MARINE AND BOTANICAL LIPIDS AS IMMUNOMODULATORY AND THERAPEUTIC AGENTS IN THE TREATMENT OF RHEUMATOID ARTHRITIS

Lipid emulsions in parenteral nutrition: current applications and future developments

INTRODUCTION

A parenteral lipid emulsion (LE), used as a key source of energy, essential fatty acids (FAs), and fat-soluble vitamins, is an integral part of a parenteral nutrition (PN) regimen. The conventional LEs, such as soybean oil (SO)-based emulsions, have caused concerns about the potential adverse effects involving oxidative stress, inflammation, and immune response probably because of undesirable FA composition.

AREAS COVERED

Recently, alternative LEs, optimizing the FA composition with partial substitution of SO with medium-chain triglyceride (MCT), olive oil (OO), and fish oil (FO), have been developed and applied in clinical practice. This review summarizes the characteristics and beneficial clinical effects of alternative parenteral LEs in critically ill, pediatric, and long-term PN patients.

EXPERT OPINION

More clinical data from sufficiently high-powered studies are required to characterize the integral biological properties of alternative LEs for further selection to fit individual needs and disease characteristics. Simultaneously, potential lipid sources with desirable FA compositions and biological properties should be selected to develop new therapeutic LEs. As supplements to current parenteral lipids, the new LEs with different therapeutic effects are expected to fit specified subpopulations of patients with different diseases. Great efforts should be devoted to the development of parenteral LEs.

Herbal therapy for treating rheumatoid arthritis

BACKGROUND

Herbal medicine interventions have been identified as having potential benefit in the treatment of rheumatoid arthritis (RA).

OBJECTIVES

To update an existing systematic (Cochrane) review of herbal therapies in RA.

SEARCH STRATEGY

We searched electronic databases Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, AMED, CINAHL, Web of Science, Dissertation Abstracts (1996 to 2009), unrestricted by language, and the WHO International Clinical Trials Registry Platform in October 2010.

SELECTION CRITERIA

Randomised controlled trials of herbal interventions compared with placebo or active controls in RA.

DATA COLLECTION AND ANALYSIS

Two authors selected trials for inclusion, assessed risk of bias and extracted data. 

MAIN RESULTS

Twelve new studies were added to the update, a total of 22 studies were included.Evidence from seven studies indicate potential benefits of gamma linolenic acid (GLA) from evening primrose oil, borage seed oil, or blackcurrent seed oil, in terms of reduced pain intensity (mean difference (MD) -32.83 points, 95% confidence interval (CI) -56.25 to -9.42,100 point pain scale); improved disability (MD -15.75% 95% CI -27.06 to -4.44%); and an increase in adverse events (GLA 20% versus placebo 3%), that was not statistically different (relative risk 4.24, 95% CI 0.78 to 22.99).Three studies compared Tripterygium wilfordii (thunder god vine) to placebo and one to sulfasalazine and indicated improvements in some outcomes, but data could not be pooled due to differing interventions, comparisons and outcomes. One study reported serious side effects with oral Tripterygium wilfordii Hook F. In the follow-up studies, all side effects were mild to moderate and resolved after the intervention ceased. Two studies compared Phytodolor(®) N to placebo but poor reporting limited data extraction. The remaining studies each considered differing herbal interventions.

AUTHORS' CONCLUSIONS

Several herbal interventions are inadequately justified by single studies or non-comparable studies in the treatment of rheumatoid arthritis. There is moderate evidence that oils containing GLA (evening primrose, borage, or blackcurrant seed oil) afford some benefit in relieving symptoms for RA, while evidence for Phytodolor® N is less convincing.Tripterygium wilfordii products may reduce some RA symptoms, however, oral use may be associated with several side effects. Many trials of herbal therapies are hampered by research design flaws and inadequate reporting. Further investigation of each herbal therapy is warranted, particularly via well designed, fully powered, confirmatory clinical trials that use American College of Rheumatology improvement criteria to measure outcomes and report results according to CONSORT guidelines.

Rotator cuff tendinopathy: is there a role for polyunsaturated Fatty acids and antioxidants?

Despite the lack of robust evidence, there has been a steady increase in the use of dietary supplements, including Omega 3 fatty acids and antioxidants, in the management of musculoskeletal conditions. One reason for this is that unsatisfactory outcomes with conventional treatments have lead sufferers to seek alternative solutions including the use of nutritional supplements. In the United Kingdom alone, the current supplement market is estimated to be over 300 pounds million per annum. One target market for nutritional supplements is tendinopathies including conditions involving the rotator cuff. This condition is debilitating and associated with considerable morbidity. Incidence increases with advancing age. High levels of cytokines, such as the pro-inflammatory interleukin 1 beta and vascular endothelial growth factor, have been reported within the bursa of patients with rotator cuff disease. There is also evidence that high concentrations of free-radical oxidants may also be involved in tendon pathology. Therefore, the possibility exists that dietary supplements may have a beneficial effect on tendon pathology, including that of the rotator cuff. A review was conducted to synthesize the available research literature on the histopathology of rotator cuff disease and the effectiveness of polyunsaturated fatty acids (PUFAs) and antioxidants on tendinopathies. A search was conducted using the MEDLINE, CINAHL, AMED, EMBASE, Cochrane, and PEDro databases using the terms "rotator cuff" and "tear/s" and "subacromial impingement syndrome," "burase," "bursitis," "tendinopathy," "tendinitis," "tendinosis," "polyunsaturated fatty acids," "PUFA," "Omega 3," "histopathology," "etiology," and "antioxidants." English language was an inclusion criterion. There were no randomized clinical trials found relating specifically to the rotator cuff. Only one trial was found that investigated the efficacy of PUFAs and antioxidants on tendinopathies. The findings suggest that some (low level) evidence exists to support the supplementation in the management of tendinopathies. Any conclusions based on this one article should be reached with caution. Subsequently, there is a distinct and clear need for well-planned randomized controlled trials that aim to investigate the efficacy of supplements in the management of tendinopathies including those of the rotator cuff.

Therapeutic effect of topical gamma-linolenic acid on refractory uremic pruritus

BACKGROUND

Pruritus is a bothersome symptom affecting up to 80% of dialysis patients. Lymphocyte and cytokine interaction has an important role in the pathogenesis of uremic pruritus. Gamma-linolenic acid (GLA) is associated with immune modulation of T lymphocytes and lymphokines. The aim of this study is to determine whether topical GLA can attenuate uremic pruritus.

METHODS

Seventeen dialysis patients with refractory uremic pruritus who passed the screening criteria entered a prospective, randomized, double-blind, placebo-controlled, crossover study. They stopped all antipruritic therapy at least 2 weeks before the study and were randomly assigned to treatment with either GLA 2.2% cream or placebo-based cream applied to the entire body after taking a bath once a day and to pruritic sites 3 times a day for 2 weeks, and then the reverse treatment after a 2-week washout period. Severity of pruritus was evaluated by using a traditional visual analogue scale (VAS) and a modified questionnaire method (pruritus score [PS]). Hemogram, aspartate and alanine aminotransferases, bilirubin, albumin, blood urea nitrogen, creatinine, calcium, phosphate, and intact parathyroid hormone were measured.

RESULTS

Sixteen patients completed the study; 1 patient was withdrawn because of an allergic skin reaction. There were no significant differences between groups except for sex distribution. Median VAS and PS values between groups did not differ significantly at baseline. There is a greater antipruritic effect of GLA based on evaluation with both the VAS and PS. There is persistence of a residual effect into the second treatment period after GLA treatment.

CONCLUSION

GLA-rich cream is better than placebo-based cream for alleviating uremic pruritus. It is a useful adjuvant in the management of refractory uremic pruritus.

Gammalinolenic acid, an unsaturated fatty acid with anti-inflammatory properties, blocks amplification of IL-1 beta production by human monocytes

Administration of gammalinolenic acid (GLA), an unsaturated fatty acid, reduces joint inflammation in patients with rheumatoid arthritis. Addition of GLA in vitro suppresses release of IL-1beta from human monocytes stimulated with LPS. LPS-induced IL-1beta release is followed by IL-1-induced IL-1beta release, an amplification process termed autoinduction. We show here with peripheral blood monocytes from normal volunteers and from patients with rheumatoid arthritis by using IL-1R antagonist to block autoinduction and IL-1alpha stimulation to simulate autoinduction that approximately 40% of IL-1beta released from LPS-stimulated cells is attributable to autoinduction and that GLA reduces autoinduction of IL-1beta while leaving the initial IL-1beta response to LPS intact. Experiments with cells in which transcription and protein synthesis were blocked suggest that GLA induces a protein that reduces pro-IL-1beta mRNA stability. IL-1beta is important to host defense, but the amplification mechanism may be excessive in genetically predisposed patients. Thus, reduction of IL-1beta autoinduction may be protective in some patients with endotoxic shock and with diseases characterized by chronic inflammation.

Herbal therapy for treating rheumatoid arthritis

BACKGROUND

The increasing popularity of the use of complementary and alternative interventions or treatments appears to be particularly evident amongst people with chronic disease. In the treatment of rheumatoid arthritis, one therapy that has been identified as having potential benefit, is herbal medicine (phytotherapy).

OBJECTIVES

To assess the effectiveness of herbal therapies in the treatment of rheumatoid arthritis.

SEARCH STRATEGY

We developed a search strategy using terms to include all forms of arthritis combined with herbal medicine. We searched the following electronic databases from 1966 to 2000: MEDLINE, EMBASE, CISCOM, AMED, CINAHL, Cochrane Controlled Trials Register (CCTR), Cochrane Musculoskeletal specialized register, Dissertation Abstracts, BIDS ISI and the Cochrane Complementary Medicine Fields Specialized Register. This was supplemented by searching the reference lists from retrieved trials.

SELECTION CRITERIA

All randomized trials of herbal interventions in rheumatoid arthritis, compared to placebo. Two reviewers independently read and selected each potential study according to the criteria published in an a priori protocol. Papers of any language were included.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by the same two reviewers and an assessment of methodological quality was conducted.

MAIN RESULTS

Eleven studies met the inclusion criteria. Seven of the studies compared gamma-linolenic acid (GLA) to placebo although three of these were not suitable for data pooling. The remaining studies considered four different herbal interventions and were assessed individually. All of the GLA studies found some improvement in clinical outcomes but methodology and study quality was variable, making it difficult to draw conclusive results. However, the better quality studies suggest potential relief of pain, morning stiffness and joint tenderness. With the exception of one intervention (Tripterygium wilfordii hook F), no serious side effects were reported.

REVIEWER'S CONCLUSIONS

There appears to be some potential benefit for the use of GLA in rheumatoid arthritis although further studies are required to establish optimum dosage and duration of treatment. The single studies are inconclusive.

The role of meat in the expression of rheumatoid arthritis

Rheumatoid arthritis (RA) is characterized by inflammation of the synovial tissues in the joints. A number of papers related to dietary components that are associated with this inflammation are reviewed. In addition, the ecological approach is used to study the links between diet and RA. Multi-country data for prevalence of RA for females from eight and fifteen countries were compared statistically with components of national dietary supply. Fat from meat and offal for the period 2 years before the prevalence data was found to have the highest statistical association with the prevalence of RA (r(2) 0.877, P<0.001 for eight countries). The statistical correlations for meat and offal were almost as high as those for their fat. Similar correlations were found for temporal changes in indices of effects of RA in several European countries between 1968 and 1978 as more meat was added to the national diets, although the correlations were higher for meat than for fat. It is hypothesized that meat and offal may be a major factor contributing to the inflammation in RA. In the present short review, the author examines some of the data that associate meat consumption with RA and the possible factors, e.g. fat, Fe and nitrite, which may contribute to the inflammation.

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.

Importance of dietary gamma-linolenic acid in human health and nutrition

Considerable debate remains regarding the distinct biological activities of individual polyunsaturated fatty acids (PUFA). One of the most interesting yet controversial dietary approaches has been the possible prophylactic role of dietary gamma-linolenic acid (GLA) in treating various chronic disease states. This strategy is based on the ability of diet to modify cellular lipid composition and eicosanoid (cyclooxygenase and lipoxygenase) biosynthesis. Recent studies demonstrate that dietary GLA increases the content of its elongase product, dihomo-gamma-linolenic acid (DGLA), within cell membranes without concomitant changes in arachidonic acid (AA). Subsequently, upon stimulation, DGLA can be converted by inflammatory cells to 15-(S)-hydroxy-8,11,13-eicosatrienoic acid and prostaglandin E1. This is noteworthy because these compounds possess both anti-inflammatory and antiproliferative properties. Although an optimal feeding regimen to maximize the potential benefits of dietary GLA has not yet been determined, it is the purpose of this review to summarize the most recent research that has focused on objectively and reproducibly determining the mechanism(s) by which GLA may ameliorate health problems.

The role of nutrition and diet in rheumatoid arthritis

Given the lack of understanding of the nutritional requirements in RA, plus the variability in its clinical course, it is difficult to produce specific dietary recommendations for RA. In general, sufferers should consume as varied a diet as possible, based on current Department of Health (1991) guidelines. Dietary counselling is important to help patients achieve this. Self-imposed elimination diets should be avoided and suspected food intolerance tested under strict clinical supervision. Nutrient megadosing is inadvisable, although dietary supplementation with Ca, vitamin D, folic acid or multivitamins and minerals should be recommended where necessary.

Nutrition and ulcerative colitis

The role of diet in the aetiology and pathogenesis of ulcerative colitis (UC) remains uncertain. Impaired utilization by colonocytes of butyrate, a product of bacterial fermentation of dietary carbohydrates escaping digestion, may be important. Sulphur-fermenting bacteria may be involved in this impaired utilization. Oxidative stress probably mediates tissue injury but is probably not of causative importance. Patients with UC are prone to malnutrition and its detrimental effects. However, there is no role for total parenteral nutrition and bowel rest as primary therapy for UC. The maintenance of adequate nutrition is very important, particularly in the peri-operative patient. In the absence of massive bleeding, perforation, toxic megacolon or obstruction, enteral rather than parenteral nutrition should be the mode of choice. Nutrients may be beneficial as adjuvant therapy. Butyrate enemas have improved patients with otherwise recalcitrant distal colitis in small studies. Non-cellulose fibre supplements are of benefit in rats with experimental colitis. Eicosapentaenoic acid in fish oil has a steroid-sparing effect which, although modest, is important, particularly in terms of reducing the risk of osteoporosis, but it seems to have no role in the patient with inactive disease. gamma-Linolenic acid and anti-oxidants also are showing promise. Nutrients may also modify the increased risk of colorectal carcinoma. Oxidative stress can damage tissue DNA but there are no data published at present on possible protection from oral anti-oxidants. Butyrate protects against experimental carcinogenesis in rats with experimental colitis. Folate supplementation is weakly associated with decreased incidence of cancer in UC patients when assessed retrospectively. Vigilance should be maintained for increased micronutrient requirements and supplements given as appropriate. Calcium and low-dose vitamin D should be given to patients on long-term steroids and folate to those on sulphasalazine.

gamma-Linolenic acid treatment of rheumatoid arthritis. A randomized, placebo-controlled trial

OBJECTIVE

To assess the clinical efficacy and adverse effects of gamma-linolenic acid (GLA), a plant seed oil-derived unsaturated fatty acid that suppresses inflammation and joint tissue injury in animal models, in the treatment of active rheumatoid arthritis (RA).

METHODS

Fifty-six patients with active RA were randomized to treatment groups in a 6-month, double-blind trial of GLA versus placebo. This was followed by a 6-month, single-blind trial during which all patients received GLA. Patients were treated with 2.8 gm/day of GLA as the free fatty acid or with sunflower seed oil (placebo) administered in identical capsules.

RESULTS

Treatment with GLA for 6 months resulted in statistically significant and clinically relevant reductions in the signs and symptoms of disease activity in patients with RA. Overall meaningful responses (at least 25% improvement in 4 measures) were also better in the GLA treatment group (14 of 22 patients versus 4 of 19 in the placebo group; P = 0.015). During the second 6 months, both groups exhibited improvement in disease activity. Thus, patients taking GLA during the entire study showed progressive improvement during the second 6 months. In this group, 16 of 21 patients showed meaningful improvement at 12 months compared with study entry.

CONCLUSION

GLA at doses used in this study is a well-tolerated and effective treatment for active RA. GLA is available as a component of several plant seed oils and is usually taken in far lower doses than were used in this trial. It is not approved in the United States for the treatment of any condition, and should not be viewed as therapy for any disease. Further controlled studies of its in RA are warranted.