• Glenn S. Rothfeld, MD

Osteoarthritis and Natural Medicines

I’m well into the Age of Arthritis, as I’m reminded each morning when I creak out of bed. And I’m not alone, I know. More than 70% of the population over 50 years of age have some evidence of osteoarthritis in one or more of their joints. Add to that the one in a hundred people who have rheumatoid arthritis, and that adds up to a lot of sore joints.

When I was in training we were taught that rheumatoid arthritis (RA) was inflammatory (due to auto-immune illness) but that osteoarthritis (OA) was merely the result of wear and tear on the joints, like the wearing down of a brake shoe on a car, or the tattering of an old jacket. It even had another name, Degenerative Joint Disease (DJD) that described this more graphically. And conventional medicine would like to perpetuate that image of a worn-out joint. Because what do we do in our culture when things wear out? We replace them! And that’s what is being done for osteoarthritic joints. More and more, they are being replaced, at huge expense to the insurance companies and the patients, as well as huge expense to the economy in workdays lost to rehabilitation, risk to patients of surgery, post-surgical complications and even long-term risk of having foreign metals in our bodies.

If joints aren’t replaced, the solution to the pain of OA is usually aspirin, or the non-steroidal anti-inflammatory drugs (NSAIDs) like Advil and Aleve. And they do seem to help temporarily. But wait a second. I just said that OA is wear-and-tear arthritis, I didn’t say anything about inflammation. So why do anti-inflammatories work??

The answer to this question is that OA is very definitely a disease of inflammation. It appears that many factors (diet, injury, infection, allergy, toxins, etc) can set off warning signals in the form of pro-inflammatory messengers. These messenger proteins are called ‘cytokines,’ These cytokines, along with pro-inflammatory enzymes (particularly cyclooxygenase or COX) and other chemicals eat away at the collagen matrix of joints, leading to more inflammation and more destruction of cellular tissue until the joint space is largely obliterated.

In fact, this is the way that nearly all diseases are generated: the triggering of immune messengers by a variety of internal and external factors, leading to inflammation and destruction of cells. In the case of OA, the cytokines that seem to do the most damage are called tumor necrosis factor alpha (TNF alpha) and interleukin one beta (IL-1b). Studies of the cartilage, synovial membranes and synovial fluid (which together make up the joint spaces) of OA patients show elevated levels of both TNF alpha and IL-1b. It’s also been shown that lessening TNF alpha lowers inflammation, and lowering IL-1b lowers damage to cartilage.

Aspirin and NSAIDs work by blocking the COX pathway (both COX-1 and COX-2). Since COX-2 is a major pro-inflammatory enzyme, this results in less inflammation, but at a major price. Because COX-1, which is also blocked by the majority of these medicines, is critical in protecting the stomach lining. And so, any of these medications can erode the stomach and cause ulcers and gastritis, even as they have a calming effect on the joints.

Furthermore, drug company attempts to produce a selective COX-2 inhibitor resulted in damage to the cardiovascular system, such that most of them have been banned, like Vioxx and Bextra, though Celebrex is still on the market.

Hence, gentle ways of inhibiting COX-2, and the cytokines involved in inflammation (Il-1b and TNF alpha) remain to be invented, right? Well, it happens that nature has already invented them. Plants, and the substances that come from plants, have major anti-inflammatory activity against arthritis (and other inflammatory conditions) without throwing the balance of pro- and anti-inflammatory activity in the body into turmoil. A recent article published in Current Opinion in Pharmacology 2007, (7:344-351 by Khanna et al) was entitled “Natural Products as a Gold Mine For Arthritis Treatment.” As its name implies, this article reviewed a number of natural substances and herbal extracts that have been proven to decrease the signals in the body that trigger and sustain inflammation.

This article listed 18 natural products with anti-arthritic activity. All of them (except the soy-derived protein Genistein) blocked COX-2. All 18 of them blocked a substance called nuclear factor kappa-B (NF-kB) the signaling molecule that regulates the inflammatory process. And half of them blocked Il-1B as well. And all of this activity with a much, much safer action than any of the drugs on the market (or in the pharmaceutical pipeline, I would guess).

I want to focus on a few of these natural medicines, and another one that has been exciting me as well. Curcumin (extracted from the household herb turmeric). Since its use in arthritis was first reported in 1980, there have been literally hundreds of studies supporting the use of curcumin in the management (and even prevention) of OA and RA. There are even some studies showing that curcumin improves the function of the COX-2 inhibitor drug Celebrex, so that lower doses of the dangerous drug can be used.

Curcumin has also been studied in conjunction with another powerful anti-inflammatory herbal product, resveratrol. This remarkable substance is readily found in grapes (including wine), berries and peanuts, and has been proven to inhibit NF-kB, IL-1B, COX-2, and another inflammatory cytokine, Interleukin 6 (IL-6). The results of blocking these substances are the lessening of cartilage destruction and even the prevention of OA before it even starts. What’s more, a paper has just been published (to be released this fall) shows that combining curcumin and resveratrol in a special way (called lipid-core nanocapsules) lowered joint inflammation and tissue destruction in an animal model, without the liver irritation that occurs with drugs, and even high doses of curcumin by itself.

The use of boswellic acid (from the Indian herb boswellia) in OA and RA also has accumulated extensive research for the past 30 years. It has been shown to block NF-kB, COX-2 and another inflammatory enzyme in the lipoxygenase pathway, (5-LOX). In one randomized double-blind placebo-controlled crossover study, by Kimmatkar et al (Phytomedicine 2003, 10:3-7) 30 patients with OA of the knee were given boswellia extract or placebo for 8 weeks, and then (after a period of time known as a “wash-out” they were switched. The group receiving the active herbal medicine showed statistically significant lessening in pain, greater walking distance, and improved flexibility.

Products such as Curcumax Pro that combine bioavailable curcumin with boswellic acid may therefore be effective for preventing or treating OA, as the two compounds combined make a great team, working synergistically to increase the benefits of one another.

These natural substances, and many others that have been equally studied, provide safe and easy alternatives to the dangers of NSAIDs and other arthritis drugs. And, just as importantly, they suggest that taking natural medicines can be powerful ways of actually preventing the aches and pains of arthritis from occurring in the first place.

#OA #arthritis #RA #boswellia #curcumin #inflammation #cytokines #naturalmedicine