Wednesday, December 7, 2011

I'm skeptical about some suggestions for arthritis

There's an old saying in medicine: "Use the new medicine while it still works." This is more than just a cute quip. The saying encompasses a few different phenomena. When a drug is tested on a few thousand people, the luck of the draw may show a greater effect than would be seen in a larger, more diverse population. Also, less common side effects will become more evident in a larger sample. Once several million people take the drug, it may turn out that the drug isn't as spectacular in a large, diverse population, and that certain side effects, though rare, are serious.

This is one of the reasons I'm a very conservative and skeptical physician. Today's miracle drug may be tomorrow's Vioxx. Less conservative doctors may make much more enthusiastic recommendations. I found one physician promoting pomegranate juice for rheumatoid arthritis (or at least linking to the article on Joe Mercola's site without comment). It sounds harmless enough, but what's the evidence? (You can hunt for the page yourself; I'm not linking to Mercola.)

The statement is based on a pilot study out of Israel consisting of data from six patients. The measures used seem quirky, but are irrelevant anyway. There are no conclusions that can be drawn from such a small sample. Despite this, the authors conclude (and Mercola and the doctor who posted the link presumably endorse) that, "Dietary supplementation with pomegranates may be a useful complementary strategy to attenuate clinical symptoms in RA patients."

Really? Based on what?

Well, based on a somewhat plausible idea, but that's it. Rheumatoid arthritis (RA) is a serious, often debilitating disease. Medicine has made some big improvements in its treatment over the last decade or so with new immune-modulating medications (so-called DMARDs, or disease-modifying anti-rheumatic drugs). And a brief mention of pomegranate juice may not be all that insane, but what follow on Mercola's website is pretty frightening.

Mercola specifically warns that juices contain lots of sugar and should be used sparingly. After that bit of sensible advice, he goes on to talk about his own treatments for RA, treatments unrecognizable to any well-trained internist or rheumatologist:

While pomegranate shows promise against RA joint pain and inflammation, I'd like to remind you of the more basic factors that can have a major impact on this disease. The treatment protocol I use for rheumatoid arthritis has helped thousands of RA patients go into remission, and one of the key factors that dramatically improved the response rate to my protocol was the dietary modification.

I cannot emphasize strongly enough the importance of this aspect of the program. It is absolutely an essential component of the RA protocol.

These dietary principles include:
--eliminating sugar and most grains,
--eating unprocessed, high-quality foods, organic and locally-grown if possible,
--eating your food as close to raw as possible, and
--getting plenty high-quality animal-based omega-3 fats, such as krill oil

Following these general guidelines alone will go a long way to dramatically reduce your risk of developing any kind of problem with chronic inflammation.

None of these suggestions have anything to do with the mechanisms of RA, mechanisms that are very complex but whose elucidation has led to the development of very successful DMARDs. There is no evidence that "raw food" or sugar and grain have anything to do with RA.

He then goes on to tout a real drug, naltrexone, as an effective agent in RA. Naltrexone is an interesting drug, one that has been used to treat substance use disorders such as alcoholism (and has been extolled as a miracle drug by some). But any effects it may have in an RA patient (and none have held up in the literature) would likely be due to its affinity for opiate receptors rather than anti-disease effects. In other words, even if naltrexone were to help (and it's not clear that it does), it wouldn't slow the destruction of joints, something that DMARDs can do.

My point here isn't that Joe Mercola is a modern snake-oil salesman. He is what he is: a family doc who, in my opinion, gives out lots of useless advice without sufficient evidence. But I expect most doctors to be a bit more skeptical. Well-trained physicians know that the latest thing may not be the latest good thing. Without real evidence guiding treatment, we're just making things up. Doctors who make things up are dangerous.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog, White Coat Underground. The blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.

Labels: alternative medicine, arthritis, diet, evidence-based medicine, guest post, Peter A. Lipson, rheumatology, White Coat Underground

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William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

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Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

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Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

White Coat Underground
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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Wednesday, December 7, 2011

I'm skeptical about some suggestions for arthritis

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