Herbal Medications Commonly Used in the Practice of Rheumatology: Mechanisms of Action, Efficacy, and Side Effects

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Objective

To review the literature on herbal preparations commonly utilized in the treatment of rheumatic indications.

Methods

Search of MEDLINE (PubMed) was performed using both the scientific and the common names of herbs. Relevant articles in English were collected from PubMed and reviewed.

Results

This review summarizes the efficacy and toxicities of herbal remedies used in complementary and alternative medical (CAM) therapies for rheumatologic conditions, by elucidating the immune pathways through which these preparations have antiinflammatory and/or immunomodulatory activity and providing a scientific basis for their efficacy. Gammalinolenic acid suppresses inflammation by acting as a competitive inhibitor of prostaglandin E2 and leukotrienes (LTs) and by reducing the auto-induction of interleukin1α (IL-1α)-induced pro-IL-1β gene expression. It appears to be efficacious in rheumatoid arthritis (RA) but not for Sjogren’s disease. The antiinflammatory actions of Harpagophytum procumbens is due to its action on eicosanoid biosynthesis and it may have a role in treating low back pain. While in vitro experiments with Tanacetum parthenium found inhibition of the expression of intercellular adhesion molecule-1, tumor necrosis factor alpha (TNF-α), interferon-γ, IκB kinase, and a decrease in T-cell adhesion, to date human studies have not proven it useful in the treatment of RA. Current experience with Tripterygium wilfordii Hook F, Uncaria tomentosa, finds them to be efficacious in the treatment of RA, while Urtica diocia and willow bark extract are effective for osteoarthritis. T. wilfordii Hook F extract inhibits the production of cytokines and other mediators from mononuclear phagocytes by blocking the up-regulation of a number of proinflammatory genes, including TNF-α, cyclooxygenase 2 (COX-2), interferon-γ, IL-2, prostaglandin, and iNOS. Uncaria tomentosa and Urtica diocia both decrease the production of TNF-α. At present there are no human studies on Ocimum spp. in rheumatic diseases. The fixed oil appears to have antihistaminic, antiserotonin, and antiprostaglandin activity. Zingiber officinale inhibits TNF-α, prostaglandin, and leukotriene synthesis and at present has limited efficacy in the treatment of osteoarthritis.

Conclusions

Investigation of the mechanism and potential uses of CAM therapies is still in its infancy and many studies done to date are scientifically flawed. Further systematic and scientific inquiry into this topic is necessary to validate or refute the clinical claims made for CAM therapies. An understanding of the mechanism of action of CAM therapies allows physicians to counsel effectively on their proper and improper use, prevent adverse drug-drug interactions, and anticipate or appreciate toxicities.

Relevance

The use of CAM therapies is widespread among patients, including those with rheumatic diseases. Herbal medications are often utilized with little to no physician guidance or knowledge. An appreciation of this information will help physicians to counsel patients concerning the utility and toxicities of CAM therapies. An understanding and elucidation of the mechanisms by which CAM therapies may be efficacious can be instrumental in discovering new molecular targets in the treatment of diseases.

Section snippets

Methods

English-language literature from 1966 to 2004 was searched using PubMed as the database. Key words used include the scientific, common, and traditional names of herbs commonly used in the treatment of rheumatic conditions. Data extracted include indications for usage, mechanisms of action, therapeutic value, and side effects of these herbs.

Gammalinolenic Acid

Gammalinolenic acid (GLA), an unsaturated fatty acid, is found in the oils of evening primrose (Oenothera biennis), borage seed (Boragio officinalis), and black currant seed (Ribes nigrum). It is thought to be effective in decreasing joint inflammation in patients with rheumatoid arthritis (RA) and the sicca symptoms of Sjogren’s syndrome. A diet rich in evening primrose oil has been found to elevate the serum concentration of GLA. GLA is metabolized to dihomogammalinolenic acid (DGLA), the

Discussion

Herbal medications, a major component of CAM therapy, are becoming increasingly popular and are of much interest to the public and health care providers. Many patients use CAM therapy thinking that natural remedies with a long history of use are safe, without any knowledge of their true clinical efficacy or side effects. Guidance to inquiring patients by their health care providers is often limited by a lack of familiarity of the practitioner with these compounds. Even if the practitioner has

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