Treatment of arthritis by acupuncture and Chinese herbal medicine

So many people suffer from arthritis pain. Folks have come to my office for the treatment of arthritis. “Can acupuncture treat arthritis?” The subject comes up frequently. Many people are affected, or know someone who is. Not everybody knows this:

1. Acupuncture and Oriental Medicine can treat arthritis pain and potentially replace opioids.

2. Acupuncture and Oriental Medicine can help to treat opioid addiction.

3. Most health insurances cover for arthritis pain related acupuncture treatments. Furthermore, treatment of addiction is usually covered.

So far most patients only seek acupuncture treatments after exhausting all other options. Their condition then already is far progressed. I would like to convey: Acupuncture can help at any stage. As it is with almost any problem, the earlier the intervention, the more effective.

Arthritis is one major symptom of many rheumatic diseases. I would like to share some more thoughts, background information and also cutting edge research results:

Highlights

• Acupuncture can provide relief (pain, fatigue, dryness etc.) in patients with all rheumatic diseases: Acupuncture and Chinese herbal medicine can help with the management of arthritic pain.[1] Clinical trials show proof. Acupuncture can be as effective in pain management as standard pharmaceutical intervention. Acupuncture also provides relief for other symptoms of rheumatic diseases. More large scale clinical trials are currently on-going (fatigue and dryness in Sjorgens syndrome or psoriasis- relief, to name some).[2,3]

• Biomedical research and Traditional Chinese Medicine (TCM)- evolving interphase:[4,5,6]

• Efficacy of disease-modifying anti-rheumatic drugs (DMARDs) and lack thereof in some patients explained by Chinese medicine diagnosis: Latest research (2017) provides correlations between the effectiveness of certain standard care pharmaceuticals (DMARDs) for Rheumatoid Arthritis (RA) and traditional Chinese medicine patters. Researchers were able to establish, why standard care is effective in some pattern sub-groups and not in others. Differentiation by common Chinese medicine patterns provides explanations (Aiping Lyu et. al.).

• Leflunomide (Arava)- AhR activation is appears critical for RA treatment4; Ligustrazine, a constituent of Chinese Herb Chuan Xiong (Ligusticum striatum) enhances efficacy of DMARD Arava by facilitating its AhR activating potential: The AhR agonist Arava is commonly prescribed for the management of RA. It is shown to slow down bone erosion. However, in a specific sub-population of RA patients (30-50%) Arava is not effective. A common biomarker among those patients is high serum levels of C-reactive protein (CRP). Co-administration of ligustrazine, a constituent of the Chinese herb Chuan Xiong, (part of many traditional Chinese herbal formulas), was shown to attenuate RA symptoms in this patient sub-population.

For more details see below:

1. “Western View”: Classification and common symptoms of rheumatic diseases

2. “Eastern View”: Diagnosis and treatment of rheumatic diseases/ arthritis with acupuncture and oriental medicine

3. Research/ Interphase of biomedical research and traditional Chinese medicine (TCM)- Leflunomide is an AhR activator

1. “Western View”: Classification and common symptoms of rheumatic diseases

The term arthritis is commonly used. Among other symptoms it is part of the presentation of several rheumatic diseases.[3] Rheumatic diseases are sub-divided into

• Seropositive (RA, Systemic lupus erythematosus (SLE), Scleroderma, Sjögren’s syndrome) which are all connective tissue disorders. Furthermore vasculititis also belongs to this group (Polyarteritis nodosa (PAN), Wegener’s granulomatosis, Giant cell arteritis).

• Seronegative (Ankylosing spondylitis (AS), Psoriatic arthritis, Inflammatory bowel disease (IBD) and

• Crystal induced (Gout, Pseudogout)

• Degenerative (osteoarthritis OA) sub-goups. Furthermore

• Fibromyalgia as well as Polymyalgia Rheumatic (which are not specific to joints, “non-articular” are also considered rheumatic disorders.

According to the Arthritis Foundation, RA is the second most common type of arthritis. It affects approximately 1.3 million people in the United States, of which 70 percent are women. Each type of arthritis has very different causes, risk factors and effects on the body. Yet they often share a common symptom: persistent joint pain. Standard care pharmaceutical care comprises:

Drugs that ease symptoms

Nonsteroidal anti-inflammatory drugs (NSAIDs) are available over-the-counter and by prescription. They are used to help ease arthritis pain and inflammation. NSAIDs include ibuprofen, ketoprofen and naproxen sodium and others. For people who have had or are at risk of stomach ulcers, the doctor may prescribe celecoxib, a type of NSAID called a COX-2 inhibitor, which is designed to be safer for the stomach. These medicines can be taken by mouth or applied to the skin (as a patch or cream) directly at a swollen joint.

Drugs that slow disease activity

Corticosteroids. Corticosteroid medications, including prednisone, prednisolone and methyprednisolone, are potent and quick-acting anti-inflammatory medications. They may be used in RA to get potentially damaging inflammation under control, while waiting for NSAIDs and DMARDs (below) to take effect. Because of the risk of side effects with these drugs, doctors prefer to use them for as short a time as possible and in doses as low as possible.

DMARDs. An acronym “for disease-modifying antirheumatic drugs”, DMARDs are drugs that work to modify the course of the disease. Traditional DMARDs include methotrexate, hydroxycholorquine, sulfasalazine, leflunomide, cyclophosphamide and azathioprine. These medicines can be taken by mouth, be self-injected or given as an infusion in a doctor’s office.

Biologics. These drugs are a subset of DMARDs. Biologics may work more quickly than traditional DMARDs, and are injected or given by infusion in a doctor’s office. Because they target specific steps in the inflammatory process, they don’t wipe out the entire immune response as some other RA treatments do. In many people with RA, a biologic can slow, modify or stop the disease – even when other treatments haven’t helped much.

JAK inhibitors. A new subcategory of DMARDs known as “JAK inhibitors” block the Janus kinase, or JAK, pathways, which are involved in the body’s immune response. Tofacitinib belongs to this class. Unlike biologics, it can be taken by mouth.

Tight control. Getting disease activity to a low level and keeping it there is what is called having “tight control of RA.” Research shows that tight control can prevent or slow the pace of joint damage.

Surgery. Last resort.

Acupuncture and Oriental Medicine can help, supportive to standard pharmaceutical care.

2. “Eastern View”: Diagnosis and treatment of arthritis with acupuncture and Oriental medicine Arthritis is one of the main symptoms of most rheumatic diseases. Arthritis is thought to develop when the continuous flow of “Qi” in the “meridians” becomes interrupted or obstructed.* The TCM term for such obstruction is “Bi-Syndrome”.

Common arthritis symptoms resulting from the obstruction are pain, soreness, numbness and/or stiffness. The overall Bi-Syndrome is sub-categorized into different types, depending of what is thought to be the main contributing factor/ pathogen. Pathogens in TMC are wind, cold, dampness or heat, based on. Diagnosis occurs by the TCM practitioner, utilizing typical TCM tools (e.g. pulse and tongue diagnosis). It is successfully treated by using a combination of TCM treatment modalities, including acupuncture and Chinese herbology. The acupuncture point combinations and herbs are tailored to the specific presentation of arthritis. Acupuncture and Oriental medicine aim to treat the specific symptoms, unique to each individual. Ten different patients coming to a TCM practitioner for joint pain, likely will be treated by using ten different acupuncture point combinations, based on each individual needs.

TCM treatment of psoriatic arthritis (PA): PA is a joint disease that affects people who suffer from psoriasis. PA can have acute episodes and also periods of remission with little to no symptoms presented. The most common symptoms of psoriatic arthritis include joint pain, stiffness, swelling and redness. Any of the joints in the body can be affected. When the spinal column is affected, spondylitis (s.a.) may develop. When the hands or feet are affected, they may become moderately to severely physically deformed.

At each state of the disease acupuncture can be highly beneficial. During times of remission, acupuncture can help strengthen the immune system and reduce the frequency, duration and severity of flare-up episodes. At the stage of flare up acupuncture can reduce the severity of symptoms. There's no reason to be hesitant of utilizing acupuncture during flare-up. Practitioners generally will only use acupuncture point combinations, avoiding areas of inflammation. Pain and other symptoms of psoriatic arthritis may fade away with regular acupuncture treatments. Your practitioner also may suggest dietary adjustments to support the healing process. Some alterations include avoiding sugary, spicy and fried foods and reduce dairy intake.

3. Research/ Interphase of Biomedical Research and TCM

TCM and DMARDs: Acupuncture and Chinese herbal medicine can help alleviate the symptoms of for symptoms of rheumatic diseases such as arthritis pain, bone erosion, psoriasis. RA especially was in the spotlight in 2017: Tremendous progress was made towards unraveling the mechanism of action of the RA DMARD Arava (leflunomide).

Standard care medications are not effective in all RA patients. In an attempt to explain why some patients benefit and others do not, large population studies were conducted: RA patients were sub-grouped by TCM patterns (primarily hot vs cold pattern). Clear correlations of between drug efficacy and a specific TCM patterns were detected. Results were presented at a symposium at Harvard Medical School in June 2017 by researchers from Hongkong Baptist University. In fact, the DMARDs methotrexate (MTX) and sulfasalazine (SSZ) were found to be efficacious in a subgroup of RA patients, diagnosed by TCM practitioners with a “cold pattern”.[4] (Aiping Lyu et.al.) Furthermore, it was shown that this set of pharmaceuticals was not effective in RA patients diagnosed with a TCM “hot pattern”. In a different study, investigating the DMARD leflunomide a similar trend was shown.[4] (Ge Zhang et.al.) Leflunomide prevents/ attenuates bone erosion in patients with C-reactive protein (CPR) low base line serum levels, but not in patients with CPR high baseline levels. In addition the researchers presented, leflunomide can be “activated” by co-administering ligustrazine, a component derived from Chuan Xiong, a plant used in Chinese herbology for more than 2000 years. Data were presented, showing efficacy of standard care arthritis treatment (Leflunomide) can be enhanced/ facilitated in the patient population with CPR high baseline levels as well as in animal models. Evidence was given that the effect was achieved ligustrazin’s ability to decrease HIF1a formation and thus allow leflunomide to activate AhR (Ge Zhang et.al.).[4] The overall findings were:

• Progressive bone erosion (PBE+) could be predicted by high baseline CPR levels in a substantial proportion of both, RA patients and CIA rats after receiving leflunomide.

• Leflunomide plays concurrent actions including DHODH immunomodulation and the by Zhang et. al. newly discovered AhR mediated CPR regulatory in CPRBL RA individuals.

• High hepatocyte CRP induces aberrant expression of HIF1a, which competitively binds ARNT, leading to ineffective AhR activation and CRP inhibition by leflunomide in CRPBH RA individuals.

• Ligustazine is screened as a candidate with clinical approval, predicted to have a high inhibitory effect on HIF1a and only few predicted overlapping adverse effects and no major structural similarity with leflunomide.

• Ligustrazine indeed could suppress HIF1a to facilitate leflunomide activating AhR to inhibit CPR production and attenuate bone erosion in CIA rats with CPRBH.

• This study not only advances mechanistic understanding of actions for leflunomide but also presents a precision medicine based therapeutic strategy i.e. ligustrazine could facilitate leflunomide inhibiting CPR production and attenuating bone erosion in CPRBH patients.

The Chinese Herbal formula Gui Zhi Shao Yao Zhi Mu Tang is commonly used for the treatment of Rheumatoid Arthritis by Chinese Medicine practitioners with good response rates. Huang et.al. investigated the biomedical mechanism of this Chinese Herbal formula and published preliminary results in Nature/ Scientific Reports.[6]

Acupuncture for pain relief: A systematic review conducted by researchers at Memorial Sloan Kettering Cancer Center (New York, NY) provided evidence for sustained relieve from pain (not limited to arthritic pain) achieved by acupuncture. It was concluded, the analgesic effects of acupuncture are superior to sham controls and the pain relief persists over time. The research team concluded that acupuncture is an effective treatment modality for chronic pain and referral to an acupuncturist is a reasonable treatment option.[1] A pilot study found in the medical publication International Journal of Rheumatic Diseases 2010, demonstrated the safety and efficacy of acupuncture in the treatment of rheumatoid arthritis (RA). The study criteria focused on the disease activity, pain scores, functional ability and quality of life issues for the study participants. The study, conducted at Kwong Wah Hospital in Hong Kong, provided an average of 14 acupuncture sessions for each patient. The overall documented improvement was significant enough to conclude that acupuncture is a viable treatment method to reduce pain and other symptoms of RA.[5]

*Traditional Chinese Medicine (TCM) conceptual thinking often relates to terms like Qi and meridians. Even though TCM becomes more widely accepted and many health insurance companies are now paying for acupuncture services, these terms still carry a mystical component. A separate blog, planned for the near future, is going to be focused latest research results, unraveling the concept of qi and trying to understand and explain the mechanism of acupuncture.

References:

1. Vickers, A.J. et. al. "Acupuncture for chronic pain: update of an individual patient data meta-analysis." The Journal of Pain (2017).

2. a. Jiang et al. ”Acupuncture for Primary Sjögren Syndrome (pSS) on symptomatic improvements: study protocol for a randomized controlled trial” BMC Complementary and Alternative Medicine (2017). b. Hindawi Publishing Corporation, Evidence-Based Complementary and Alternative Medicine, Volume 2016, Article ID 3164105, 13 pages, http://dx.doi.org/10.1155/2016/3164105 (2016).

3. Davis J.M. et. al., “My Treatment Approach to Rheumatoid Arthritis”, Mayo Clin. Proc.;87(7):659-673 (2012).

4. Traditional Chinese and Western Medicine- What can we learn from each other? Boston, June 20 - 21, Joseph B Martin Conference Center (2017). https://tcmsymposium.hms.harvard.edu/video-recordings

5. Lao WN et al. Effects of Acupuncture on Rheumatoid Arthritis. International Journal of Rheumatic Diseases. Conference: 14th Congress of Asia Pacific League of Associations for Rheumatology, APLAR 2010 Hong Kong. Conference Publication; 13: 231 (2010).

6. Huang L et.al. “Deciphering the Potential Pharmaceutical Mechanism of Chinese Traditional Medicine” (www.nature.com/scientificreports/) on Rheumatoid Arthritis www.nature.com/scientificreports/ (2016).