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 Natural Anti-inflammatory Supplements Research Status and Clinical Application By James Meschino, DC, MS, ND In recent years, scientific studies have demonstrated that many forms of arthritis and joint-inflammation conditions can be managed effectively through specific dietary and supplementation practices, in addition to other natural treatments such as joint mobilization, manipulation, muscle therapy, acupuncture and exercise.1 Glucosamine sulfate is an effective intervention to halt joint-cartilage destruction and help regenerate new cartilage in osteoarthritis cases. Substantial clinical and experimental evidence also supports the use of other natural health products which demonstrate proven abilities to block the inflammatory process, reducing the signs and symptoms of arthritis and other joint-inflammatory conditions. Studies indicate many of these natural agents provide similar efficacy as conventional anti-inflammatory drugs, yet are safer with respect to reported adverse side effects.As of yet, most medical practitioners have failed to embrace these alternative anti-inflammatory agents and tend to rely primarily on synthetic anti-inflammatory drugs as their principle approach.2 It's well-documented that non-steroidal anti-inflammatory drugs (NSAIDs) produce intestinal tract ulcers (with potential internal bleeding) in 10-30 percent of long-term users and erosions of the stomach lining and intestinal tract in 30-50 percent of cases.3 As a result of these side effects, NSAID use is associated with 10,000-20,000 deaths per year in the U.S.4 Even the new COX-2 inhibitor drugs have only been reported to reduce intestinal tract damage by 50 percent and their toxicity to the liver and kidneys still is under review.5 Anti-inflammatory drugs have been shown to accelerate damage and erosion of joint cartilage, advancing the osteoarthritic process. Conventional NSAIDs also are known to cause liver and kidney damage with long-term use.6 These and other statistics have lead certain investigators to conclude, "The epidemiological data highlight the importance of implementing ASA/NSAID therapy only when strictly necessary."7 Reducing Inflammation Naturally The discovery that certain natural agents produce marked anti-inflammatory effects in regards to inflammatory joint diseases presents an opportunity for naturopaths and other natural health practitioners to add an important and effective adjunct to the management of these cases. As such, a review of proven natural anti-inflammatory herbal agents enables practitioners to use these substances in a safe and responsible way to help patients eliminate or minimize reliance upon more dangerous NSAIDs and other synthetic anti-inflammatory drugs. Experimental research reveals the efficacy of many natural anti-inflammatory agents stems from their ability to modulate the activity of the enzymes, cyclooxygenase and/or 5-lipoxygenase.8 The pathophysiology of joint-inflammatory conditions involves the conversion of arachidonic acid to prostaglandin series 2 (PG-2) by the cyclooxygenase enzyme. PG-2 synthesis is known to produce a pro-inflammatory effect, exacerbating joint-inflammatory conditions. Accordingly, the conversion of arachidonic acid to leukotriene B4 (LTB-4) by the 5-lipoxygenase enzyme within white blood cells, also is known to contribute to the inflammatory process. White blood cell count in normal synovial fluid is less than 100 ml on average. However, cellular response rises to 800 ml or more in osteoarthritis, and much higher than this in rheumatoid diseases. This implicates white blood cells in the T-cell-mediated inflammatory response.9 The active constituents of anti-inflammatory herbs have been shown to block the activity of the cyclooxygenase and lipoxygenase enzymes, inhibiting the synthesis of pro-inflammatory eicosanaoids of the PG-2 and LTB-4 series. As such, these natural substances have been shown to reduce inflammation and pain associated with various types of arthritis and traumatic joint injuries. Unlike their synthetic counterparts, they have not been shown to cause erosion injury to the intestinal tract, accelerate cartilage destruction or produce liver and kidney toxicity.8 For these reasons, the following herbal agents can be considered viable alternatives to the use of conventional anti-inflammatory drugs in a large percentage of arthritic patients and those suffering from other joint-inflammatory conditions. Effective Anti-inflammatory Herbs and Supplements Curcumin is the active anti-inflammatory agent found in the spice turmeric. It has been shown to inhibit the activity of the 5-lipoxygenase and cyclooxygenase enzymes, blocking the synthesis of pro-inflammatory eicosanoids (PG-2, LTB-4). A large double-blind study demonstrated that curcumin was as effective as the powerful NSAID phenylbutazone (Butazolidine) in reducing pain, swelling and stiffness in patients with rheumatoid arthritis. It also has been shown to be effective in the treatment of post-surgical inflammation. Other studies indicate curcumin can lower histamine levels and is a potent antioxidant. These factors also might contribute to its anti-inflammatory capabilities. For best results, practitioners should consider using a 95 percent standardized extract of curcumin derived from turmeric. As a single agent, the daily dose to consider is 400-600 mg, taken one to three times per day. Lower doses can be used if part of a combination formula containing other anti-inflammatory agents. Side effects are rare, but primarily include heartburn and esophageal reflux. Since curcumin inhibits the cyclooxygenase enzyme system, it might reduce platelet aggregation and thus, may potentiate the effects of anti-coagulant drugs. To date, no bleeding disorders have been reported with curcumin supplementation, but its concurrent use with warfarin (Coumadin) should be considered a contra-indication.2,8,10-14 Boswellia. In clinical studies, the gum resin of the boswellia tree (yielding 70 percent boswellic acids) has been shown to improve symptoms in patients with osteoarthritis and rheumatoid arthritis.12,13 Research indicates that boswellic acids inhibit the 5-lipoxygenase enzyme in white blood cells. As a single agent, the usual dose is 150 mg, taken one to three times per day. Lower doses are effective when combined with other natural anti-inflammatory agents. Boswellia appears to have no important side effects or drug-nutrient interactions.15,16 White-willow bark extract provides anti-inflammatory phenolic glycosides such as salicin, which have been shown to be effective in the treatment of arthritis, back pain and other joint-inflammatory conditions. These phenolic glycosides are known to inhibit cyclooxygenase, blocking the production of PG-2 and exert a mild analgesic effect. Unlike ASA (synthetic acetylsalicylic acid), naturally occurring salicin (salicylic acid) does not irreversibly inhibit platelet aggregation, reducing the potential for a bleeding disorder. White-willow extract has been shown to be slower-acting than ASA, but of longer duration in effectiveness. The usual dose is 20-40 mg of salicin, one to three times per day (100 mg of white-willow extract at a 15 percent standardized extract of salicin content yields 15 mg of salicin per dose). A lower dose can be used if part of a combination formula containing other anti-inflammatory agents. Side effects are rare, but primarily include nausea, headache and digestive upset. Contra-indications might include conditions where ASA is contraindicated including gout, diabetes, hemophilia, kidney disease, active peptic ulcer, glucose-6-phosphate dehydrogenase deficiency, and possibly asthma. However, the salicin content in a single dose of white-willow extract is very low compared to the acetylsalicylic acid content of ASA (15 mg vs. 320 mg ). Thus, these conditions might not be absolute contraindications for the use of white-willow bark extract. It's important to realize that besides salicin, white-willow extract contains other phenolic glycosides, which are also known to possess anti-inflammatory properties.8,17-19 Ginger root extract contains oleo-resins that have shown clinical benefit in the management of various arthritic and muscle inflammation problems, including rheumatoid arthritis, osteoarthritis and myalgias. The active constituents are gingerols (oleo-resins), which inhibit the cyclooxygenase and lipoxygenase enzymes. The usual dose is 500 mg, one to three times daily, standardized to 5 percent gingerol content. A lower dose can be used if part of a combination formula containing other anti-inflammatory agents. Side effects are rare, but include heartburn and digestive upset. It should not be given to patients with gallstones. It also might induce a mild anticoagulant effect (by inhibiting cyclooxygenase enzyme in platelets), therefore it should not be taken concurrently with warfarin (Coumadin). However, there are no reports of bleeding disorders with ginger supplementation and no adverse drug-nutrient interactions have been reported in the scientific literature to date.2,8,14,20,21 Bromelain contains anti-inflammatory enzymes that have proven ability to suppress the inflammation and pain of rheumatoid arthritis and osteoarthritis, sports injuries and other joint-inflammatory conditions. Bromelain has been shown to inhibit the cyclooxygenase enzyme, inhibiting the synthesis of PG-2. Bromelain also helps to break down fibrin (fibrinolytic), thereby minimizing local swelling. The usual dose is 400 mg, one to three times per day. A lower dose can be used as part of a combination anti-inflammatory formulation. Bromelain might inhibit platelet clotting and is known for its fibrinolytic properties. Therefore, it might potentiate the effects of anticoagulant drugs such as warfarin (Coumadin) and should not be recommended in these cases.2,8,14,22-24 Quercetin is a bioflavonoid compound that blocks the release of histamine and other anti-inflammatory enzymes at supplemented doses (minimum 100-1,500 mg per day). Although human studies with arthritic patients are lacking at this time, anecdotal evidence is strong for this application as is experimental research investigation. There are no well-known side effects or drug-nutrient interactions for quercetin.14,25-27 Devil's claw contains the anti-inflammatory agent harpogoside. Devil's claw has demonstrated efficacy in the management of low back pain and is used traditionally as an anti-inflammatory by numerous southern African tribes. The usual dose is 100-400 mg, one to three times per day. A lower dose can be used if part of a combination anti-inflammatory formula. The only consistently reported side effect is mild digestive upset on rare occasions. It's contraindicated in patients with active gastric ulcers (may increase gastric acid secretion) and in patients taking warfarin (Coumadin) due to its anti-coagulant effects.8,14,28,29 Clinical Application The body of evidence supports the use of natural anti-inflammatory agents as viable alternatives to synthetic drugs or as a means to help patients lower their requirements for conventional anti-inflammatory pharmaceutical agents. A number of quality-oriented companies manufacture single and combination natural anti-inflammatory supplement products that meet the above dosage and standardized-grade criteria. Along with dietary changes to lower arachidonic concentrations, support joint cartilage synthesis and promote the formation of anti-inflammatory eicosanoids (e.g. PG-1 and PG-3), Naturopaths and other practitioners interested in more natural, safe and effective interventions to help manage joint-inflammatory conditions might consider recommending the use of these herbal and accessory nutrients as an adjunct. References
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All Rights Reserved, Naturopathy Digest, 2011.
Date Last Modified - Friday, 17-Oct-2008 12:11:20 PDT
About the Author: Dr. James Meschino practices in Toronto, Ontario. He can be contacted via his Web site: 