Fish Oil: will you now use this for Rheumatoid Arthritis?

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Courtesy of photobucket.com

Courtesy of photobucket.com

 

By Dr Roberto Russo, Rheumatologist

Fish oil has literally become the flavour of the month!

So much so that there are now a host of variants available on the shelf, including Super Fish oil, liquid fish oil, and Krill oil, with each option promising an advantage over the other! The popularity of the product seems to be ever increasing, particularly in the management of cardiovascular disease and joint conditions. The latter is the primary focus of this article.

The beneficial constituents of Fish oil are the omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexanoic acid (DHA). These have been shown to suppress inflammatory mediators including:

  • Proinflammatory lipid mediators
    • Prostaglandin E2
    • Leukotriene B4
  • Peptide mediators
    • TNF-alpha
    • IL-1 beta

These are effectively the same inflammatory mediators that are inhibited by the use of NSAIDs and the biological TNF blockers (albeit at a much lesser extent), thereby providing a biological plausibility to their use (especially in inflammatory joint conditions)!

However, the amount of EPA+DHA required to obtain symptomatic benefit in this context is relatively high at greater than 2.7g each day, which is more than is required for cardiovascular benefit.

The standard Fish oil capsule contains about 400mg of EPA+DHA and as such a patient would need to take at least 7 of those capsules a day, which would challenge even the most ardent of patients to comply with such a regime!! No wonder there are so many options available (as mentioned above).

But does Fish oil have a real benefit in patients with Rheumatoid arthritis, especially in the context of the modern management of the disease, which often involves the use of a combination of immunomodulating drugs to render the disease into remission?

That is the exact question that a group of our colleagues from South Australia set out to answer.

They chose to divide a cohort of patients with early Rheumatoid arthritis (defined as <12 months) into two groups, whereby one received 10mL of liquid Fish oil (providing 5.5g/day) and the other a low dose equivalent to 400mg/day, which is the dose often taken for cardiovascular disease.

Both groups were then treated for their disease according to the current standard approach, whereby disease modifying medications (DMARDs) were introduced in sequential order (including TNF blockers if required), with the aim being to achieve remission (a strategy termed treat to target).

What they found was the group receiving a high dose of Fish oil:

  • Required a shorter time to achieve a meaningful improvement in their disease control
  • Achieved a higher the rate of remission (according to the American College of Rheumatology criteria)
  • Had a lower failure rate to triple DMARD therapy, thereby requiring less use of TNF blockers
  • Required less use of NSAIDs

No differences though were found in overall disease activity, dose of Methotrexate or Prednisone used, or physical function.

The concern for an increased risk of bleeding was not found in their study, albeit I would remain cautious in prescribing Fish oil in those on blood thinning medications such as Warfarin or a combination of anti-platelet agents.

In conclusion, it would appear that there are indeed benefits to be gained with the use of high dose Fish oil as an adjunct to the current approach of treating Rheumatoid arthritis.

I would encourage you to read the article in full, which can be found in the Annals of Rheumatic Diseases (reference given below).

Whilst I am already in the habit of suggesting my patients take Fish oil, these results strengthen my conviction in this recommendation and remind me to ensure they are taking a sufficient amount.

I look forward to reading similar high quality research regarding the use of Fish oil in other joint diseases, especially in Osteoarthritis.

If you are a doctor, I would be most interested to know if you recommend fish oil, and if so what doses to you suggest?

If you are a patient, have you been recommended fish oil, and if so what doses do you take?

Reference: Proudman SM, James MJ, et al. Fish oil in recent onset Rheumatoid arthritis: a randomised, double-blind controlled trial within algorithm-based drug use. Annals of Rheumatic Disease, 2013; 0: 1-7. doi:10.1136/annrheumdis-2013-204145

Can reducing stress on the legs of Mice teach us about Spondyloarthritis?

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http://i650.photobucket.com/albums/uu221/dunc_89/mouse-cute.jpg

Courtesy of photobucket.com

By Dr Irwin Lim, Rheumatologist

Professor Dirk Elewaut visited us at our Parramatta clinic today. He’s on a speaker tour around Australia and kindly agreed to come to talk to our team (I’m really ticked off that I forgot to get a photo for this post).

He talked about many aspects of Ankylosing Spondylitis (AS) and spondyloarthritis (SpA). It was entertaining and engaging. One particular topic has been playing on my mind so I thought I’d give you my simple man’s interpretation.

In a series of experiments, his group looked at how mechanical stress can lead to enthesitis (learn about enthesitis here) and new bone formation, features common to AS/SpA.

  • They convinced some genetically modified mice to take part. These mice get a spondyloarthritis-type disease.
  • The first signs of inflammation in these mice occur at the enthesis, and typically at the achilles tendon insertion and/or plantar fascia insertion.
  • When they looked under a microscope, these areas in these mice show lots of inflammatory cells. This is what would be expected.
  • They then (as ethically & comfortably as possible) suspended the hind limbs of the mice. This meant that there was much reduced load on these hind limbs.
  • In these unloaded hind limbs, there was very much less accumulation of inflammatory cells at the enthesis. There is also less new bone formation.

The conclusion is that these findings provide proof of the concept that actual mechanical strain drives both entheseal inflammation and new bone formation (click here for the abstract).

Now, mice and humans are quite different.

But, let’s assume that these findings can be applied to patients with SpA.

We know our patients with AS and SpA get a lot of heel pain and achilles problems, in addition to enthesitis elsewhere.

If a trigger for this is mechanical load or stress, some questions arise:

  • is this why males get the disease in their early adulthood when they’re running around and playing more vigorous sport?
  • exercise usually helps patients with AS and SpA greatly but could it possibly be detrimental?
  • perhaps, the type of exercise matters more: high impact like jogging versus lower impact like swimming
  • is a desk-based sit-on-your-bum job better than a stand-all-day type of job?

I am by no means advocating stopping or changing exercise if you have AS or SpA. We just don’t know yet.

A lot more research in mice (they’re convincing some mice to now run very far and very fast to see what this does to the entheseal region) and some research in humans will be needed.

But, I thought it would be interesting for you to ponder.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
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An Easy Case of Rheumatoid

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By Dr Irwin Lim, Rheumatologist

My rheumatology colleague, Andrew Jordan just presented a rheumatoid arthritis case at our GP meeting.

A 60-something year-old lady presenting with swelling and pain involving the small joints of her hands. Early morning stiffness and some carpal tunnel symptoms. A pretty classic story.

The diagnosis was made even easier by the presence of an elevated rheumatoid factor in her blood tests, and raised inflammatory markers.

The GP was astute and referred her early. She presented to a rheumatologist within 2 months of the onset of her symptoms.

Methotrexate was commenced with a small dose of Prednisone to help calm her symptoms. Within a few weeks, Prednisone had been weaned and ceased. She continued only on Methotrexate and was doing well.

One and a half years since her presentation, she remains in remission, both from her point of view and from the point of view of DAS-28 remission. She is symptom-free with absence of synovitis, the swelling rheumatologists look for when they examine joints.

All this on Methotrexate alone. 2 small tablets (10mg each) once a week only.

Easy.

This is a near-perfect example of the window-of-opportunity.

Rob Russo then made a telling comment. A decade or two ago, it would be strange to talk about an “easy” case of rheumatoid.

And of course, many cases don’t pan out like this. Some patients have terribly aggressive disease. Sometimes, there are all sorts of logistical issues preventing early rheumatology review and early treatment.

There’s a lot of debate currently about the very expensive treatments we use for rheumatoid (read about triple therapy vs biologics).

There are massive cost savings to be had if we can treat patients early.

Within this window-of-opportunity, Methotrexate, a very cheap medication, works well for those who tolerate it.

Within this window-of-opportunity, this difficult disease becomes somewhat easier.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
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Dinner Meeting vs Webinar for a GP talk

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By Dr Irwin Lim, Rheumatologist

2 more GP talks will end my speaking engagements for the year.

Next week, with my fellow rheumatologists, Herman Lau, Andrew Jordan & Roberto Russo, we’ll be presenting cases to highlight how ideas have changed surrounding a variety of the inflammatory conditions we treat.

This will be held in a private room at a local restaurant in the Hills District of Sydney. Dinner meetings rely on doctors being energetic enough after a long day at work to attend a talk. The dinner is usually so-so. The GPs listen and hopefully engage for a couple of hours. With Sydney traffic, it’s usually a fight to get to the venue. If the weather is bad, turn-out suffers.

We expect up to 15 GPs to turn up. Sydney GPs are apparently spoiled for choice with a variety of evening talks from different specialities through the week so turn out tends to be variable.

The following week, I’m presenting a webinar, my second (read about my 1st experience here).

It’s much more convenient for me. I’ll be home. No added travel. After the webinar, I can immediately get on with my usual routines.

I assume it’s more convenient for the GPs as well. I hope the webinar attracts different GPs, with different commitments, and at different stages of their lives.

ehealthspace invite

This time, we are aiming for a wider audience. The web solution being used can apparently cope with 50 people watching the webinar. Hopefully, there’s actually that much interest!

Still, it is a commitment to attend, either in person or on the computer. GPs are time-poor and many different craft groups are fighting for their attention. I’m not sure how they choose and it’s likely the GPs in most need of an update are least likely to attend.

So, trialling new ways to reach a broader audience and to make it easier to listen seems sensible.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
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Is it easy to forget to see your rheumatologist?

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A 6yo's interpretationBy Dr Irwin Lim, Rheumatologist

Saw a patient last week after an absence of 13 months.

Life apparently got busy and he “forgot”. At least, that was the reason given.

He’s on a disease modifying agent (a DMARD), which usually requires regular monitoring blood tests. He “forgot” these.

He didn’t attend his GP either. So no regular monitoring of any sort.

He’s now back because I wrote a recall letter reminding him of missed appointments and the need to be reviewed. His disease is actually relatively well controlled and thankfully, blood tests showed no organ damage.

This sort of scenario does happen from time to time. If the problem was me, I’d expect the patient to just ignore my reminder as they may be seeing some other rheumatologist or they may have decided not to be treated.

Can you help me understand this behaviour?

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
This blog focuses on arthritis, healthcare in general, and Connected Care. Please subscribe to keep in touch:
 
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