Complementary medicines and non-pharmacological treatments for pain (3.4) Flashcards
What 3 complementary medicines have strong scientific evidence
- Glucosamine
- Chondroitin
- Omega-3 fatty acids, fish oil, alpha-linolenic acid
What is glucosamine sulphate used for?
- Chondroprotective: – stimulates proteoglycan biosynthesis & inhibits proteoglycan breakdown
- Anti-inflammatory: actions observed in studies: prevents production of inflammatory mediators
Effective in:
- Treating the symptoms of OA such as pain (due to breakdown of cartilage)
- Slowing disease progression (due to further breakdown of cartilage)
- Use dona glucosamine
Practice points:
- Symptom relief after 2-6 weeks –> but may take up to 6 months or longer for joint protection effects to be seen
- May be taken in combination with chondroitin
- Considered very safe
Caution:
- Diabetic patients should check with their Dr if starting glucosamine
- Derived from shellfish
What is chondroitin used for
- Reduces symptoms of OA
- May reduce progression of disease
Chondroitin sulphate found naturally in the body (vital part of catilage, manufactured from shark or bovine cartilage)
Actions
- Chondro-protective (gives cartilage elasticity by retaining water and inhibits activity of enzymes and subsntaces that cause joint damage and breakdown)
- Anti-inflammatory effects
- May stimulate repair mechanisms
- Symptom relief within 2-4 months
- Maximum benefit may take years of use
- Use with caution in patients with clotting disorders or on anticoagulants
Why should you give glucsoamine and chondroitin together
as effective as celecoxib (NSAID) for treating symptoms of OA (pain, stiffness, swelling) but with less side effects
- Daily intake of glucosamine sulphate and chondroitin significantly reduced joint space narrowing between the knees in OA patients
What are essential FA and eicosanoids
- Alpha-linolenic acid (ALA) – parent compound to omega-3 fatty acid family
- Linoleic acid (LA) – parent compound to omega-6 family
Role of essential fatty acids is the synthesis of the eicosanoids
- Eiconasoids: prostaglandins, thromboxanes, leukotrienes
How are eicosanoids classified?
The Prostaglandin and Thromboxanes
- Series 1 – anti-inflammatory (mild), inhibit platelet aggregation, vasodilatory, immune enhancing, modulate release of arachidonic acid (AA)
- Series 2 –pro-inflammatory, thrombotic, vasoconstrictor –> very important in the transmission of pain signals
- Series 3 – anti-inflammatory (strong), thrombolytic
The Leukotrienes
- Leukotriene 4 – strong immune mediated pro-inflammatory and chemotactic agents
- Leukotriene 5 – weak immune mediated pro-inflammatory and chemotactic (low physiological activity)
Which fatty acids form types of eicosanoids?
The omega 3 pathway (ALA) goes on to form: Anti-inflammatory, thrombolytic
- EPA (eicosapentaenoic acid)
- DHA (docosahexaenoic acid)
- Series 3 prostaglandins
- Series 5 leukotrienes
The omega 6 pathway (LA) forms arachidonic acid (AA), which goes on to form:
- PG series 1
- PG series 2
- Thromboxane series 2
- Leukotrienes series 4
Pro-inflammatory/platelet aggregation
How does NSAIDS work?
MOA of NSAIDS is to inhibit prostaglandin series 2 synthesis (via COX) – thus ↓ inflammation
What are some sources of Omega 3
Marine sources - Deep water oily fish salmon, mackerel, halibut, herring – omega 3’s found as:
- DHA (docosahexaenoic acid)
- EPA (eicosapentaenoic acid)
- Rapidly absorbed and can be used by the body
Plant souces: Linseed oil, Flaxseed, soybean oil, pumpkin
- Found predominantly still in parent ALA form (inactive)
- Human body capable of only very inefficient conversion of ALA into EPA & DHA
- Plant sources thus do not yield sufficient Omega-3’s
What are some uses for omega 3
- RA: Possibly effective
- Dysmenorrhoea (period cramps): possibly effective
- Osteoarthritis: ineffective
- Migraine headache: ineffective
How does the anti-inflammatory effects of Omega 3 arise?
Anti-inflammatory effects mainly due to EPA
EPA inhibits formation of AA and competes for COX (cyclooxygenase) and LOX (lipooxygenase)
- Decreases production of PG2 (inflammatory action)
- Decreases production of leukotriene B4 (inducer of inflammation; inducer of leukocyte adherence and chemotaxis)
EPA give rise to bodys natural anti-inflammatory mediators
- Increase in series 3 prostaglandins (PG3)
- Increases production of leukotriene B5
What are the benefits of using omega 3 as an adjunct therapy
- Rheumatoid arthritis (greatest benefit)
- Inflammatory bowel disease
- Dysmenorrhoea
> About 2-3 g/day of isolated DHA/EPA to reduce inflammation (need high EPA in particular)
> For >3 months
What is some Omega 3 Practice points
Doses of >3g/day EPA/DHA should be suspended one week before surgery
- May need 2-3 months of therapy before benefit seen
- Regular ongoing use required for benefit in most chronic conditions
5-HTP is the precursor to serotonin (5HT). What are some of its uses and efffectiveness
- FIbromyalgia and depression: Possibly effective
- Headaches: Insufficient evidence
5HTP use for fibromyalgia, what are some of the things it may reduce?
Alsio what are some interactions of 5HTP
Fibromyalgia –> will reduce;
- the number of tender points
- anxiety
- intensity of pain
- may improve sleep, fatigue
- morning stiffness
Interactions
- Antidepressants: SSRI’s, TCA, MAOI, St John’s Wort – risk serotonin syndrome
- Other CNS drugs – caution
What is MSM (Methylsulphonylmethane) used for?
Osteoarthritis: possibly effective
- benefits appear small
- patients with OA should take glucosamine sulphate or chondroitin sulphate rather than MSM
What is devils claw (harpagophytum procumbens) used for?
Osteoarthritis and low back pain: possibly effective
- Reduces pain and inflammation
- Evidence of a chondroprotective effect
May allow for a dosage reduction in NSAIDs/pain medication
What is SAMe ( S-Adenosyl-L-methionine) used for? what are its proiperties?
- Depression/OA: effective/likely effective
- Fibromyalgia: Possibly effective
> Anti-inflammatory, analgesic, anti-depressant, hepatoprotective
> Synthesised endogenously
> Stimulates synthesis of cartilage
Practice points
- Take with food
- Precaution in bipolar depression
- Interacts with antidepressant drugs
- Permitted in sports
What is comfrey (symphytum officinale) used for?
- Back pain, sprains, OA –> topical (possibly effective)
- reduces inflammation and pain associated with OA, sprains and muscle injuries
- Not for use on broken skin, or children <12 years
- Only as toxic formulation
What is arnica used for?
- Osteoarthritis (possibly effective)
- Pregnancy and lactation –> likely unsafe when used orally or topically
- Short term use –> upto 3 weeks –> improves pain and function in hand OA
- Does not significantly reduce bruising
What is ashwagandha (Withania somnifera) used for?
OA: insufficient reliable evidence to rate
- dont use in pregnnacy
- Joint deformity, pain, stiffness symptoms were reduce but there was no radiological imporvements after treatment
- Dont use in diabetics or cardiovascular disease (may lower BP)
- Combined with multivitamins as a stress wellbeing type product
What is boswellia boswellia serrata (indian frankinsense) used for?
- OA (possibly effective)
- RA (insufficient evidence to rate)
> Analgesic and anti-inflammatory properties have been demonstrated with boswellia
> Clinically significant benefits shown in OA – decreased pain, decreased swelling, improved mobility
What is eucalyptus oil used for?
Insufficient evidence for arthritis and headaches
- ndigenous Australians traditionally used eucalyptus to treat wounds, fungal infections, fevers & respiratory infections
- Eucalyptus inhibits prostaglandin synthesis in vitro
- Anti-inflammatory and anti-nociceptive effects have been demonstrated in animal models
For ginger (zingiber officinale)
Can suggest ginger tea as adjunct treatment
A) what is it used for
B) discuss its pharmacology
C) Safety concerns
A)
- Dysmenorrhoea and osteroarthritis (anti-inflammatory)
B)
- Studies suggest that ginger has an effect on the arachidonic acid cascade
- Inhibition of COX-1, COX-2 has reported
- High doses ginger shown to lower serum PG2 and thromboxane B2 levels (in rats)
- Suppress leukotriene biosynthesis
- Inhibits Tx synthesis and decreases platelet aggregation
C)
- Gastric irritation, heartburn and bloating have been reported, but usually only at high doses
- Individuals with gastric ulcers or reflux should use ginger with caution
- High dose supplements (>10g/day) should be discontinued one week prior to surgery
- Doses of up to 2g /day (dried root) are considered safe for use (pregnancy and lactation)
Interactions
- Anti-coagulants or anti-platelet drugs
- Theoretical risk of increased bleeding
- Ginger = anti-platelet activity
What is New Zeland green lipped mussel (NZ GLM) for?
Insufficent evidence in OA and RA
Anti-inflammatory effects reported
- Inhibition of COX-1 and COX-2
- Inhibition of 5-lipoxygenase pathway
- Inhibition of synthesis of leukotriene B4 and PGE2
- Free radical scavenging
What is rosehip (rosa canina)?
OA: possibly effective
- OA –> reduction in pain
- Inhibitory effect on chemotaxis of peripheral neutrophils and polymorphonuclear cellsa and reudces oxygen radical generation
For turmeric (curcumin –> key constituent)
Poorly absorbed – therefore important to only recommend products with enhanced bioavailability
A) What is it used for
B) Actions
C) what does it inhbit
D) Adverse effects
E) CI/ precaution/ warning
A)
Effective in OA –> improves in pain and functionality, reduced need for analgesics and NSAIDs
Not enough evidence for RA (but still effective)
B)
- Anti-inflammatory ; inhibits pro-inflammatory mediators
- Antioxidant - reduces oxidation of LDL cholesterol
- Anticancer
- Antidiabetic
- Inhibits allergic reponses
- GIT actions and hepatoprotective\
C)
Inhibits;
- lipoxygenase
- cyclooxygenase
- thromboxane B2
- leukotriene B4 formation
D)
Safety and tolerability well established - Doses up to 10g/day appear safe.
E)
- Bile duct obstruction – C/I
- Fertility –> said to avoid high doses in both males and females
- Pregnancy: Safe at dietary doses, but unknown at therapeutic doses
Interactions:
Antiplatelet drugs - Theoretical interaction
Anticoagulants - High doses theoretically increase the risk of bleeding
Summarise drugs use for osteroarthritis
Summarise drugs use for rheumatoid arthritis
What is RICER (for soft tissue injuries)
HARM
No heat
No alcohol
Reinjury
No massage
R: rest (24-48 after injury)
I: Ice (reduce swelling)
C: Compression (reduce swelling)
E: elevation (reduce swelling)
R: referral
What are some topical treatments: heat
- Avoid within 48 hrs of injury
- Reduces joint stiffness, relieves muscle spasms
- Includes heat can be generated by:
> Topical analgesics with massage, heating pads, hot packs, hot water bottles, infrared lamps, hot bath, ultrasound equipment, thermal supports
Thermal supports
- available in most pharmacies
- worn on the affected area
- Some brands e.g. Thermoskin® claim that they can raise the skin and subcutaneous tissue temperature by up to 1.8oC
- Promoted to provide increased blood flow, compression, optimal muscle function, proprioception
