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Hypersensitivity vasculitis

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Related Terms
  • Allergic, allergic reaction, allergic vasculitis, allergy, antibodies, arthritis, blood vessels, Churg-Strauss syndrome, cutaneous leukocytoclastic vasculitis, drug-induced vasculitis, ESR, HIV, HV, hypersensitive, hypersensitivity, immune disorder, inflamed blood vessels, inflamed vessels, inflammation, kidney damage, kidney failure, leukocyte, leukocytoclastic, lupus, lupus erythematosus, neutrophils, polyarteritis nodosa, purpuric eruptions, rheumatoid arthritis, rheumatology, Sjögren's syndrome, skin biopsy, small-vessel vasculitis, systemic, vasculitis, Wegener granulomatosis, white blood cells.

Background
  • Hypersensitivity vasculitis, also known as leukocytoclastic vasculitis (LCV), is a hypersensitivity reaction to a drug or foreign agent that causes inflammation and damage to blood vessels. The condition occurs when the body produces antibodies against a foreign substance, which is usually a drug. Complexes of these antibodies are then deposited in the blood vessel walls, which causes symptoms such as fever, rash and arthritis to appear.
  • The condition may be localized to the skin or it may progress to one or more organs in the body. The internal organs most commonly affected by LCV include the gastrointestinal tract and the kidneys. The joints are also commonly affected.
  • The disorder may be acute (lasting only a few weeks) or chronic (causing recurrent purpuric eruptions). Most patients will recover completely within a couple of weeks if the disease only affects the skin and does not manifest in the organs. While most patients do not require treatment, nonsteroidal anti-inflammatory drugs (NSAIDs) and immunosuppressants may be prescribed. In severe cases, treatment with corticosteroids may be necessary.
  • The incidence of LCV in the United States is unknown, but it is considered a rare condition.

Author information
  • This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography
  1. Johns Hopkins University Vasculitis Center. . Accessed July 15, 2009.
  2. Madison's Foundation. Hypersensitivity Vasculitis. . Accessed July 15, 2009.
  3. MedlinePlus. Allergic Vasculitis. . Accessed July 15, 2009.
  4. Natural Standard: The Authority on Integrative Medicine. . Copyright © 2008. Accessed July 15, 2009.
  5. Vasculitis Foundation. Hypersensitivity Vasculitis. . Accessed July 15, 2009.

Causes
  • Researchers estimate that as many as 50% of cases are idiopathic (no known cause). The remaining 50% of cases may be the result of drugs, infections, foods or diseases.
  • Drugs: Drugs are the most common cause of hypersensitivity vasculitis. While almost any drug can cause the condition, antibiotics (particularly beta-lactams like penicillin, amoxicillin and cephalosporins) are the most likely to cause vasculitis. Nonsteroidal anti-inflammatory drugs (NSAIDs) and diuretics also frequently cause vasculitis.
  • Infections: Many types of infections have been associated with hypersensitivity vasculitis. Upper respiratory tract infections (particularly beta-hemolytic streptococcal infection) and viral hepatitis are most often implicated. In addition, HIV infection may also be associated with some cases of vasculitis.
  • Food: Foods or food additives may cause vasculitis.
  • Diseases: Collagen vascular diseases (immune disorder that damages the tendons, bones, and connective tissues, which are made from collagen) account for 10-15% of cases of vasculitis. In particular, rheumatoid arthritis, Sjögren's syndrome (autoimmune disease that destroys the glands that produce tears and saliva) and lupus erythematosus (autoimmune disorder that causes skin lesions) have been associated with vasculitis. Also, Wegener granulomatosis (type of vasculitis that affects the lungs, kidneys and other organs), polyarteritis nodosa (autoimmune disorder that causes inflammation of the small and medium-sized arteries) and Churg-Strauss syndrome (connective tissue disease that causes vasculitis) have also been associated with vasculitis. Inflammatory bowel disease (ulcerative colitis or Crohn's disease) may also be associated with hypersensitivity vasculitis.

Symptoms
  • Symptoms often include skin lesions (usually on the legs, buttocks or trunk of the body), palpable purpura (bleeding into the skin), multiple papules (small, raised areas on the skin), blisters on the skin, urticaria (hives), itchy skin, burning sensations, enlarged lymph nodes and necrotic ulcers (open sores with dead tissue).
  • Complications may include permanent damage to the blood vessels or skin with scarring. Organ involvement in addition to rash formation is rare, but it can cause severe complications. Kidney inflammation, as well as lung, heart or brain damage has occurred in patients with hypersensitivity vasculitis.

Diagnosis
  • The American College of Rheumatology developed diagnostic criteria for LCV. Patients must meet at least three of the four criteria: 1) Older than 16 years of age 2) Use of a drug before symptoms developed 3) Skin rash is present 4) A skin biopsy shows neutrophils (type of white blood cell) around a small blood vessel.
  • Skin biopsy: A skin biopsy is most often performed to confirm a diagnosis. During the procedure, a small sample of skin tissue is removed and analyzed under a microscope in a laboratory. The analysis will determine whether vasculitis is present.
  • ESR: An erythrocyte sedimentation rate (ESR) test may be conducted to monitor the patient's condition. The one-hour test measures the distance (in millimeters) that red blood cells settle in unclotted blood toward the bottom of a test tube.
  • Urine sample: A physician can detect kidney inflammation after evaluating a urine sample. Kidney inflammation is indicated when the urine contains a small amount of blood or protein.

Treatment
  • If possible, exposure to the causative medication (or other antigen) must be discontinued. Most patients recover without treatment. Treatment is aimed at reducing the inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs) and immunosuppressants may be prescribed. In severe cases, treatment with corticosteroids may be necessary.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs): Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Advil® or Motrin®) have been used to reduce inflammation associated with vasculitis.
  • Immunosuppressants: Immunosuppressants like azathioprine (Imuran®) are commonly used to treat patients who have autoimmune disorders like Wegener granulomatosis or Churg-Strauss syndrome, which are often associated with vasculitis.
  • Corticosteroids: Corticosteroids like prednisone (Deltasone®) have been used to reduce inflammation caused by ulcers. Treatment generally lasts from one to two weeks.

Integrative therapies
  • Good scientific evidence:
  • Borage seed oil: Preliminary evidence suggests that gamma linolenic acid (GLA) may have anti-inflammatory effects that may make it beneficial in treating rheumatoid arthritis. Additional research is needed to determine the optimal dose and administration.
  • Avoid if allergic or hypersensitive to borage, its constituents, or members of the Boraginaceae family. Use cautiously in patients with bleeding disorders or in those taking warfarin or other anticoagulant or antiplatelet (blood thinning) agents. Use cautiously in patients with epilepsy or in those taking anticonvulsants. Avoid in patients with compromised immune systems or similar immunological conditions. Avoid during pregnancy and breastfeeding.
  • Bromelain: Some physicians use bromelain, an enzyme derived from pineapple, to help reduce inflammation. It is sometimes recommended to be taken with turmeric (Curcuma longa), which may enhance the effects of bromelain.
  • Avoid if allergic to bromelain, pineapple, honeybee, venom, latex, birch pollen, carrots, celery, fennel, cypress pollen, grass pollen, papain, rye flour, wheat flour, or members of the Bromeliaceaefamily. Use cautiously with a history of bleeding disorders, stomach ulcers, or heart, liver, or kidney disease. Use caution before dental or surgical procedures or while driving or operating machinery. Avoid if pregnant or breastfeeding.
  • DHEA (dehydroepiandrosterone): The majority of clinical trials investigating the effect of DHEA for systemic lupus erythematosus (SLE) support its use as an adjunct treatment. Additional research is needed to confirm these results.
  • Avoid if allergic to DHEA. Avoid with a history of seizures. Use cautiously with adrenal or thyroid disorders. Use cautiously if taking anticoagulants or drugs, herbs, or supplements that treat diabetes, heart disease, seizures, or stroke. Stop use two weeks before and immediately after surgery/dental/diagnostic procedures with bleeding risks. Avoid if pregnant or breastfeeding.
  • Omega-3 fatty acids, fish oil, alpha-linolenic acid: Multiple randomized controlled trials report improvements in rheumatoid arthritis, including morning stiffness and joint tenderness, with the regular intake of fish oil supplements for up to three months. Benefits have been reported as additive with anti-inflammatory medications such as NSAIDs (like ibuprofen or aspirin). However, because of weaknesses in study designs and reporting, better research is necessary before a strong favorable recommendation can be made. Effects beyond three months of treatment have not been well evaluated.
  • People who are allergic to fish should avoid fish oil or omega-3 fatty acid products derived from fish. People who are allergic or hypersensitive to nuts should avoid alpha linolenic acid or omega-3 fatty acid products that are derived from the types of nuts to which they react. Avoid during active bleeding. Use cautiously with bleeding disorders, diabetes, low blood pressure or drugs, herbs or supplements that treat any such conditions. Use cautiously before surgery. The Environmental Protection Agency (EPA) recommends that intake be limited in pregnant/nursing women to a single six-ounce meal per week and less than two ounces per week in young children. For farm-raised, imported or marine fish, the U.S. Food and Drug Administration (FDA) recommends that pregnant/nursing women and young children avoid eating types with higher levels of methylmercury and less than 12 ounces per week of other fish types. Women who might become pregnant are advised to eat seven ounces or less per week of fish with higher levels of methylmercury or up to 14 ounces per week of fish types with about 0.5 parts per million (such as marlin, orange roughy, red snapper or fresh tuna).
  • Psychotherapy: Although group therapy may somewhat decrease pain in people with rheumatoid arthritis and depression, individual therapy coupled with anti-depressants may be more effective.
  • Psychotherapy cannot always fix mental or emotional conditions. Psychiatric drugs are sometimes needed. In some cases symptoms may worsen if the proper medication is not taken. Not all therapists are qualified to work with all problems. Use cautiously with serious mental illness or some medical conditions because some forms of psychotherapy may stir up strong emotional feelings.
  • Unclear or conflicting scientific evidence:
  • Acupuncture: Further research is needed before acupuncture can be recommended for the treatment of rheumatoid arthritis.
  • Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, or neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.
  • Astaxanthin: More well-designed clinical trials are necessary before astaxanthin can be recommended for the treatment of rheumatoid arthritis.
  • Avoid if allergic/hypersensitive to astaxanthin, related carotenoids, or astaxanthin algal sources. Use cautiously if taking 5-alpha-reductase inihibitors, hypertensive agents, asthma medications, cytochrome P450 metabolized agents, menopause agents or oral contraception, or Helicobacter pylori agents. Use cautiously with hypertension, parathyroid disorders, and osteoporosis. Avoid with hormone-sensitive conditions, immune disorders, or if taking immunosuppressive therapies. Avoid with previous experience of visual changes while taking astaxanthin and with low eosinophil levels. Avoid if pregnant or breastfeeding.
  • Ayurveda: There is some evidence that a traditional Ayurvedic herbal formula RA-1 may reduce joint swelling but not other symptoms in rheumatoid arthritis. RA-1 contains Withania somnifera (ashwagandha), Boswellia serrata (gugulla), Zingiberis officinale (ginger) and Curcuma longa (turmeric). A resin that is extracted from Boswellia serrata (H15, indish incense) is regarded in Ayurvedic medicine as having anti-inflammatory properties. However, evidence from one study showed no benefit in patients with rheumatoid arthritis. More studies are needed to determine efficacy of these treatments for rheumatoid arthritis.
  • Ayurvedic herbs should be used cautiously because they are potent and some constituents can be potentially toxic if taken in large amounts or for a long time. Some herbs imported from India have been reported to contain high levels of toxic metals. Ayurvedic herbs can interact with other herbs, foods and drugs. A qualified healthcare professional should be consulted before taking.
  • Beta sitosterol: Beta-sitosterol and beta-sitosterol glucoside have been observed to lower blood levels of IL-6 and, therefore, have been studied for possible as a treatment for rheumatoid arthritis. Larger populations of patients with rheumatoid arthritis should be evaluated in well-conducted clinical study if conclusions are to be made.
  • Avoid if allergic or hypersensitive to beta-sitosterol, beta-sitosterol glucoside, or pine. Use cautiously with asthma or breathing disorders, diabetes, primary biliary cirrhosis (destruction of the small bile duct in the liver), ileostomy, neurodegenerative disorders (like Parkinsonism or Alzheimer's disease), diverticular disease (bulging of the colon), short bowel syndrome, celiac disease and sitosterolemia. Use cautiously with a history of gallstones. Avoid if pregnant or breastfeeding.
  • Black cohosh: There is not enough human research to make a clear recommendation regarding the use of black cohosh for rheumatoid arthritis pain.
  • Use cautiously if allergic to members of the Ranunculaceaefamily such as buttercups or crowfoot. Avoid with hormone conditions (breast cancer, ovarian cancer, uterine cancer, endometriosis). Avoid if allergic to aspirin products, non-steriodal anti-inflammatories (NSAIDs, Motrin®, ibuprofen, etc.), blood-thinners (like warfarin) or with a history of blood clots, stroke, seizures, or liver disease. Stop use before surgery/dental/diagnostic procedures with bleeding risk and avoid immediately after these procedures. Avoid if pregnant or breastfeeding.
  • Black currant: Early study shows promise for the use of black currant seed oil in reducing the signs and symptoms of rheumatoid arthritis. However, additional study is needed to confirm these findings.
  • Avoid if allergic or hypersensitive to black currant, its constituents, or plants in the Saxifragaceae family. Avoid in patients with hemophilia or those on blood thinners unless otherwise recommended by a qualified healthcare provider. Use cautiously with venous disorders or gastrointestinal disorders. Use cautiously if taking MAOIs (antidepressants) or vitamin C supplements. Avoid if pregnant or breastfeeding.
  • Boswellia: Boswellia has been noted in animal and laboratory studies to possess anti-inflammatory properties. Based on these observations, boswellia has been suggested as a potential treatment for rheumatoid arthritis. However, data is conflicting, and combination products were used in some studies. Therefore, there is currently insufficient evidence to recommend for or against the use of boswellia for rheumatoid arthritis.
  • Avoid if allergic to boswellia. Avoid with a history of stomach ulcers or stomach acid reflux disease (GERD). Use cautiously if taking lipid-soluble medications, agents metabolized by the liver's cytochrome P450 enzymes, or sedatives. Use cautiously with impaired liver function or liver damage or lung disorders. Use cautiously in children. Avoid if pregnant due to potential abortifacient effects or if breastfeeding.
  • Bromelain: Bromelain cannot be recommended for the treatment of rheumatoid arthritis until further research is conducted.
  • Avoid if allergic to bromelain, pineapple, honeybee, venom, latex, birch pollen, carrots, celery, fennel, cypress pollen, grass pollen, papain, rye flour, wheat flour, or members of the Bromeliaceaefamily. Use cautiously with history of a bleeding disorder, stomach ulcers, heart disease, or liver or kidney disease. Use caution before dental or surgical procedures or while driving or operating machinery. Avoid if pregnant or breastfeeding.
  • Cat's claw: Several laboratory and animal studies suggest that cat's claw may reduce inflammation, and this has led to research of cat's claw for conditions such as rheumatoid arthritis. Large, high-quality human studies are needed before a conclusion can be drawn.
  • Avoid if allergic to cat's claw or Uncaria plants or plants in the Rubiaceae family such as gardenia, coffee, or quinine. Avoid with a history of conditions affecting the immune system (such as AIDS, HIV, some types of cancer, multiple sclerosis, tuberculosis, rheumatoid arthritis, lupus). Use cautiously with bleeding disorders or a history of stroke, or if taking drugs that may increase the risk of bleeding. Discontinue use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Cat's claw may be contaminated with other Uncaria species. Reports exist of a potentially toxic, Texan grown plant, Acacia gregii being substituted for cat's claw. Avoid if pregnant, breastfeeding, or trying to become pregnant.
  • Chlorophyll: Diets high in chlorophyll have been hypothesized to modify intestinal flora resulting in improved management of immune disorders including rheumatoid arthritis. More evidence is needed to support the use of chlorophyll in autoimmune diseases.
  • Avoid if allergic or hypersensitive to chlorophyll or any of its metabolites. Use cautiously with photosensitivity, compromised liver function, diabetes or gastrointestinal conditions or obstructions. Use cautiously if taking immunosuppressant agents or antidiabetes agents. Avoid if pregnant or breastfeeding.
  • Copper: Preliminary study suggests that copper offers no benefit to individuals with systemic lupus erythematosus (SLE). Further research is required.
  • Avoid if allergic or hypersensitive to copper. Avoid use of copper supplements during the early phase of recovery from diarrhea. Avoid with a high amount of copper in the blood (hypercupremia), genetic disorders affecting copper metabolism (e.g. Wilson's disease, Indian childhood cirrhosis, or idiopathic copper toxicosis), or HIV/AIDS. Use cautiously with water containing copper concentrations greater than 6 milligrams per liter. Use cautiously with anemia (low red blood cell count), arthralgias (painful joints), or myalgias (muscle pain). Use cautiously if taking oral contraceptives. Use cautiously if at risk for selenium deficiency. Pregnant and breastfeeding women should not consume doses that exceed the recommended dietary allowance (RDA).
  • Dandelion: Research in laboratory animals suggests that dandelion root may possess anti-inflammatory properties. There is a lack of well-conducted human studies currently available in this area.
  • Avoid if allergic to chamomile, feverfew, honey, yarrow, or any related plants such as aster, daisies, sunflower, chrysanthemum, mugwort, ragweed, or ragwort. Use cautiously with diabetes or bleeding disorders, gastroesophageal reflux disease (GERD), kidney or liver diseases, or a history of stroke or electrolyte disorders. Potassium blood levels should be monitored. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.
  • DHEA (dehydroepiandrosterone): Preliminary evidence suggests that DHEA (dehydroepiandrosterone) may not offer benefit to individuals with rheumatoid arthritis or Sjögren's syndrome. Further research is needed in this area.
  • Avoid if allergic to DHEA. Avoid with a history of seizures. Use cautiously with adrenal or thyroid disorders. Use cautiously if taking anticoagulants or drugs, herbs, or supplements that treat diabetes, heart disease, seizures, or stroke. Stop use two weeks before and immediately after surgery/dental/diagnostic procedures with bleeding risks. Avoid if pregnant or breastfeeding.
  • DMSO (dimethyl sulfoxide): Applying DMSO to the skin may help treat rheumatoid arthritis. More research is needed before a conclusion can be drawn.
  • Avoid if allergic or hypersensitive to DMSO. Use caution with urinary tract cancer or liver and kidney dysfunction. Avoid if pregnant or breastfeeding.
  • Evening primrose oil: Benefits of evening primrose oil in the treatment of rheumatoid arthritis have not clearly been shown. More research is needed before a conclusion can be made.
  • Avoid if allergic to plants in the Onagraceae family (willow's herb, enchanter's nightshade) or gamma-linolenic acid. Avoid with seizure disorders. Use cautiously with mental illness drugs. Stop use two weeks before surgery with anesthesia. Avoid if pregnant or breastfeeding.
  • Eyebright: Several iridoid glycosides isolated from eyebright, particularly aucubin, may possess anti-inflammatory properties comparable to those of indomethacin (a nonsteroidal anti-inflammatory drug). However, there is currently insufficient evidence to recommend for or against eyebright as an anti-inflammatory agent.
  • Avoid with a known allergy or hypersensitivity to eyebright. Hypersensitivity to members of the Scrophulariaceae family may lead to a cross-sensitivity reaction. Use cautiously as an eye treatment, particularly homemade preparations, due to the risk of infection if not sterile. Use cautiously with diabetes and drugs that are broken down by the liver. Avoid if pregnant or breastfeeding.
  • Feverfew: There is currently not enough evidence to support the use of feverfew for rheumatoid arthritis. Further research is warranted.
  • Avoid if allergic to feverfew and other plants of the Compositaefamily (chrysanthemums, daisies, marigolds, ragweed). Stop use prior to surgery and dental or diagnostic procedures. Avoid with drugs that increase bleeding risk. Avoid stopping feverfew use all at once. Avoid if history of heart disease, anxiety or bleeding disorders. Caution is advised with a history of mental illness, depression and headaches. Avoid if pregnant or breastfeeding.
  • Flaxseed and flaxseed oil: Flaxseed and flaxseed oil/linseed oil are rich sources of the essential fatty acid alpha-linolenic acid (omega-6). Alpha-linolenic acid is a building block in the body for omega-3 fatty acids. Flaxseed oil should be refrigerated at all times. There is currently a lack of strong evidence available on the use of flaxseed for lupus nephritis. More research is needed before a firm recommendation can be made.
  • Flaxseed has been well-tolerated in studies for up to four months. Avoid if allergic to flaxseed, flaxseed oil, or other plants of the Linaceae family. Avoid with prostate cancer, breast cancer, uterine cancer, or endometriosis. Avoid ingestion of immature flaxseed pods. Avoid large amounts of flaxseed by mouth and mix with plenty of water or liquid. Avoid flaxseed with a history of esophageal stricture, ileus (loss of bowel motility), gastrointestinal stricture or bowel obstruction. Avoid with a history of acute or chronic diarrhea, irritable bowel syndrome, diverticulitis (bowel inflammation), or inflammatory bowel disease. Avoid topical flaxseed in open wounds or abraded skin surfaces. Use cautiously with a history of a bleeding disorders, high triglyceride levels, diabetes, mania, seizures, or asthma. Use cautiously if taking drugs that increase the risk of bleeding or nonsteroidal anti-inflammatory drugs (NSAIDs). Avoid if pregnant or breastfeeding.
  • Gamma linolenic acid (GLA): Several clinical studies indicate significant therapeutic improvements in rheumatoid arthritis symptoms with use of gamma linolenic acid (GLA). Currently, there is limited evidence showing that GLA is effective in treating Sjogren's syndrome. Additional study is needed before a conclusion can be made.
  • Reports of allergic reactions to GLA are currently lacking in the available literature. Use cautiously with drugs that increase the risk of bleeding like anticoagulants and anti-platelet drugs. Avoid if pregnant or breastfeeding.
  • Ginger: Well-designed clinical trials are necessary before ginger can be recommended for the treatment of rheumatoid arthritis.
  • Avoid if allergic to ginger or other members of the Zingiberaceaefamily. Avoid with anticoagulation therapy. Avoid large quantities of fresh cut ginger with inflammatory bowel disease or a history of intestinal obstruction. Use cautiously prior to surgery and with gastric or duodenal ulcers, gallstones, cardiovascular disease, and diabetes. Use cautiously long-term and in underweight patients. Use cautiously if taking heart medications or sedatives and if driving or operating heavy machinery. Use cautiously if pregnant or breastfeeding.
  • Glucosamine: Preliminary human research reports benefits of glucosamine in the treatment of joint pain and swelling in rheumatoid arthritis patients. However, additional research is needed before a conclusion can be made.
  • Avoid if allergic or hypersensitive to shellfish or iodine. Some reports suggest a link between glucosamine/chondroitin products and asthma. Use caution with diabetes or a history of bleeding disorders. Avoid if pregnant or breastfeeding.
  • Guggul: There is currently insufficient evidence to support the use of guggul or guggul derivatives for the management of rheumatoid arthritis.
  • Avoid if allergic to guggul. Avoid with a history of thyroid disorders, anorexia, bulimia, or bleeding disorders. Signs of allergy to guggul may include itching and shortness of breath. Avoid if pregnant or breastfeeding.
  • Guided imagery: Cognitive-behavioral interventions for pain may be an effective adjunct to standard pharmacologic interventions for pain in patients with juvenile rheumatoid arthritis. Further research is needed to confirm these results.
  • Guided imagery is usually intended to supplement medical care, not to replace it, and should not be relied on as the sole therapy for a medical problem. Contact a qualified health care provider if mental or physical health is unstable or fragile. Never use guided imagery techniques while driving or doing any other activity that requires strict attention. Use cautiously with physical symptoms that can be brought about by stress, anxiety or emotional upset because imagery may trigger these symptoms. Speak with a qualified health care provider before practicing guided imagery if feeling unusually anxious while practicing guided imagery, or with a history of trauma or abuse.
  • Hops: Early clinical research suggests that a combination formula containing hops may help reduce symptoms of rheumatic diseases. However, well-designed human trials using hops alone are needed to determine if these positive effects are specifically the result of hops.
  • Avoid if allergic to hops, its constituents, members of the Cannabaceae family, peanuts, chestnuts, or bananas. Use cautiously if driving or operating heavy machinery. Use cautiously with hormone-sensitive conditions (e.g. breast cancer, uterine cancer, cervical cancer, prostate cancer, or endometriosis) and diabetes. Use cautiously if taking hormonal agents (e.g. contraceptives or fertility agents). Use cautiously if pregnant or breastfeeding; some hops preparations contain high levels of alcohol and should be avoided during pregnancy.
  • Hypnotherapy: Although multiple trials report diminished pain levels or requirements for pain-relieving medications after hypnotherapy, there is limited research for rheumatoid arthritis pain specifically. Other signs of rheumatoid arthritis, such as joint mobility or blood tests for rheumatoid factor, have not been adequately assessed.
  • Use cautiously with mental illnesses like psychosis/schizophrenia, manic depression, multiple personality disorder or dissociative disorders. Use cautiously with seizure disorders.
  • Lavender: Early human studies have found conflicting results on the use of massage with lavender aromatherapy for rheumatoid arthritis pain. More research is needed to make a conclusion.
  • Avoid if allergic or hypersensitive to lavender. Avoid with a history of seizures, bleeding disorders, eating disorders (anorexia, bulimia) or anemia (low levels of iron). Avoid if pregnant or breastfeeding.
  • Licorice: Because licorice may affect the metabolism of steroids, licorice is sometimes used to help decrease inflammation. Additional study is needed to make a conclusion.
  • Avoid with a known allergy to licorice, any component of licorice, or any member of the Fabaceae (Leguminosae) plant family. Avoid with congestive heart failure, coronary heart disease, kidney or liver disease, fluid retention, high blood pressure, hormonal abnormalities or if taking diuretics. Licorice can cause abnormally low testosterone levels in men or high prolactin or estrogen levels in women. This may make it difficult to become pregnant and may cause menstrual abnormalities.
  • Magnet therapy: Initial evidence has failed to show improvements in rheumatoid arthritis pain with the use of magnet therapy. However, due to methodological weaknesses of this research, the conclusions cannot be considered definitive.
  • Avoid with implantable medical devices like heart pacemakers, defibrillators, insulin pumps, or hepatic artery infusion pumps. Avoid with myasthenia gravis or bleeding disorders. Avoid if pregnant or breastfeeding. Magnet therapy is not advised as the sole treatment for potentially serious medical conditions, and should not delay the time to diagnosis or treatment with more proven methods. Patients are advised to discuss magnet therapy with a qualified healthcare provider before starting treatment.
  • Moxibustion: There is preliminary evidence suggesting that patients suffering from rheumatoid arthritis may experience improved immune function as a result of acupuncture and moxibustion. However, evidence is insufficient at this time for making conclusions.
  • Use cautiously over large blood vessels and thin or weak skin. Avoid with aneurysms, any kind of "heat syndrome," cardiac disease, convulsions or cramps, diabetic neuropathy, extreme fatigue and/or anemia, fever, inflammatory conditions, over allergic skin conditions or ulcerated sores, or skin adhesions. Avoid if pregnant or breastfeeding. Avoid areas with an inflamed organ, contraindicated acupuncture points, face, genitals, head, inflamed areas in general, nipples, and skin adhesions. Avoid in patients who have just finished exercising or if taking a hot bath or shower. Caution with elderly people with large vessels. It is advised to not bathe or shower for up to 24 hours after a moxibustion treatment.
  • Omega-3 fatty acids: It has been suggested that omega-3 fatty acids may help alleviate symptoms of systemic lupus erythematosus SLE. However, scientific evidence is inconclusive. Further research is warranted before a firm conclusion can be made.
  • Avoid if allergic or hypersensitive to fish, omega-3 fatty acid products that come from fish, nuts, linolenic acid, or omega-3 fatty acid products that come from nuts. Avoid during active bleeding. Use cautiously with bleeding disorders, diabetes, low blood pressure, or if taking drugs, herbs or supplements that treat any such conditions. Use cautiously before surgery. Pregnant and breastfeeding women should not consume doses that exceed the recommended dietary allowance (RDA).
  • Pantothenic acid (vitamin B5): It has been reported that pantothenic acid levels are lower in the blood of rheumatoid arthritis patients than healthy individuals. However, it is not clear if this is a cause, effect or a beneficial adaptive reaction. There is currently insufficient scientific evidence in this area in order to form a clear conclusion.
  • Avoid if allergic or hypersensitive to pantothenic acid or dexpanthenol. Avoid with gastrointestinal blockage. Pantothenic acid is generally considered safe in pregnant and breastfeeding women when taken at recommended doses.
  • Papain: Review study found that proteolytic enzymes, including papain, may reduce pain and inflammation in rheumatic disorders. Additional research is needed to confirm these results.
  • Use cautiously in patients sensitive to papain, being treated for prostatitis, with bleeding disorders or taking anticoagulants or antiplatelets. Use cautiously as an adjuvant to radiation therapy. Avoid in patients with gastroesophageal reflux disease or in those using immunosuppressive therapy.
  • Para-aminobenzoic acid: Para-aminomethylbenzoic acid (PAMBA), a derivative of PABA, has been studied for use in autoimmune disorders such as pemphigus vulgaris. Additional high quality trials are needed.
  • Pharmaceutical doses of PABA and its derivatives should only be taken under appropriate medical supervision. Avoid oral use in children and pregnant or nursing women. Avoid with known hypersensitivity to PABA or its derivatives. Use cautiously in patients with renal disease, liver disorders, diabetes, hypoglycemia, bleeding disorders, or in those taking anticoagulants.
  • Peony: Peony's anti-inflammatory effects may benefit patients with rheumatoid arthritis. However, there is currently not enough evidence for or against this use of peony.
  • Avoid if allergic or sensitive to peony. Avoid with bleeding disorders or if taking drugs, herbs, or supplements that increase bleeding risk. Use cautiously with estrogen-sensitive cancers or if taking drugs, herbs, or supplements with hormonal activity. Avoid if pregnant or breastfeeding.
  • Physical therapy: Several studies have indicated that treatment of rheumatoid arthritis with physical therapy may help improve morning stiffness and grip strength. Treatment should be conducted by a specially trained physical therapist and that physical therapy. Some experts have suggested a long-term, high-intensity exercise program. Beneficial effects may last up to one year. Despite promising early evidence, better-designed studies are needed to draw a firm conclusion.
  • Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with a qualified healthcare professional before beginning any treatments. Physical therapy may aggravate pre-existing conditions. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the physical therapy literature although causality is unclear. Erectile dysfunction has also been reported. Physical therapy has been used in pregnancy and although reports of major adverse effects are lacking the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.
  • Podophyllum: Preliminary research suggests that podophyllum may be helpful for rheumatoid arthritis. Research is limited due to the possible adverse effects like severe diarrhea associated with oral podophyllum. Additional research is needed before a firm conclusion can be drawn.
  • Avoid if allergic/hypersensitive to podophyllum or to members of the Berberidaceae family. Podophyllum, when applied topically, may be absorbed through the skin and cause irritation of the stomach and intestines. Podophyllum toxicity may cause heart palpitations and blood pressure changes, muscle paralysis, difficulty walking, confusion, and convulsions. Using podophyllum and laxatives may result in dehydration and electrolyte depletion. Use cautiously with arrhythmia, Crohn's disease, cardiovascular problems, gallbladder disease or gallstones, high blood pressure, irritable bowel syndrome, liver insufficiency, muscular, and neurologic disorders, psychosis, or kidney insufficiency. Use cautiously if taking antimiotic agents like vincristine, anti-psychotic agents, or laxatives. Avoid if pregnant or breastfeeding.
  • Prayer, distant healing: Initial research suggests that in-person intercessory prayer (praying by others in the presence of patients) may reduce pain, fatigue, tenderness, swelling and weakness in rheumatoid arthritis when it is used in addition to standard care. Better quality research is necessary before a firm conclusion can be drawn.
  • Prayer is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time it takes to consult with a healthcare professional or receive established therapies. Sometimes religious beliefs come into conflict with standard medical approaches, and require an open dialog between patients and caregivers. Based on limited clinical study, patients certain that they were receiving intercessory prayer had a higher incidence of complications following cardiac bypass surgery than those who did not know they were being prayed for.
  • Probiotics: In limited study, Lactobacillus GG was associated with improved subjective well-being, as well as reduced symptoms of rheumatoid arthritis. However, these findings were not statistically significant. More studies on the effects of probiotics in rheumatoid arthritis are needed.
  • Probiotics are generally considered safe and well-tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant. Caution is advised when using probiotics in neonates born prematurely or with immune deficiency.
  • Propolis: Based on anti-inflammatory action observed in laboratory research, propolis has been proposed as a possible treatment for rheumatic diseases. However, there is currently not enough scientific human study to make a conclusion.
  • Avoid if allergic or hypersensitive to propolis, black poplar (Populas nigra), poplar bud, bee stings, bee products, honey, and Balsam of Peru. Severe allergic reactions have been reported. Use cautiously with asthma or gastrointestinal disorders. Avoid if pregnant or breastfeeding because of the high alcohol content in some propolis products.
  • Psychotherapy: There is conflicting evidence as to whether or not brief supportive-expressive group psychotherapy reduces psychological distress and medical symptoms and improves quality of life of women with systemic lupus erythematosus (SLE). Further studies are needed before a firm conclusion can be drawn.
  • Psychotherapy cannot always fix mental or emotional conditions. Psychiatric drugs are sometimes needed. In some cases, symptoms may worsen if the proper medication is not taken. Not all therapists are qualified to work with all problems. Use cautiously with serious mental illness or some medical conditions because some forms of psychotherapy may stir up strong emotional feelings and expression.
  • Pycnogenol®: Pycnogenol® is the patented trade name for a water extract of the bark of the French maritime pine (Pinus pinaster ssp. atlantica). Pycnogenol® may be useful as a second-line therapy to reduce inflammation associated with systemic lupus erythematosus (SLE). Further research is needed before a firm conclusion can be made.
  • Avoid if allergic or hypersensitive to pycnogenol, its components, or members of the Pinaceae family. Use cautiously with diabetes, hypoglycemia (low blood sugar), or bleeding disorders. Use cautiously if taking hypolipidemics (cholesterol-lowering medications), medications that may increase the risk of bleeding, hypertensive (high blood pressure) medications, or immune stimulating or inhibiting drugs. Avoid if pregnant or breastfeeding.
  • Reishi mushroom: A combination of reishi mushroom and San Miao San (a mixture of several Chinese herbs) may help reduce the pain of rheumatoid arthritis. However, these herbs did not reduce swelling. More research with reishi mushroom alone is needed.
  • Avoid if allergic or hypersensitive to any constituents of Ganoderma lucidum or any member of its family. Use cautiously with diabetes, blood disorders (including hemophilia), low blood pressure, or ulcers. Avoid if pregnant or breastfeeding.
  • Relaxation therapy: Limited preliminary research reports that muscle relaxation training may improve function and well being in patients with rheumatoid arthritis. Additional research is necessary before a conclusion can be reached.
  • Avoid with psychiatric disorders like schizophrenia/psychosis. Jacobson relaxation (flexing specific muscles, holding that position, then relaxing the muscles) should be used cautiously with illnesses like heart disease, high blood pressure, or musculoskeletal injury. Relaxation therapy is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time to diagnosis or treatment with more proven techniques.
  • Selenium: Selenium supplementation has been studied in rheumatoid arthritis patients with mixed results. Additional research is necessary before a clear conclusion can be drawn.
  • Avoid if allergic or sensitive to products containing selenium. Avoid with history of nonmelanoma skin cancer. Selenium is generally regarded as safe for pregnant or breastfeeding women. However, animal research reports that large doses of selenium may lead to birth defects.
  • Shark cartilage: Chondroitin sulfate, a component of shark cartilage, has been shown to benefit patients with osteoarthritis. However, the concentrations of chondroitin in shark cartilage products may be too small to be helpful. The ability of shark cartilage to block new blood vessel growth or reduce inflammation is suggested to be helpful in rheumatoid arthritis. However, there is limited research in these areas, and more studies are needed before a recommendation can be made.
  • Avoid if allergic to shark cartilage or any of its ingredients (including chondroitin sulfate and glucosamine). Use cautiously with sulfur allergy. Avoid with a history of heart attack, vascular disease, heart rhythm abnormalities (arrhythmias) or heart disease. Use cautiously with a history of liver or kidney disorders, tendency to form kidney stones, breast cancer, prostate cancer, multiple myeloma, breathing disorders (like asthma), cancers that raise calcium levels (like breast, prostate, multiple myeloma or squamous cell lung cancer) and diabetes. Avoid if pregnant or breastfeeding.
  • Spiritual healing: There is currently not enough evidence that spiritual healing adds any benefit to conventional treatment in rheumatoid arthritis. Spiritual healing should not be used as the only treatment approach for medical or psychiatric conditions, and should not delay the time it takes to consider more proven therapies.
  • Stinging nettle: Stinging nettle is widely used as a folk remedy to treat arthritis and rheumatic conditions throughout Europe and Australia. Pre-clinical evidence suggests that certain constituents in the nettle plant have anti-inflammatory and/or immunomodulatory activity and may be of benefit in rheumatoid arthritis. Well-designed, randomized controlled trials are needed to further support its use in humans.
  • Avoid if allergic or hypersensitive to nettle, members of the Urticaceae family, or any ingredient of nettle products. Use cautiously with diabetes, bleeding disorders, or low sodium levels in the blood. Use cautiously with diuretics and anti-inflammatory drugs. The elderly should also use nettle cautiously. Avoid if pregnant or breastfeeding.
  • Tai chi: There is not enough scientific evidence showing that tai chi reduces rheumatoid arthritis symptoms, although tai chi may help improve range of motion of the lower extremities.
  • Avoid with severe osteoporosis or joint problems, acute back pain, sprains, or fractures. Avoid during active infections, right after a meal, or when very tired. Some believe that visualization of energy flow below the waist during menstruation may increase menstrual bleeding. Straining downwards or holding low postures should be avoided during pregnancy, and by people with inguinal hernias. Some tai chi practitioners believe that practicing for too long or using too much intention may direct the flow of chi (qi) inappropriately, possibly resulting in physical or emotional illness. Tai chi should not be used as a substitute for more proven therapies for potentially serious conditions. Advancing too quickly while studying tai chi may increase the risk of injury.
  • TENS (Transcutaneous Electrical Nerve Stimulation): Preliminary studies of TENS in rheumatoid arthritis report improvements in joint function and pain. However, most research is not well designed or reported, and better studies are necessary before a clear conclusion can be reached.
  • Avoid with implantable devices, like defibrillators, pacemakers, intravenous infusion pumps, or hepatic artery infusion pumps. Use cautiously with decreased sensation, like neuropathy, and with seizure disorders. Avoid if pregnant or breastfeeding.
  • Thymus extract: Preliminary results indicate that articular and cutaneous symptoms associated with systemic lupus erythematosus may be improved with thymus extract use. Well designed clinical trials are required before thymus extract can be recommended for this use.
  • Avoid if allergic or hypersensitive to thymus extracts. Use bovine thymus extract supplements cautiously due to potential for exposure to the virus that causes "mad cow disease." Avoid use with an organ transplant or other forms of allografts or xenografts. Avoid if receiving immunosuppressive therapy, with thymic tumors, myasthenia gravis (neuromuscular disorder), untreated hypothyroidism, or if taking hormonal therapy. Avoid if pregnant or breastfeeding; thymic extract increases human sperm motility and progression.
  • Turmeric: Turmeric is a perennial plant native to India and Indonesia, and it is often used as a spice in cooking. Turmeric has been used historically to treat rheumatoid arthritis. Laboratory and animal studies show anti-inflammatory activity of turmeric and its constituent curcumin, however, reliable human research is lacking.
  • Avoid if allergic or hypersensitive to turmeric (curcumin), yellow food colorings or plants belonging to the Curcuma or Zingiberaceae (ginger) families. Use cautiously with history of bleeding disorders, immune system deficiencies, liver disease or gallstones. Use cautiously with blood-thinners (e.g. warfarin). Use cautiously if pregnant or breastfeeding.
  • Zinc: The majority of trials do not show significant improvements in rheumatoid arthritis symptoms following zinc treatment. Interpretation of some data is difficult because patients in the studies were permitted to continue their previous arthritis medication and most studies used a small number of participants. Well-designed clinical trials are needed before a definitive conclusion can be made.
  • Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride since studies have not been done on its safety or effectiveness. Avoid with kidney disease. Use cautiously if pregnant or breastfeeding.
  • Fair negative scientific evidence:
  • Green lipped mussel: There is conflicting evidence of the effect of green-lipped mussel supplementation for treating rheumatoid arthritis. Overall, the evidence does not support this use.
  • Green-lipped mussel is generally considered safe. Use cautiously with anti-inflammatory agents. Use cautiously with asthma. Avoid in patients with liver disease. Avoid with allergy or sensitivity to green-lipped mussel or other shellfish. Avoid if pregnant or breastfeeding.
  • Willow bark: Based on limited clinical study, willow bark extract has not shown efficacy in treating rheumatoid arthritis. More high-quality studies of larger design are needed to make a conclusion.
  • Avoid if allergic/hypersensitive to aspirin, willow bark (Salix spp.), or any of its constituents, including salicylates. Use cautiously with gastrointestinal problems, such as ulcers, hepatic disorders, diabetes, gout, hypertension, hyperlipidemia, history of allergy or asthma, and leukemia. Use cautiously if taking protein-bound medications, antihyperlipidemia agents, alcohol, leukemia medications, beta-blockers, diuretics, Phenytoin (Dilantin®), probenecid, spironolactone, sulfonylureas, valproic acid, or methotrexate. Use cautiously if pre-disposed to headaches. Avoid operating heavy machinery. Avoid in children with chickenpox and any other viral infections. Avoid with blood disorders, and renal disorders. Avoid if taking other NSAIDs, acetazolamide or other carbonic anhydrase inhibitors. Avoid with elevated serum cadmium levels. Avoid if pregnant or breastfeeding.
  • Zinc: In limited study, zinc supplementation did not seem to have a beneficial effect on symptoms of patients with chronic inflammatory rheumatic disease.
  • Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride since studies have not been done on its safety or effectiveness. Avoid with kidney disease. Use cautiously if pregnant or breastfeeding.

Prevention
  • Avoid exposure to known drug allergens.

Copyright © 2011 Natural Standard (www.naturalstandard.com)


The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.

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