Putative analgesic activity of repeated oral doses of vitamin E in the treatment of rheumatoid arthritis. Results of a prospective placebo controlled double blind trial

Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases

BACKGROUND

Animal and physiological research as well as observational studies suggest that antioxidant supplements may improve survival.

OBJECTIVES

To assess the effect of antioxidant supplements on mortality in primary or secondary prevention randomised clinical trials.

SEARCH STRATEGY

We searched The Cochrane Library (Issue 3, 2005), MEDLINE (1966 to October 2005), EMBASE (1985 to October 2005), and the Science Citation Index Expanded (1945 to October 2005). We scanned bibliographies of relevant publications and wrote to pharmaceutical companies for additional trials.

SELECTION CRITERIA

We included all primary and secondary prevention randomised clinical trials on antioxidant supplements (beta-carotene, vitamin A, vitamin C, vitamin E, and selenium) versus placebo or no intervention. Included participants were either healthy (primary prevention trials) or had any disease (secondary prevention trials).

DATA COLLECTION AND ANALYSIS

Three authors extracted data. Trials with adequate randomisation, blinding, and follow-up were classified as having a low risk of bias. Random-effects and fixed-effect meta-analyses were performed. Random-effects meta-regression analyses were performed to assess sources of intertrial heterogeneity.

MAIN RESULTS

Sixty-seven randomised trials with 232,550 participants were included. Forty-seven trials including 180,938 participants had low risk of bias. Twenty-one trials included 164,439 healthy participants. Forty-six trials included 68111 participants with various diseases (gastrointestinal, cardiovascular, neurological, ocular, dermatological, rheumatoid, renal, endocrinological, or unspecified). Overall, the antioxidant supplements had no significant effect on mortality in a random-effects meta-analysis (relative risk [RR] 1.02, 95% confidence interval [CI] 0.99 to 1.06), but significantly increased mortality in a fixed-effect model (RR 1.04, 95% CI 1.02 to 1.06). In meta-regression analysis, the risk of bias and type of antioxidant supplement were the only significant predictors of intertrial heterogeneity. In the trials with a low risk of bias, the antioxidant supplements significantly increased mortality (RR 1.05, 95% CI 1.02 to 1.08). When the different antioxidants were assessed separately, analyses including trials with a low risk of bias and excluding selenium trials found significantly increased mortality by vitamin A (RR 1.16, 95% CI 1.10 to 1.24), beta-carotene (RR 1.07, 95% CI 1.02 to 1.11), and vitamin E (RR 1.04, 95% CI 1.01 to 1.07), but no significant detrimental effect of vitamin C (RR 1.06, 95% CI 0.94 to 1.20). Low-bias risk trials on selenium found no significant effect on mortality (RR 0.91, 95% CI 0.76 to 1.09).

AUTHORS' CONCLUSIONS

We found no evidence to support antioxidant supplements for primary or secondary prevention. Vitamin A, beta-carotene, and vitamin E may increase mortality. Future randomised trials could evaluate the potential effects of vitamin C and selenium for primary and secondary prevention. Such trials should be closely monitored for potential harmful effects. Antioxidant supplements need to be considered medicinal products and should undergo sufficient evaluation before marketing.

Antioxidant intervention in rheumatoid arthritis: results of an open pilot study

There is evidence that reactive oxygen species play a causal role in auto-immune diseases, such as rheumatoid arthritis (RA). Despite the supporting evidence for a beneficial effect of antioxidants on clinical characteristics of RA, the right balance for optimal effectiveness of antioxidants is largely unknown. To determine the potential beneficial effects of an antioxidant intervention on clinical parameters for RA, an open pilot study was designed. Eight non-smoking female patients with rheumatoid factor + RA and a Disease Activity Score (DAS 28) higher than 2.5 were enrolled in the study. Patients had to be receiving stable non-steroidal anti-inflammatory drug treatment and/or 'second line' medication for at least 3 months. The pilot group consumed 20 g of antioxidant-enriched spread daily during a period of 10 weeks. The intervention was stopped after 10 weeks and was followed by a 'wash-out' period of 4 weeks. At t = 0, t = 10 weeks and t = 14 weeks, patients' condition was assessed by means of DAS. In addition, standard laboratory analyses were performed, and blood-samples for antioxidants were taken. The antioxidant-enriched spread was well tolerated. All laboratory measures of inflammatory activity and oxidative modification were generally unchanged. However, the number of swollen and painful joints were significantly decreased and general health significantly increased, as reflected by a significantly improved (1.6) DAS at t = 10 weeks. The antioxidant effect was considered beneficial as, compared to the scores at t = 0, the DAS significantly reduced at t = 10 weeks. Increase of the DAS (0.7) after the "wash-out period" at t = 14 confirmed a causal relation between changes in clinical condition and antioxidants. This open pilot study aimed to assess the clinical relevance of an antioxidant intervention as a first step in assessing potential beneficial effects of antioxidants on rheumatoid arthritis. These conclusions need to be validated in a larger controlled study population.

Effect of allopurinol and vitamin e on rat model of rheumatoid arthritis

OBJECTIVES

Rat collagen II-induced arthritis is a model of chronic inflammation induced by mycobacterium butyricum and collagen II. It is characterized by similar pathophysiological and pathobiochemical changes as rheumatoid arthritis (RA) in humans. In the present study, the biochemical effects of vitamin E and allopurinol (Allo) on RA of rats were investigated.

METHODS

Forty male rats were divided into four groups (10 rats each): control group, collagen II-induced RA group (CII group), CII group treated with allopurinol (CII+ Allo), and CII group treated with vitamin E (CII + Vit E). After 6 weeks of treatment, the plasma levels of lipid peroxides (LPO), nitric oxide (NO), ceruloplasmin (CP), superoxide dismutase (SOD), uric acid (UA) and glutathione (GSH) were detected using colorimetric methods. The plasma levels of PGE2 were measured using ELISA assay. The plasma levels of copper (Cu) and zinc (Zn) were determined using atomic absorption spectrometer.

RESULTS

In CII treated group, the levels of LPO, NO, PGE2, UA, CP and Cu were significantly higher, but the levels of SOD, GSH and Zn were significantly lower than controls. In CII + Allo treated group, the levels of SOD and GSH were significantly increased, but the levels of PGE2, LPO, NO, UA, Cu and CP were significantly decreased in comparison with CII-treated group. The levels of SOD, GSH and Zn were significantly increased, but the levels of PGE2, NO and CP were significantly decreased in the vitamin E treated group in comparison with CII-treated group. The levels of PGE2, LPO, Cu and Zn were significantly lower in vitamin E treated group than Allo-treated group. In conclusion, the study suggests that proper antioxidant intake management may reduce free radical generation and improve antioxidant status in RA. Allopurinol and vitamins E may effectively normalize in different degrees the impaired the oxidant/antioxidant system and may be useful in delaying the complication of RA. Moreover, they display anti-inflammatory action by decreasing PGE2 level in RA.

Rheumatoid arthritis: the role of reactive oxygen species in disease development and therapeutic strategies

Autoimmune diseases such as rheumatoid arthritis (RA) are chronic diseases that cannot be prevented or cured If the pathologic basis of such disease would be known, it might be easier to develop new drugs interfering with critical pathway. Genetic analysis of animal models for autoimmune diseases can result in discovery of proteins and pathways that play key function in pathogenesis, which may provide rationales for new therapeutic strategies. Currently, only the MHC class II is clearly associated with human RA and animal models for RA. However, recent data from rats and mice with a polymorphism in Ncf1, a member of the NADPH oxidase complex, indicate a role for oxidative burst in protection from arthritis. Oxidative burst-activating substances can treat and prevent arthritis in rats, as efficiently as clinically applied drugs, suggesting a novel pathway to a therapeutic target in human RA. Here, the authors discuss the role of oxygen radicals in regulating the immune system and autoimmune disease. It is proposed that reactive oxygen species set the threshold for T cell activation and thereby regulate chronic autoimmune inflammatory diseases like RA. In the light of this new hypothesis, new possibilities for preventive and therapeutic treatment of chronic inflammatory diseases are discussed.

Inhibition of monosodium urate monohydrate-mediated hemolysis by vitamin E

Microcrystals of monosodium urate monohydrate (MSUM) induce cytolysis and hemolysis in erythrocytes. In this report, we studied the effect of vitamin E on MSUM-mediated hemolysis in human erythrocytes. Vitamin E significantly inhibited hemolysis induced by MSUM. The hydroxyl group in the chromanol ring of vitamin E is dispensable for protecting erythrocytes against hemolysis induced by MSUM, indicating that the inhibitory effect of vitamin E is not due to its antioxidant properties. However, both the chromanol ring and the isoprenoid side chain are important for vitamin E to suppress MSUM-induced hemolysis. Our current study suggests that vitamin E inhibits hemolysis induced by MSUM as a membrane stabilizer.

Nutrition and Osteoarthritis in Dogs: Does It Help?

Osteoarthritis (OA) is a common disease, and nutrition has become an integral part of management. This article focuses on the role and dietary ingredients in OA, evaluating current evidence for obesity management, omega-3 fatty acids, and chondromodulating agents. Additionally, keeping an animal in optimal to slightly lean body condition has been shown to decrease the risk of development of OA and to aid management of dogs with OA.

Alpha-lipoic acid suppresses the development of collagen-induced arthritis and protects against bone destruction in mice

OBJECTIVE

To test the ability of alpha-lipoic acid (LA) to attenuate the development of collagen-induced arthritis (CIA) in mice.

METHODS

Mice were divided into three groups and treated with intraperitoneal administration of LA (10 or 100 mg/kg) or placebo. Clinical, histologic, and biochemical parameters were assessed. Human synovial fibroblasts and peripheral blood mononuclear cells were cocultured in various concentrations of LA to evaluate the effects on osteoclastogenesis.

RESULTS

LA was associated with a dose-dependent reduction of CIA, as well as preventing bone erosion and destructive changes. Intracellular reactive oxygen species in lymphocytes obtained from inguinal lymph nodes, which was significantly higher in CIA than control mice, was significantly reduced in CIA by LA. The concentrations of TNF-alpha, IL-1beta, and IL-6 in the paws, and synovial NF-kappaB binding, all of which were markedly higher in CIA than control mice, were reduced by treatment with LA. In addition, LA inhibited the formation of human osteoclasts in vitro.

CONCLUSION

Amelioration of joint disease by LA was associated with reduction in oxidative stress, as well as inhibition of inflammatory cytokine activation and NF-kappaB DNA binding activity. Moreover, LA inhibited bone destruction in vivo and osteoclastogenesis in vitro. Collectively, these results indicate that LA may be a new adjunctive therapy for rheumatoid arthritis.

Diet and rheumatoid arthritis: a review of the literature

INTRODUCTION

Rheumatoid arthritis is a common inflammatory condition. A large number of patients seek alternative or complementary therapies of which diet is an important component. This article reviews the evidence for diet in rheumatoid arthritis along with the associated concept of oral tolerization.

METHODS

References were taken from Medline from 1966 to September 2004. The keywords, rheumatoid arthritis, diet, n-3 fatty acids, vitamins, and oral tolerization, were used.

RESULTS

Randomized controlled trials (RCTs) indicate that dietary supplementation with n-3 fatty acids provides modest symptomatic benefit in groups of patients with rheumatoid arthritis. Epidemiological studies and RCTs show cardiovascular benefits in the broader population and patients with ischemic heart disease. A number of mechanisms through which n-3 fats may reduce inflammation have been identified. In a small number of patients with rheumatoid arthritis, other dietary manipulation such as fasting, vegan, and elimination diets may have some benefit. However, many of these diets are impractical or difficult to sustain long term.

CONCLUSIONS

Dietary manipulation provides a means by which patients can a regain a sense of control over their disease. Dietary n-3 supplementation is practical and can be easily achieved with encapsulated or, less expensively, bottled fish oil.

Oxidative stress and nutritional prevention in autoimmune rheumatic diseases

The hypothesis that oxidative stress favours flogistic and immune processes inducing autoimmune rheumatic diseases (ARDs) and their complications is still under discussion. In this review we take into consideration both the aetiopathological role of the diet in such diseases and the possible efficacy of dietary supports as adjuvants for the usual specific therapies. Moreover, we shall examine the hypothetical pathophysiological role of oxidative stress on ARDs and their complications, the methods for its evaluation and the possibility of intervening on oxidative pathways by means of nutritional modulation. It is possible that in the future we will be able to control connective pathology by associating an immuno-modulating therapy ('re-educating') with natural products having an anti-oxidant activity to current immunosuppressive treatment (which has potentially toxic effects).

Oxidation in rheumatoid arthritis

Oxygen metabolism has an important role in the pathogenesis of rheumatoid arthritis. Reactive oxygen species (ROS) produced in the course of cellular oxidative phosphorylation, and by activated phagocytic cells during oxidative bursts, exceed the physiological buffering capacity and result in oxidative stress. The excessive production of ROS can damage protein, lipids, nucleic acids, and matrix components. They also serve as important intracellular signaling molecules that amplify the synovial inflammatory-proliferative response. Repetitive cycles of hypoxia and reoxygenation associated with changes in synovial perfusion are postulated to activate hypoxia-inducible factor-1alpha and nuclear factor-kappaB, two key transcription factors that are regulated by changes in cellular oxygenation and cytokine stimulation, and that in turn orchestrate the expression of a spectrum of genes critical to the persistence of synovitis. An understanding of the complex interactions involved in these pathways might allow the development of novel therapeutic strategies for rheumatoid arthritis.

Antioxidant status in rheumatoid arthritis and role of antioxidant therapy

BACKGROUND

Oxygen free radicals have been implicated as mediators of tissue damage in patients of rheumatoid arthritis (RA). This study was designed to elucidate plasma oxidant/antioxidant status in rheumatoid arthritis, with the aim of evaluating the importance of antioxidant therapy in the management of this disease.

METHODS

The study included 40 patients of rheumatoid arthritis who were randomly divided into two subgroups of 20 each. One group received conventional treatment for 12 weeks and in the other group conventional treatment was supplemented with antioxidants for the same duration. Twenty age- and sex-matched normal individuals constituted the control group. Blood samples of controls and patients were collected at the time of presentation and analyzed for total thiols, glutathione, vitamin C and malondialdehyde (MDA-marker of oxidative stress). The investigations were repeated in the patients after 12 weeks.

RESULTS

The blood concentrations of total thiols, glutathione and vitamin C were found to be significantly lower in rheumatoid arthritis patients as compared to healthy controls, while the concentrations of MDA were much higher. There was a statistically significant increase in the posttreatment concentrations of these antioxidants, along with a decrease in the concentrations of MDA.

CONCLUSIONS

The antioxidant defense system is compromised in rheumatoid arthritis patients. There is a shift in the oxidant/antioxidant balance in favor of lipid peroxidation, which could lead to the tissue damage observed in the disease. The results suggest the necessity for therapeutic co-administration of antioxidants along with conventional drugs to such patients. However, due to the limited number of cases included in this study, more studies may be required to substantiate the results and arrive at a definite conclusion, in terms of safety and efficacy of adding on antioxidant therapy for the treatment of RA.

Nutrient supplementation with polyunsaturated fatty acids and micronutrients in rheumatoid arthritis: clinical and biochemical effects

OBJECTIVE

To investigate in a double-blind placebo-controlled, parallel group study, the effects of a nutrient supplement, containing, among other ingredients, the omega-3 fatty acids eicosapentaenoic acid (1.4 g EPA), docosahexaenoic acid (0.211 g DHA), omega-6 fatty acid gamma-linolenic acid (0.5 g GLA) and micronutrients in patients with active rheumatoid arthritis (RA).

DESIGN, SUBJECTS AND INTERVENTION

RA patients were randomized to receive either daily liquid nutrient supplementation or placebo for 4 months. The primary end point was the change in tender joint count at 2 and 4 months. Other clinical variables included swollen joint count, visual analogue scales for pain and disease activity, grip strength, functionality score and morning stiffness. Biochemical parameters included plasma concentrations of PUFA and vitamins C and E.

SETTING

Outpatient university clinic.

RESULTS

In all, 66 patients enrolled, 55 completed the study. No significant change from baseline in tender joint count or any of the other clinical parameters was detected in either group. Patients receiving nutrient supplementation, but not those receiving placebo, had significant increases in plasma concentrations of vitamin E (P=0.015), and EPA, DHA and docosapentaenoic acid concomitant with decreases of arachidonic acid (P=0.01). Intergroup differences for PUFA and vitamin E were significantly different (P=0.01 and 0.03, respectively).

CONCLUSIONS

This double-blind, placebo-controlled study in RA patients did not show superior clinical benefit of daily nutrient supplementation with EPA, GLA and micronutrients at the doses tested as compared to placebo. The study adds information regarding doses of omega-3 fatty acids, below which anti-inflammatory effects in RA are not seen.

Inadequate antioxidant nutrient intake and altered plasma antioxidant status of rheumatoid arthritis patients

OBJECTIVE

Elevated free radical generation in inflamed joints and impaired antioxidant system have been implicated in rheumatoid arthritis (RA). The present study was performed to evaluate dietary nutrient intake and plasma oxidant/antioxidant status in RA patients.

METHODS

RA patients (n = 97) and their age, gender-matched controls (n = 97) participated in this cross-sectional case-control study. Nutrient intake was estimated using a semi-quantitative food frequency questionnaire. Twenty subjects from each group provided blood samples, and plasma concentrations of alpha-tocopherol and malondiadehyde (MDA) were measured. Also, plasma activities of superoxide dismutase (SOD) and glutathione peroxidase (GPx) were measured.

RESULTS

The mean calorie intake of RA patients was lower than that of the healthy controls. Energy-adjusted intake of fat, vitamin A and beta-carotene were significantly lower in patients than those of the control subjects. RA patients had a decreased mean plasma alpha-tocopherol level. The activity of plasma SOD and GPx in patients was significantly lower than that in control subjects.

CONCLUSION

These results suggest proper antioxidant nutrient intake management may reduce free radical generation and improve antioxidant status in RA patients.

Antioxidant intake, plasma antioxidants and oxidative stress in a randomized, controlled, parallel, Mediterranean dietary intervention study on patients with rheumatoid arthritis

BACKGROUND

Previously we have reported that patients with rheumatoid arthritis (RA) obtained a significant reduction in disease activity by adopting a Mediterranean-type diet. The present study was carried out to investigate the antioxidant intake, the plasma levels of antioxidants and a marker of oxidative stress (malondialdehyde) during the study presented earlier.

METHODS

RA patients randomized to either a Mediterranean type diet (MD group; n = 26) or a control diet (CD group; n = 25) were compared during a three month dietary intervention study. Their antioxidant intake was assessed by means of diet history interviews and their intake of antioxidant-rich foods by a self-administered questionnaire. The plasma levels of retinol, antioxidants (alpha- and gamma-tocopherol, beta-carotene, lycopene, vitamin C and uric acid) and urinary malondialdehyde (MDA), a marker for oxidative stress, were determined using high performance liquid chromatography. The Student's t-test for independent samples and paired samples were used to test differences between and within groups. For variables with skewed distributions Mann-Whitney U-test and Wilcoxon signed ranks test were performed. To evaluate associations between dietary intake of antioxidants, as well as between disease activity, MDA and antioxidants we used Pearson's product moment correlation or Spearman's rank correlation.

RESULTS

The MD group had significantly higher intake frequencies of antioxidant-rich foods, and also higher intakes of vitamin C (p = 0.014), vitamin E (p = 0.007) and selenium (p = 0.004), and a lower intake of retinol (p = 0.049), compared to the CD group. However, the difference between the groups regarding vitamin C intake was not significant when under- and over-reporters were excluded (p = 0.066). There were no changes in urine MDA or in the plasma levels of antioxidants (after p-lipid adjustments of the tocopherol results), from baseline to the end of the study. The levels of retinol, vitamin C and uric acid were negatively correlated to disease activity variables. No correlation was found between antioxidant intake and the plasma levels of antioxidants.

CONCLUSIONS

Despite an increase in reported consumption of antioxidant-rich foods during the Mediterranean diet intervention, the levels of plasma antioxidants and urine MDA did not change. However, the plasma levels of vitamin C, retinol and uric acid were inversely correlated to variables related to RA disease activity.

Nutritional management of rheumatoid arthritis: a review of the evidence

Rheumatoid arthritis (RA) is a debilitating disease and is associated with increased risk of cardiovascular disease and osteoporosis. Poor nutrient status in RA patients has been reported and some drug therapies, such as nonsteroidal anti-inflammatory drugs (NSAIDs), prescribed to alleviate RA symptoms, may increase the requirement for some nutrients and reduce their absorption. This paper reviews the scientific evidence for the role of diet and nutrient supplementation in the management of RA, by alleviating symptoms, decreasing progression of the disease or by reducing the reliance on, or combating the side-effects of, NSAIDs. Supplementation with long-chain n-3 polyunsaturated fatty acids (PUFA) consistently demonstrates an improvement in symptoms and a reduction in NSAID usage. Evidence relating to other fatty acids, antioxidants, zinc, iron, folate, other B vitamins, calcium, vitamin D and fluoride are also considered. The present evidence suggests that RA patients should consume a balanced diet rich in long-chain n-3 PUFA and antioxidants. More randomized long-term studies are needed to provide evidence for the benefits of specific nutritional supplementation and to determine optimum intake, particularly for n-3 PUFA and antioxidants.

The role of complementary and alternative therapies in managing rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic, inflammatory autoimmune disease that is characterized by joint stiffness in the morning, symmetric joint swelling, and generalized fatigue. Given the limitations of medical treatment and the ongoing problems with symptom management, it is not at all surprising that many individuals with RA turn to complementary and alternative medicine (CAM) therapies. This article provides a brief overview of what is known about CAM use in RA, presents information on a few of the most popular therapies, and recommends further resources for nurses who work with individuals with RA.

Effects of dietary omega3 and omega6 lipids and vitamin E on chemokine levels in autoimmune-prone MRL/MpJ-lpr/lpr mice

Elevated levels of chemokines, such as Regulated upon Activation, Normal T cell Expressed and Secreted (RANTES), Monocyte Chemotactic Protein-1 (MCP-1), Macrophage Inflammatory Protein-1alpha (MIP-1alpha), and Macrophage Inflammatory Protein-1beta (MIP-1beta) have been found in rheumatoid arthritis (RA) and juvenile arthritis (JA), and they may be associated with the pathogenesis of these diseases. These chemokines are implicated in the migration of specific leukocytes into the joints. Omega-3 (omega3) fatty acid rich-fish oil (FO) and vitamin E may delay the progress of certain autoimmune diseases. The present study was designed to understand the effects of dietary lipids (omega-6 and omega-3 fatty acids) and vitamin E on the production of chemokines in autoimmune-prone MRL/lpr (a mouse model for RA) and congenic control MRL/++ mice. The MRL mice were fed for 4.5 months omega-6 and omega-3 diets that varied in lipid sources (corn oil; CO and fish oil; FO) and vitamin E levels (269 I.U./kg and 694 I.U./kg diet). Spleen cells were isolated and cultured aseptically in the presence of PHA for 48 h at 37 degrees C and the levels of chemokines (RANTES, JE/MCP-1 and MIP-1alpha) were determined in the cell-free supernatants. The levels of RANTES and JE/MCP-1 were significantly higher in MRL/lpr mice compared to MRL/++ mice. The FO had differential effect on RANTES and MCP-1 production by spleen cells. The production of RANTES and JE/MCP-1 by spleen cells in mice fed the FO diets was significantly lower than in mice fed the CO diets (p < 0.0001). The levels of vitamin E did not affect the production of RANTES and JE/MCP-1. The levels of vitamin E had a significant effect on MIP-1alpha as the spleen cells of mice fed diets containing 694 IU/kg diet of vitamin E produced significantly higher levels of MIP-1alpha compared to the group of mice fed the diets containing 269 IU of vitamin E (p < 0.0001). The data obtained from this study in MRL/lpr and MRL/++ mice suggest that FO diets containing omega-3 fatty acids are beneficial in decreasing the levels of certain pro-inflammatory chemokines (RANTES and MCP-1) thereby delaying the onset of and severity of autoimmune symptoms in MRL/lpr mouse model.

Vitamin E uncouples joint destruction and clinical inflammation in a transgenic mouse model of rheumatoid arthritis

OBJECTIVE

Reactive oxygen species are thought to play a role in rheumatoid arthritis (RA) in humans. We postulated that antioxidant treatment could have a beneficial effect in this disease. We therefore investigated the effects of vitamin E in the transgenic KRN/NOD mouse model of RA.

METHODS

Mice were treated by gavage with oral vitamin E (alpha-tocopherol). Clinical, histologic, and biochemical parameters were assessed for 6 weeks.

RESULTS

Vitamin E treatment did not modify the clinical features of the disease (date of onset or disease intensity, as measured by the articular index), but it did prevent joint destruction, as measured by qualitative and semiquantitative analyses. Redox status did not differ between treated and control mice. White blood cell chemiluminescence was higher in transgenic KRN/NOD mice than in controls, but vitamin E treatment attenuated this difference. Vitamin E treatment of the transgenic animals led to a significant decrease in the levels of interleukin-(IL-1beta) but not tumor necrosis factor alpha.

CONCLUSION

Vitamin E seems to uncouple joint inflammation and joint destruction in this model of RA, with a beneficial effect on joint destruction. Since many investigations are currently in progress to evaluate the benefit of interventions targeted toward anti-IL-1beta, our findings suggest opportunities of therapeutic interest in human RA.

Vitamin E is ineffective for symptomatic relief of knee osteoarthritis: a six month double blind, randomised, placebo controlled study

OBJECTIVE

There is a putative role for antioxidant treatment in osteoarthritis (OA) based on animal, epidemiological, and human clinical studies. Vitamin E, a fat soluble vitamin, is one of the major dietary antioxidants. Short term clinical studies using vitamin E in the form of alpha-tocopherol suggested a benefit over placebo of similar dimension to that of diclofenac for relief of OA pain.

METHODS

A six month, double blind, randomised, placebo controlled study of vitamin E 500 IU/day was carried out. Primary outcome measures were pain, stiffness, and function. Statistical analysis was performed on an intention to treat basis.

RESULTS

77 patients were included in the study. Vitamin E showed no benefit over placebo at one month, three months, or six months for any of the outcome measures. The placebo group had higher pain levels (p=0.15) and body mass index (p=0.03) at baseline, and lower pain levels (p=0.02) at completion of the study. Radiological score, exercise score, age, or antioxidant intake at baseline or six months did not differ between the groups. The reasons for the better performance of the placebo group are uncertain but may relate to the initially higher pain score and subsequent regression to the mean.

CONCLUSIONS

Vitamin E shows no benefit for the management of symptomatic knee OA. The role of vitamin E in preventing OA progression is currently under investigation.

Effects of diets containing fish oil and vitamin E on rheumatoid arthritis

Animal, tissue culture, and human studies have evaluated the effects of fish oil supplementation in patients with rheumatoid arthritis (RA) over the last two decades. These studies have clearly shown potentially beneficial changes in cytokine and eicosanoid metabolism. The overall clinical improvement, however, has been only moderate. European clinical trials have shown significant pain reduction in patients with RA treated with vitamin E. A recent animal study in RA-prone mice evaluated the effects of vitamin E in addition to omega-3 and omega-6 fatty acids on cytokine and eicosanoid production. The authors suggest that vitamin E might have an additional positive effect on autoimmune disease by decreasing proinflammatory cytokines and lipid mediators. Is this information ultimately important in terms of dietary advice for patients with RA? Are further clinical trials indicated? The following article will present a brief critical review.

Protective effects of aspirin and vitamin E (alpha-tocopherol) against copper- and cadmium-induced toxicity

A 24-h exposure to copper (400 microM, 600 microM) or cadmium (5 microM, 10 microM) significantly reduces the viability of COS-7 cells. A 2-h preincubation with vitamin E does not protect COS-7 cells from copper-induced toxicity, but does protect against cadmium-induced toxicity. Preincubation with aspirin protects cells from both copper- and cadmium-induced toxicity. A combination of aspirin and vitamin E (10 microM and 25 microM, respectively) increases cell viability in copper-exposed cells in a clearly additive manner, while in cadmium-exposed cells the effects are slightly additive. These results indicate that aspirin and vitamin E can protect cells from metal-induced toxicity. Differences in the protective effects of aspirin and vitamin E on copper versus cadmium-induced toxicity may be due to alternative mechanisms of metal toxicity or antioxidant activity.

Herbal and dietary therapies for primary and secondary dysmenorrhoea

BACKGROUND

Dysmenorrhoea refers to the occurrence of painful menstrual cramps of uterine origin and is a common gynaecological complaint. Common treatment for dysmenorrhoea is medical therapy such as nonsteroidal anti-inflammatories (NSAIDs) or oral contraceptive pills (OCPs) which both work by reducing myometrial activity (contractions of the uterus). The efficacy of conventional treatments such as nonsteroidals is considerable, however the failure rate is still often 20-25%. Many consumers are now seeking alternatives to conventional medicine and research into the menstrual cycle suggests that nutritional intake and metabolism may play an important role in the cause and treatment of menstrual disorders. Herbal and dietary therapies number among the more popular complementary medicines yet there is a lack of taxonomy to assist in classifying them. In the US, herbs and other phytomedicinal products (medicine from plants) have been legally classified as dietary supplements since 1994. Included in this category are vitamins, minerals, herbs or other botanicals, amino acids and other dietary substances. For the purpose of this review we use the wider term herbal and dietary therapies to include the assorted herbal or dietary treatments that are classified in the US as supplements and also the phytomedicines that may be classified as drugs in the European Union.

OBJECTIVES

To determine the efficacy and safety of herbal and dietary therapies for the treatment of primary and secondary dysmenorrhoea when compared to each other, placebo, no treatment or other conventional treatments (e.g. NSAIDS).

SEARCH STRATEGY

Electronic searches of the Cochrane Menstrual Disorders and Subfertility Group Register of controlled trials, CCTR, MEDLINE, EMBASE, CINAHL, Bio extracts, and PsycLIT were performed to identify relevant randomised controlled trials (RCTs). The Cochrane Complementary Medicine Field's Register of controlled trials (CISCOM) was also searched. Attempts were also made to identify trials from the National Research Register, the Clinical Trial Register and the citation lists of review articles and included trials. In most cases, the first or corresponding author of each included trial was contacted for additional information.

SELECTION CRITERIA

The inclusion criteria were RCTs of herbal or dietary therapies as treatment for primary or secondary dysmenorrhoea vs each other, placebo, no treatment or conventional treatment. Interventions could include, but were not limited to, the following; vitamins, essential minerals, proteins, herbs, and fatty acids. Exclusion criteria were: mild or infrequent dysmenorrhoea or dysmenorrhoea from an IUD.

DATA COLLECTION AND ANALYSIS

Seven trials were included in the review. Quality assessment and data extraction were performed independently by two reviewers. The main outcomes were pain intensity or pain relief and the number of adverse effects. Data on absence from work and the use of additional medication was also collected if available. Data was combined for meta-analysis using Peto odds ratios for dichotomous data or weighted mean difference for continuous data. A fixed effects statistical model was used. If data suitable for meta-analysis could not be extracted, any available data from the trial was extracted and presented as descriptive data.

MAIN RESULTS

MAGNESIUM: Three small trials were included that compared magnesium and placebo. Overall magnesium was more effective than placebo for pain relief and the need for additional medication was less. There was no significant difference in the number of adverse effects experienced. VITAMIN B6: One small trial of vitamin B6 showed it was more effective at reducing pain than both placebo and a combination of magnesium and vitamin B6. MAGNESIUM AND VITAMIN B6: Magnesium was shown to be no different in pain outcomes from both vitamin B6 and a combination of vitamin B6 and magnesium by one small trial. The same trial also showed that a combination of magnesium and vitamin B6 was no different from placebo in reducing pain. VITAMIN B1: One large trial showed vitamin B1 to be more effective than placebo in reducing pain. VITAMIN E: One small trial comparing a combination of vitamin E (taken daily) and ibuprofen (taken during menses) versus ibuprofen (taken during menses) alone showed no difference in pain relief between the two treatments. OMEGA-3 FATTY ACIDS: One small trial showed fish oil (omega-3 fatty acids) to be more effective than placebo for pain relief. JAPANESE HERBAL COMBINATION: One small trial showed the herbal combination to be more effective for pain relief than placebo, and less additional pain medication was taken by the treatment group.

REVIEWER'S CONCLUSIONS

Vitamin B1 is shown to be an effective treatment for dysmenorrhoea taken at 100 mg daily, although this conclusion is tempered slightly by its basis on only one large RCT. Results suggest that magnesium is a promising treatment for dysmenorrhoea. It is unclear what dose or regime of treatment should be used for magnesium therapy, due to variations in the included trials, therefore no strong recommendation can be made until further evaluation is carried out. Overall there is insufficient evidence to recommend the use of any of the other herbal and dietary therapies considered in this review for the treatment of primary or secondary dysmenorrhoea.

Synergistic inhibition of cyclooxygenase-2 expression by vitamin E and aspirin

The use of aspirin in rheumatoid arthritis is limited since inhibition of the pro-inflammatory enzyme cyclooxygenase-2 occurs only at higher aspirin doses that are often associated with side effects such as gastric toxicity. Using a macrophage cell line (J774. 1A), the present study explores possible synergistic effects of aspirin and vitamin E on the expression and activity of cyclooxygenase-2. Lipopolysaccharide-induced prostaglandin E(2) formation was significantly reduced by aspirin (1-100 microM) or vitamin E (100-300 microM). When combined with vitamin E, aspirin-dependent inhibition of prostaglandin E(2) formation was increased from 59% to 95% of control. Likewise, lipopolysaccharide-induced cyclooxygenase-2 protein and mRNA expression were virtually abolished by the combined treatment of aspirin and vitamin E, whereas the two agents alone were only modestly effective. Vitamin C did not mimic the actions of vitamin E under these conditions, suggesting that redox-independent mechanisms underlie the action of vitamin E. In agreement with this, vitamin E and aspirin were without effect on lipopolysaccharide-induced translocation of the redox-sensitive transcription factor NF-kappa B. Our results show that co-administration of vitamin E renders cyclooxygenase-2 more sensitive to inhibition by aspirin by as yet unknown mechanisms. Thus, anti-inflammatory therapy might be successful with lower aspirin doses when combined with vitamin E, thereby possibly avoiding the side effects of the usually required high dose aspirin treatment.

Diets, dietary supplements, and nutritional therapies in rheumatic diseases

Rheumatoid arthritis and many other systemic rheumatic diseases remain illnesses of unknown cause for which current therapy is often inadequate. This leads patients to seek questionable remedies, prominent among which are dietary manipulations. Is there a role for dietary modifications in the routine therapy for patients with rheumatic diseases? This article discusses the relationships between diets, fasting, elemental nutrition, vitamins, minerals, and foods for rheumatic diseases. Known scientific-based evidence for the use, safety, and efficacy of diets and dietary-related practices subscribed by patients with rheumatic diseases are presented. Studies that link diet with arthritis offer the possibility of identifying new therapeutic approaches for selected patients and of developing new insights to disease pathogenesis. Dietary therapy for arthritis, however, is still being investigated.