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IPT 1 Lectures > Complementary medicines and non-pharmacological treatments for pain (3.4) > Flashcards

Complementary medicines and non-pharmacological treatments for pain (3.4) Flashcards

1
Q

What 3 complementary medicines have strong scientific evidence

A
  • Glucosamine
  • Chondroitin
  • Omega-3 fatty acids, fish oil, alpha-linolenic acid
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2
Q

What is glucosamine sulphate used for?

A
  • 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
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3
Q

What is chondroitin used for

A
  • 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
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4
Q

Why should you give glucsoamine and chondroitin together

A

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
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5
Q

What are essential FA and eicosanoids

A
  • 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
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6
Q

How are eicosanoids classified?

A

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)
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7
Q

Which fatty acids form types of eicosanoids?

A

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

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8
Q

How does NSAIDS work?

A

MOA of NSAIDS is to inhibit prostaglandin series 2 synthesis (via COX) – thus ↓ inflammation

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9
Q

What are some sources of Omega 3

A

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

  1. Found predominantly still in parent ALA form (inactive)
  2. Human body capable of only very inefficient conversion of ALA into EPA & DHA
  3. Plant sources thus do not yield sufficient Omega-3’s
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10
Q

What are some uses for omega 3

A
  • RA: Possibly effective
  • Dysmenorrhoea (period cramps): possibly effective
  • Osteoarthritis: ineffective
  • Migraine headache: ineffective
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11
Q

How does the anti-inflammatory effects of Omega 3 arise?

A

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
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12
Q

What are the benefits of using omega 3 as an adjunct therapy

A
  • 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

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13
Q

What is some Omega 3 Practice points

A

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
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14
Q

5-HTP is the precursor to serotonin (5HT). What are some of its uses and efffectiveness

A
  • FIbromyalgia and depression: Possibly effective
  • Headaches: Insufficient evidence
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15
Q

5HTP use for fibromyalgia, what are some of the things it may reduce?

Alsio what are some interactions of 5HTP

A

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
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16
Q

What is MSM (Methylsulphonylmethane) used for?

A

Osteoarthritis: possibly effective

  • benefits appear small
  • patients with OA should take glucosamine sulphate or chondroitin sulphate rather than MSM
17
Q

What is devils claw (harpagophytum procumbens) used for?

A

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

18
Q

What is SAMe ( S-Adenosyl-L-methionine) used for? what are its proiperties?

A
  • 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
19
Q

What is comfrey (symphytum officinale) used for?

A
  • 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
20
Q

What is arnica used for?

A
  • 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
21
Q

What is ashwagandha (Withania somnifera) used for?

A

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
22
Q

What is boswellia boswellia serrata (indian frankinsense) used for?

A
  • 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

23
Q

What is eucalyptus oil used for?

A

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
24
Q

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

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
25
Q

What is New Zeland green lipped mussel (NZ GLM) for?

A

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
26
Q

What is rosehip (rosa canina)?

A

OA: possibly effective

  • OA –> reduction in pain
  • Inhibitory effect on chemotaxis of peripheral neutrophils and polymorphonuclear cellsa and reudces oxygen radical generation
27
Q

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

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

28
Q

Summarise drugs use for osteroarthritis

A
29
Q

Summarise drugs use for rheumatoid arthritis

A
30
Q

What is RICER (for soft tissue injuries)

HARM

No heat

No alcohol

Reinjury

No massage

A

R: rest (24-48 after injury)

I: Ice (reduce swelling)

C: Compression (reduce swelling)

E: elevation (reduce swelling)

R: referral

31
Q

What are some topical treatments: heat

A
  • 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

IPT 1 Lectures (24 decks)

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