 3 Barnes PM, Powell-Griner E, McFann K, Nahin RL Complementary and Alternative Medicine Use Among Adults: United States, 2002 Hyattsville, MD: National Center for Health Statistics; 2004:343 4 Quandt SA, Chen H, Gryzywacz JG, Bell RA, Lang W, Arcury TA Use of complementary and alternative medicine by persons with arthritis: results of the National Health Interview Survey Arthr Rheum [Arthr Care Res] 2005;535:748-755 5 Sleath B, Callahan L, DeVellis RF, Sloane PD Patients perceptions of primary care physicians participatory decision-making style and communication about complementary and alternative medicine for arthritis J Complement Alt Med 2005;113:449-453 6 Saydah SH, Eberhardt MS Use of complementary and alternative medicine among
adults with chronic disease: United States, 2002 J Complement Alt Med 2006;128:805-812 7 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;1316:409-416 8 Kaboli PJ, Doebbeling BN, Saag KG, Rosenthal GE Use of complementary and alternative medicine by older patients with arthritis: a population-based study Arthr Rheum Aug 2001;454:398-403 9 Arcury TA, Bernard SL, Jordan JM, Cook HL Gender and ethnic differences in alternative and conventional arthritis remedy use among community dwelling rural adults with arthritis Arthr Care Res 1996;95:384-390 10 Katz P Lee F Race/ethnic differences in the use of complementary , and alternative medicine in patients with arthritis J Clin Rheumatol 2007;131:3-11 11 Arcury TA, Preisser JS, Gesler WM, Sherman JE Complementary and alternative medicine use among rural residents in Western North Carolina Complement Health Pract Rev
2004;92:93-102 12 McAlindon TE, LaValley MP, Gulin JP, Felson DT Glucosamine and chondroitin for the treatment of osteoarthritis: A systematic quality assessment and meta-analysis JAMA 2000;28311:1469-1475 13 Reginster JY, Deroisy R, Rovato LC, et al Long-term effects of glucosamine sulfate on osteoarthritis progression: a randomised, placebo-controlled clinical trial Lancet 2001;3579252:251-256 14 Noack W, Fischer M, Forster KK, et al Glucosamine sulfate in osteoarthritis of the knee Osteoarthr Cart 1994;21:51 15 Mueller-FasBender H, Bach GL, Haase W, et al Glucosamine sulfate compared to ibuprofen in osteoarthritis of the knee Osteoarthr Cart 1994;21:61
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16 Vlad SC, LaValley MP, McAlindon TE, Felson DT Glucosamine for pain in osteoarthritis: why do the trial results differ? Arthr Rheum 2007;567:2267-2277 17 Clegg DO, Reda DJ, Harris CL, et al Glucosamin, chondroitin sulfate, and the two in combination for painful knee
osteoarthritis New Engl J Med 2006;3548:795-808 18 Hochberg MC Nutritional supplements for knee osteoarthritis –still no resolution New Engl J Med 2006;3548:858-860 19 Kaptchuk TJ Acupuncture: theory, efficacy, practice Ann Intern Med 2002;1365:374-383 20 Manheimer E, Linde K, Lao L, Bouter L, Berman BM Meta-analysis: acupuncture for osteoarthritis of the knee Ann Intern Med 2007;14612:868-877 21 Witt CM, Jena S, Brinkhaus B, Liecker B, Wegsheider K, Willich SN Acupuncture in patients with osteoarthritis of the knee and hip: a randomized, controlled trial with an additional non-randomized arm Arthr Rheum 2006;5411:3485-3493
22 Witt C, Brinkhaus B, Jena S, et al Acupuncture in patients with osteoarthritis of the knee: a randomised trial Lancet 2005;3669480:136-143 23 Scharf HP, Mansmann U, Streitberger K, et al Acupuncture and knee osteoarthritis: a three-arm randomized trial Ann Intern Med 2006;1451:12-20 24 Sugarman J, Burk L Physicians ethical obligations regarding alternative
medicine JAMA 1998;28018:1623-1625 25 Rao JK, Kroenke K, Mihaliak KA, Grambow S, Weinberger M Rheumatology patients use of complementary therapies: Results from a one-year longitudinal study Arthr Care Res 2003;495:619-623 26 Studdert DM, Eisenberg DM, Miller FH, Curto DA, Kaptchuk TJ, Brennan TA Medical malpractice implications of alternative medicine JAMA 1998;28018:1610-1615 27 Cohen MH, Eisenberg DM Potential physician malpractice liability associated with complementary and integrative therapies Ann Intern Med 2002;1368:596-603
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