complementary and alternative practices in rheumatology

Best Practice & Research Clinical RheumatologyVol. 22, No. 4, pp. 741–757, 2008

doi:10.1016/j.berh.2008.05.001
available online at http://www.sciencedirect.com
10

Complementary and alternative

practices in rheumatology

Cesar Ramos-Remus* MD, MSc

Director, UIECD, Professor of Rheumatology, Universidad de Guadalajara, and Attending

Rheumatologist at Hospital General Regional 45, IMSS Guadalajara, Mexico

Colomos 2292, Providencia, Guadalajara, Jal. 44620, Mexico

Ashwinikumar Raut MD

Director, Clinical Research & Integrative Medicine

Medical Research Centre of Kasturba Health Society, SJAD, 17, K. Desai Road,

Ville Parle (West), Mumbai 400 056, India

Hundreds of non-conventional treatment modalities have been used to treat patients withdiverse diseases. Whatever term is used, non-conventional remedies, complementary medicineand/or alternative therapies (CAM), or even traditional systems of medicine, have become anincreasingly prominent part of health-care utilization by the healthy general population and bypatients with various diseases, even in an era of rapidly advancing medical technology. It hasbecome a significant topic not just in the lay press but also in the biomedical literature. Since1966 more than 46,000 publications that bear this or a related term in titles or abstractshave been referenced in Medline alone. Several important journals have devoted editorialsand original papers to this subject during past decade. This review presents the most recentdata on the epidemiology of CAM utilization by rheumatic patients, with special emphasis onmagnitude and patterns of use, and concepts of alternative versus complementary medicine.

Key words: alternative therapies; complementary therapies; arthritis; rheumatic diseases;herbs; epidemiology; CAM therapies.

WHO USES COMPLEMENTARY AND ALTERNATIVE MEDICINE?

It appears that the use of complementary and alternative medicine (CAM) is a world-wide phenomenon which is not restricted to any particular geographic or ethnicgroup, social status, or economic situation. Prevalence is in the range 6–73% of the

* Corresponding author. Fax: þ52 33 38 17 63 35.

E-mail address: [email protected] (C. Ramos-Remus).

1521-6942/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved.

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742 C. Ramos-Remus and A. Raut

general population (Table 1). Variations in prevalence are better explained by differ-ences in study design, definition of CAM, the instruments used, and population selec-tion than by geographic, economic or ethnic factors. What it is clear is that its use hasbeen exponentially increasing in the past decade.

A high prevalence of CAM use has been also reported for a number of disease-specific groups. For instances, 7–64% of patients with cancer used CAM, accordingto a recently published systematic review1, as did 27% of patients attending a gastroen-terology clinic2, 20% of patients with inflammatory bowel disease3, 29% of the at-tendees of a rehabilitation outpatients clinic in New York4, and patients with AIDS,irritable bowel syndrome, and depression, among other conditions.5–7 In a survey of45,000 patients from 35 selected districts of India, about one third of patients pre-ferred indigenous systems of medicine for their common ailments.8

The scope of rheumatic diseases involves more than 150 different entities that pa-tients may suffer for 20–30 or more years, with a multidimensional impact on all as-pects of daily living. Given these characteristics, and the lack of curative therapiesfor many of them, the usage of CAM should not be a surprise. Evidence exists thatrheumatic patients use CAM whether they live in developed or developing countries,are well or less-well educated, or richer or less fortunate (Table 1).

For instance, in one of the first papers on the frequency of CAM use in rheumatol-ogy, Kronenfeld and Wasner reported the results of a face-to-face interview with 98rheumatic patients attending a rheumatology clinic in a university setting in the UnitedStates.9 The mean usage was 3.7 different remedies, with three patients each havingtried 13 different modalities. Topical remedies were used by over 80% of all respon-dents, including alcohol, whiskey, snake oil, and gasoline; 36% of the respondentshad visited a CAM provider at least once for their arthritis. Interestingly, 5% usedCAM before having contacted a physician, whereas 83% had been seeing a physicianfor more than 1 year before they sought these remedies. In another survey from

Table 1. Reported frequencies of complementary and alternative medicine (CAM) utilization.

CAM users (%) References

General population:

Australia 20e48.5 35

Canada 11e32 36,37,118

United States 25e73 15,20,32,34,67,85

Israel 6 33

Netherlands 16 68

United Kingdom 25 68

France 36 68

South Africa 38.5 47

India 33 8

Rheumatic patients:

United States 18e94% 9,10,32,34,119e123

Canada 60e91 14,16,38

Mexico 56e83 17,124

Australia 40e82 125e127

Germany 78 128

India 43e72 11e13

Complementary and alternative practices 743

California, 84% of the patients with self-reported osteoarthritis or rheumatoid arthri-tis had used CAM during the previous 6 months.10 Two Indian studies, one each fromsouth and north India, in patients of rheumatoid arthritis have indicated CAM usage ofabout 43%11,12, whereas another study from Western India indicated use of CAM by72% patients.13

According to a Canadian survey, CAM practitioner use and dietary manipulationwere used more frequently by fibromyalgia patients.14 CAM usage was identified in91% of fibromyalgia patients and 63% of the other rheumatic patients. Of the fibro-myalgia patients, 79% had visited CAM practitioners, and 63% of them reported fre-quent use (defined as more than six visits per year). Fibromyalgia patients wereasked to rate their satisfaction with CAM on a scale of 0–10. The overall score givenwas 6.7. Health-care utilization by fibromyalgia patients was higher among the CAMusers (7.5 medical doctor visits per year) than in those that did no use CAM (4.5 med-ical doctor visits per year). Similar patterns have been reported in the United States.15

In other Canadian study16, 60% of the patients had used a total of 530 CAM rem-edies (range 1–25), and 79% of these patients had used 309 CAM remedies in the pre-vious 12 months (mean of 3, range 1–15 remedies). Overall, 47% had used at least oneCAM before the first rheumatology consultation, but an additional 8% initiated CAMafter their first contact with a rheumatologist. The group of CAM users saw a rheuma-tologist a mean of 6 times (range 1–52) and their family physicians 11 times (range0–52) during the previous year. Of the 119 users of CAM, 41 (34%) visited CAM pro-viders at least once in the previous 12 months (mean 11, range 1–105). Of the 41patients who not only used CAM but also visited a CAM provider, there was a similarnumber of total visits to family physicians (mean 11, range 0–52) but a reduction invisits to rheumatologists (mean 3, range 0–25). Most of the patients (72%) usedCAM in the expectation of pain relief. Patients perceived great improvement with11% of the CAM remedies used, mild improvement with 29%, and no improvementat all with 59% of the remedies.

A Mexican survey17 of 300 consecutive rheumatic patients at three outpatientrheumatology clinics found that 83% of patients had a life-time usage of 1386 CAMremedies (mean 5.5 remedies, range 1–19); 203 patients (68%) had used CAM inthe previous 12 months (mean 3.5, range 1–15). In 61%, at least one CAM remedywas received before the first rheumatology consultation, but an additional 18% initi-ated these remedies after their initial contact with a rheumatologist. Interestingly,14% of the interviewed patients discontinued formal treatment on at least one occa-sion in order to receive CAM. Patients claimed that CAM practitioners recommendeddiscontinuation of conventional therapy on 57% of the occasions when formal treat-ments were discontinued; other authors found similar practices of formal treatmentdiscontinuation in South Africa18 and Mexico.19

In another study from Mexico, the authors conducted face-to-face interviews with107 consecutive patients with systemic lupus erythematosus (SLE).19 The mean dis-ease duration was 8� 6 years, and the mean follow-up in the clinics was 6 years.Of these 107 patients, 70 (65%) had used CAM for a total of 121 remedies, equivalentto 14 new remedies per 100 person-years. There were 52 discontinuations of thetreatments prescribed by rheumatologists in 33 patients (31%, 1.6 per patient). Ofthe 33 patients who had used CAM, 28 (85%) discontinued formal treatment duringthe period using CAM, compared to 42 of 74 (60%) who had never used CAM(OR¼ 4.3, 95%CI 1.5–12.3). Previous hospitalizations due to severity and/or compli-cations were higher in CAM users (0.83 per patient) than in non-users (0.32 perpatient) (P¼ 0.008).


The former assumption that Western physicians discourage the use of CAM rem-edies and/or providers is not supported by the recently published data on referral pat-terns of general practitioners and some specialists from various countries. Forinstance, in one study from the United States20 89% of both adult primary-care phy-sicians and obstetricians had used or recommended to patients at least one of the20 CAM remedies listed in the survey during the previous 12 months; 40% of thosephysicians interested in CAM were motivated by uncontrolled observations or anec-dotal experiences, whereas in only 5% was their interest motivated by articles read ina professional journal.

In Washington State, New Mexico, and southern Israel, Borkan et al found thatmore than 60% of community physicians (response rate 50%) had referred at leastone patient for CAM in the previous year21; 12% of the respondents incorporatedCAM techniques into their practice, and 47% had used CAM for themselves, their fam-ily members, or both. In one of the prescription studies from a tertiary-care allopathichospital in India, the prescriptions contained 12% Ayurvedic drugs.22

Canada and some European countries have similar referral patterns. For example,in one cross-sectional study of general practitioners in the provinces of Ontario andAlberta, 54% of the 200 respondents (52% response rate) indicated that they refer pa-tients to CAM practitioners, and 16% indicated that they practised some form ofCAM.23 In another study, 76% of 200 general practitioners in both rural and urbansites in Britain had referred patients to CAM during the year preceding the investiga-tion. Their views about the efficacy of different therapies were influenced primarily byuncontrolled observations or personal experiences (79%) and by the media (14%).24 Inthe district of Kassel, Germany, 95% of the general practitioners who replied to a mailsurvey (56% response rate) occasionally used at least some form of CAM: most com-monly herbal medicine, neural therapy, or homeopathy.25 Ernst et al reported that 67%of local health authorities in the United Kingdom are purchasing at least one form ofCAM.26 More recent evidence shows that CAM is gaining more acceptance among pri-mary-care health professionals, at least in Great Britain27, Switzerland28, Italy29, andAustralia.30 Even rheumatologists have begun using CAM to treat their patients inthe United States.31

WHY DO RHEUMATIC PATIENTS USE CAM?

The published information on consumer behaviour with respect to CAM is scarce. Ingeneral, people who use CAM come from all social classes, but tend to be overrepre-sented in the middle and upper classes, whether class is measured by income or levelof education.32–36 They are more likely to be women, who are also more likely thanmen to use CAM services, and to be middle-aged.33,35–37 It appears that many patientsuse physicians and CAM remedies or providers concurrently for the same medicalcondition32–34, but some patients rely primarily on CAM to treat a medical condi-tion.32–34 However, an important proportion of patients will not tell their physicianthey are using CAM.34

Rheumatic patients also come from all social classes, but the association with in-come or level of education has not been consistent.9,14,16,17,19,38 It seems that,amongst rheumatic patients, CAM users are slightly more disabled than non-users16,17,but associations with other disease characteristics have not been found. More patientsused more CAM remedies after the first rheumatology consultation9,16,17; this patterncould perhaps be explained by longer disease duration allowing greater opportunity


for using such remedies, or by discrepancy between patient expectations of formaltreatment and actual response to therapy.

As shown in population studies, most of the rheumatic patients who use CAM con-currently use conventional therapies, and will not inform their attending physicians ofthis fact. It appears also that CAM users tend to be higher users of health care thannon-users, and those users of CAM practitioners tend to visit CAM providersmore frequently than general practitioners or rheumatologists.14,16,17 Moreover, sev-eral studies have identified a particular subgroup of higher CAM users (around 5% oftheir samples).9,14,16,17

Some authors suggest that sick people use CAM because of dissatisfaction withmainstream health care; however, other consuming patterns have not been properlyassessed. Health is influenced by factors in five domains: genetic, environmental expo-sures, behavioural patterns, social conditions, and health care.39 For most chronic con-ditions, such as many of the rheumatic diseases, the single greatest domain in whichhealth can be improved and premature disability reduced is personal behaviour.40,41

Figure 1 shows an explanatory framework for the use of CAM by rheumatic patients.Two of the domains influencing health – genetics and environmental exposures – givethe risks for the development of an illness, but the other three influence decisions toseek treatment in an ill person, and hence the outcome of a disease. At this point, in-troducing the marketing concept of ‘positioning’ seems appropriate. Positioning is theperception in the minds of the target market: in this case, rheumatic patients. It is theaggregate perception the market has of a particular product or service (e.g. CAM) inrelation to their perceptions of the competitors in the same category (mainstream

Figure 1. A conceptual framework to explain the use of complementary and alternative medicine (CAM) by

rheumatic patients.


health care).42 People have learned to rank products on mental ladders, and the easyway to get into a person’s mind is to be first.42 Our hypothesis is that the positioningof CAM products and services is much higher in many rheumatic patients than main-stream health care, and there is a clear evidence to support our belief.43,44

In the framework we are presenting here (Figure 1), several factors interact and in-fluence behavioural patterns, social conditions and health-care domains to promotethe use of CAM. In many cases, for instance, CAM arrived first: e.g. the first descrip-tion of copper bracelets to treat ‘arthritis’ appears in the Ebers papyrus 1550 B.C., andpeople in Europe and Mexico are still using it for the same purpose nowadays. In Mex-ico one third of the most frequently prescribed herbal remedies for rheumatic condi-tions have been used for the same purposes for the last three centuries.45 Culturalcongruence related to CAM is further supported by the disclosure of CAM versus or-thodox medicine. The first ‘knows’ the aetiology of ‘the rheumatism’ or ‘the arthritis’,while the second may diagnose over 180 different rheumatic diseases, and assign tomost of them an ‘unknown’ or at best ‘multifactorial’ aetiology. Many CAM remediesprovide ‘natural’ products with no declared safety profile, intended to ‘cure’ the illness;in contrast, orthodox medicine gives informed consent forms, bulky labels withstrange and scary language inside the products, and they are intended only to ‘improve’the disease. Some authors support this view.46–48

It is well known that rheumatic diseases such as rheumatoid arthritis have a multi-dimensional impact in patients and their families, including helplessness, social andwork performance, economic costs, etc. The placebo effect of a ‘risk-free’ remedyaimed to ‘cure’ the illness may be important; indeed, placebo effect has been reportedto be as high as 40% of participating patients in randomized controlled clinical trials.Denial period of the bereavement process, ‘powerful others’ dimension of locus ofcontrol49,50, and characteristics of coping strategies of patients with rheumatic dis-eases also interact and influence behavioural patterns to use CAM.

Social network is other important factor that interacts with cultural congruence inthe domain of social conditions. It refers to people around patients and has importantfunctions for patients, such as help and advice. Its efficacy is an important outcomepredictor for rheumatic patients, and is determined by perceptions. It is expectedthat social network belongs to the same social and cultural background of the patient,and it may influence a patient’s decision to use CAM.

Media and advertisement are playing a much more important role now than previ-ously in positioning and perceptions of CAM. They are business-oriented and clearlysupport the payers and what sells better.51 The market, and advertisements related toCAM, is substantial52–55, and as Jarvis noted: ‘at the present time, commercialism hasoverwhelmed professionalism in the marketing of alternative remedies’56; the expen-diture associated with CAM is rated in billions.57 In contrast, rheumatology as a med-ical speciality, or even many rheumatic diseases, remain largely unknown to the generalpopulation, at least in some countries.58

The last domain, health care, may also be a promoter of CAM; health-care systemsfor restricted coverage, costs or delays in proper treatments59 may cause some pa-tients to seek an ‘alternative’ treatment. Indeed, physicians and even rheumatologistsare directly prescribing CAM. Yet medicalization is another way to encourage CAM.Medicalization refers to the process by which maladies that are part of everyday lifebecome medical issues, and thus come within the purview of physicians to engagewith, study and treat. Medicalization usually is driven by the availability of treatments.60

For all these reasons, it is possible that amongst the hundreds of remedies to treattheir rheumatic illnesses, rheumatologists and orthodox drugs are perceived by


patients as just one of the options. Bearing this model in mind, it should not be sur-prising that more patients used more CAM remedies after their first rheumatologyconsultation.

CONSIDERATIONS ON SAFETY PROFILES OF CAM REMEDIES ANDPROVIDERS

There is a growing knowledge on the use of CAM both by the general population andby rheumatic patients. However, the medical literature should be interpreted with cau-tion. For example, several studies related to CAM have important flaws in their design,and these are not just restricted to small sample size but include conceptual differ-ences in basic definitions, such as diagnostic certainty, variable endpoints for efficacy,and the instruments used to assess them. For instance, some authors concluded thatSuogudan Granule is effective and safe for the treatment of rheumatoid arthritis afterperforming a clinical trial of 6 weeks’ duration in 90 patients with rheumatoid arthritiswhere the primary endpoints included, among others, changes from basal of a ‘totaleffective rate’, serum levels of rheumatoid factor and antiestreptolysin O.61 In otherstudies, Zhang et al62,63 assessed the diagnosis agreement among traditional Chinesemedicine practitioners. Licensed acupuncturists with experience and education in Chi-nese herbs examined separately the same rheumatoid patients following the tradi-tional ‘four diagnostic methods’. The agreement among practitioners with respectto diagnosis was below 35%. He et al64 compared the components of ACR20 responsecriteria against the 18 manifestations typically assessed in traditional Chinese medicineto predict treatment efficacy in rheumatoid arthritis patients. Half of patients wererandomly assigned to receive Western medicine and the other half to Chinese herbalmedicine; 89% of the patients receiving Western medicine and 65.8% of those on Chi-nese herbs achieved ACR20 responses. In the Western medicine group efficacy wasnegatively related to subjective symptoms of dizziness, and positively related to jointtenderness and thirst; in the Chinese herb group the efficacy was positively related tojoint tenderness and joint pain, and negatively related to the joint stiffness and morenocturia. However, these and other methodological issues seem to have been over-come in more recent publications from Asia.65 Another problem is that the prevalenceof CAM users depends largely on the definition of CAM and what is listed as CAM inthe surveys. For instance, non-prescribed vitamins were considered as CAM in theAustralian survey35, and their inclusion contributed up to 50% of the prevalence ofCAM usage; others studies have specifically excluded vitamins. The cross-sectional de-sign of most studies precludes cause–effect inferences on the explanatory models forthe use of CAM. In the same way, cross-sectional surveys of rheumatic patients attend-ing rheumatology clinics prevent assumptions on efficacy, satisfaction and safety of dif-ferent CAM remedies. In many instances non-pharmacological articles scored lowerthan pharmacological articles in terms of quality, so the assessments of non-pharma-cological treatments must take into consideration additional methodological issues.66

Rheumatic patients use CAM products more often than products formally pre-scribed through CAM providers. Differences among countries depend mainly on thecharacteristics of the ‘folk’ medicine, the ‘faddish’ CAM, and on the availability ofCAM providers, rather than on geographic, ethnic or disease characteristics. For in-stance, the products used by Australians includes non-prescribed vitamins and herbs;in the United States topical remedies such as alcohol, whiskey, peanut oil, snake oil,gasoline, kerosene, motor oil and copper or other jewellery9,67; in Canada,


chiropractic, deep heat rubs, fish oil and acupuncture16; and in Mexico local herbs, ho-meopathy, topical marijuana diluted in alcohol, and snake pills.17,45 Overall, the mostused CAM providers by rheumatic patients are chiropractors, acupuncture, massage,herbs and homeopathy.

The safety profile of each CAM modality should be a primary concern. However,most of the literature on CAM-related side-effect are case-reports where publicationbias should be considered. However, there is growing evidence that the use of a CAMremedy can be a morbid factor, even if it is ‘natural’ (Table 2).32,34,35,68 In many in-stances, CAM products have flooded the international market without any monitoringon safety. CAM market products may contain the substances listed on the label in theamounts claimed, but they need not. The remedy itself may prove to be harmful eitherdirectly69–75 or through undeclared addition of drugs such as non-steroidal anti-inflam-matory drugs (NSAIDs), benzodiazepines, ephedrine or steroids.76–79 In a recentstudy, 23% of the 2609 samples of traditional Chinese medicines were adulterated,largely those claimed to be effective for rheumatic diseases or to have analgesic oranti-inflammatory activity. More than half of the adulterated samples contained twoor more adulterants such as caffeine, analgesics, NSAIDs and prednisone.79 In a reviewof Chinese medicinal herbs available in the United Kingdom80 it was estimated that10–25% were of doubtful authenticity. Cui et al81 assessed 50 commercial ginsengpreparations sold in 11 countries; 12% did not contain any ginseng, one contain ephed-rine, and in 44 of these preparations the concentration of ginseng varied from 1.9% to9.9%. Russell et al82 also assessed the content of active ingredient in 14 over-the-counter, commercially available capsules of glucosamine sulphate preparations inCanada. The amount of free base varied from 41 to 108% of the milligram contentstated on the label; the amount of glucosamine varied from 59 to 138% even whenexpressed as sulphate. Draves et al83 reported similar features in St John’s Wort prep-arations available in Canada and the United States.

Table 2. Safety concerns related to complementary and alternative medicine (CAM) utilization.

Direct toxicity

Undeclared addition of prescribed drugs:

NSAIDs

Analgesics

Steroids

Others

Contamination:

Heavy metals

Microorganisms

Additives

Authenticity and adulterants

Pharmacological interactions between CAM and prescribed drugs

Quackery

Behavioural patterns:

Discontinuation of formal treatment

High use of CAM

No professional supervision for CAM users

Low willingness to report CAM-associated adverse reactions


Asian patent medicines were recently screened for adulterants in California.84 Ofthe 260 products, 83 (32%) contained undeclared pharmaceuticals or heavy metals,and 23 had more than one adulterant; similar features were found more recently.85

Another source of CAM-associated morbidity is contamination with arsenic, mercury,or microorganisms.81,86–89 In a recent study from Australia90 5–65% of the investigatedtraditional Chinese medicines contained arsenic, lead and mercury, some with levels ashigh as 2760-fold of the tolerable daily intake. Drug interactions between conventionaland CAM therapy is another potential concern.91,92

Some specific practices related to CAM utilization deserve further comment. A1982 survey in the United Kingdom93 identified a total of 30,000 CAM practitionersof one variety or another. The majority of CAM providers in Britain and the US arenot medically trained practitioners.94 On the other hand, approximately 50% of theindividuals who used CAM for a medical condition did so on their own, withoutany supervision; that is, without either visiting a provider of CAM or discussing theirCAM usage with their medical doctor.34,95 In the United States, less than 10% of therheumatic patients are attended by rheumatologists.96 Extrapolation of the above datasuggests that many rheumatic patients are without any supervision at all. A pattern ofhigher consumption of medical resources has also been identified among users ofCAM97, representing additional risks.

Patients may discontinue formal treatment in order to use CAM. In one series, 5%of the cancer patients did that6, while in another series 14% of rheumatic patients dis-continued formal treatment.17 This practice has been identified that as a leading con-tributing cause of death in patients with SLE.19 One other concern relates to thosepatients who use CAM more than the mean (more than 6 remedies). This subgroupof high CAM users has been identified in several reports, at a prevalence around5%. For instances, one study17 found that patients at the upper bounds of CAM utili-zation received up to 19 remedies, discontinued their formal treatment 11 times, vis-ited CAM providers up to 180 times, and spent the equivalent of 1333 days’ wages onCAM, all of these in 1 year. These patients who are exposed to more CAM modalitieshave a higher risk of side-effects. Other problems are related to secondary prevention.Patients may use CAM at the beginning of their disease, delaying proper diagnosis andtimely treatment.98 As discussed previously, many individuals with chronic diseases useCAM without the knowledge of the attending physician, and, at least in one study, 26%of the CAM users would not consult their physician in case of presenting an adversereaction associated with CAM.44,99

MARKETING CONSIDERATIONS

The market for the use of CAM is substantial and is growing rapidly worldwide. Thereported prevalence rates of CAM use by the general population are 20–73% in coun-tries such as Australia, Belgium, France, Germany, United Kingdom, Canada, UnitedStates, Mexico and India.

Expenditure associated with the use of CAM is rated in billions. For instance, extrap-olations suggest that in 1990 the US population made an estimated 425 million visits toproviders of CAM. This number exceeds the number of visits to all US primary-carephysicians (388 million). The average charge per visit to CAM providers was $27.60,and the overall estimated expenditure associated with CAM use in that year amountedto $13.7 billion.34 The Australian survey estimated a natural expenditure of $AU930million for CAM remedies and providers in 1993.35 In 1990, sales in the EuropeanUnion totalled £1 billion, with sales in the UK estimated at £200 million pounds.100


The high prevalence of CAM utilization among patients with rheumatic diseases isnot a surprise. In spite of the disparity of the prevalence rates of 2 out of 10 for rheu-matic patients in the general population and 9 out of 10 for clinic-based populations,which is probably the result of methodology issues, these figures are impressive. Thereported prevalence rates of utilization of CAM providers is 12–33%, with an averageof 4–9 visits per year, which is superior to the reported utilization of rheumatologycare. In Canada, the reported expenditures for CAM providers is C$489.00 and forCAM products C$133.00 per patient per year.14,38 In Mexico, the mean expenditureper patient for fees to CAM providers was equivalent to 28 days of the official mini-mum daily wage, and 13 days for the remedies themselves.17 Extrapolation fromknown data indicated that the potential market for CAM products alone used by rheu-matic patients in the Americas would be US$23 billion per year.57

CLOSING REMARKS

The evidence is clear that the use of complementary and/or alternative medicines bysufferers of rheumatic diseases is highly prevalent. Furthermore, notwithstanding thesignificant advances in our understanding and conventional treatment programmes forthese diseases, the evidence is clear that the usage of alternative therapies is increas-ing. It is therefore judicious for physicians and rheumatologists alike to ensure that notonly are they acquainted with the alternative therapies that their patients may be tak-ing, they should also have some insight into the nature of these remedies, as they maysignificantly impact patient management.

It is clear then that amongst the hundreds of CAM modalities, items and remediesto treat patients with diverse diseases, some of them are harmless while others mayhave significant toxicity.32,34,35,68 Indeed, some of CAM that may be inoffensive may beturned into hazardous goods by means of fraud and quackery. Quackery, as defined byJarvis56, is ‘the promotion of false and unproven health schemes for a profit’. However,it is also clear that other CAM remedies may really work as ‘complementary’ to or-thodox medicine. The ‘alternative’ part of the CAM definition poses a much morecomplex problem. One of the definitions of the word ‘alternative’ is ‘necessitatinga choice between mutually exclusive possibilities’. What ‘alternative’ remedies may ex-ist to biological agents or DMARDs to lessen the structural damage of rheumatoid ar-thritis? Considering the multidimensional impact of many rheumatic diseases,‘complementary’ modalities may help patients to better deal with the disease and tolive with it. For example, besides CAM, traditional medical systems – such as Chinesemedicine, acupressure, acupuncture, tai-chi, ayurveda, yoga, unani, siddha, Japanesekampo medicine, Tibetan medicine – have been used in their countries of origin with-out interruption for several centuries. These traditional medical systems are now be-ing subjected to scientific validation, and research in this field is growing qualitativelyand quantitatively. China has integrated traditional Chinese medicine into its nationalhealth-care system, and about 95% of general hospitals in China have traditional med-icine departments.101 In India the central government has a separate department ofAYUSH under the ministry of health. AYUSH covers medical systems conventionallyconnoted as CAM. These include those originating in India and also those from outsidewhich became adopted and adapted in India in the course of time. These are ayurveda,yoga, unani, sidhha and homeopathy (AYUSH). These systems have separate governingcouncils and infrastructure for training (total colleges 460, undergraduate seats 25,200,postgraduate seats 1791), services (around 700,000 registered practitioners),


medicine manufacturing (8500 units) and research.102 India has a unique scenario of‘medical pluralism’. While separate research councils for each AYUSH system are nur-tured for their distinctive identities, the Government has also been engaged in inte-grating AYUSH systems into national health-care delivery.103 Government-sponsored major endeavours such as the ‘Golden Triangle Project’, ‘NMITLI pro-gramme’ (New Millennium Indian Technology Leadership Initiative) and ‘Science initia-tive in ayurveda’ are essentially intended to facilitate interface of Indian traditionalmedicine with progressive science and technology, and also to develop globally com-petitive natural medicines inspired from these age-old health-care traditions. Thenovel path of ‘reverse pharmacology’ in drug development from traditional medicineis proving to be time- and cost-effective.104 Reverse pharmacology is essentially a prag-matic integration of observational therapeutics, application of relevant science, anddrug discovery.105

A few examples of medicinal plants from the ayurvedic tradition which have beeninvestigated through experimental and clinical studies on their possible efficacy inrheumatic diseases include Commiphora wightii106,107, Curcuma longa108,109, Zingiber ofi-cinale110,111, Tinospora cordifolia112,113, Semecarpus anacardium114–116, and Withania som-nifera.117 Through a constant interface with progressive modern science andtechnology, and an evidence-based approach in research endeavours, these age-oldhealth-care systems could not only yield safe and effective medicinal products butcould also be helpful in health promotion and disease prevention.

Thus, if it is feasible that ‘complementary’ therapies may help rheumatic patients tobetter deal with their lives, no place should be given to quackery, clientelism, or mis-leading information. Meanwhile, high-quality research on CAM effectiveness is neededto guide physicians’ behaviour, to safeguard patients’ safety, and to assist policy-makersin planning regulations for CAM usage.

Practice points

� the use of CAM therapies is increasing among rheumatic patients and is notrestricted to any particular geographic or ethnic group, social status or eco-nomic situation� primary-care physicians, and even rheumatologists, are increasingly prescribing

CAM therapies to their rheumatic patients� more patients used more remedies after the first rheumatology consultation;

however, an important proportion of patients will not tell their physicianthey are using CAM� it seems that the positioning of CAM products and services is much higher in

many rheumatic patients than mainstream health care� cultural congruence, social network, the media and advertisement, placebo ef-

fect and medicalization are important contributing factors to the use of CAMremedies� the safety profile of each CAM modality should be a primary concern; some of

them are clearly harmless, but others may have significant toxicity� taking into account the multidimensional impact of several rheumatic diseases

in all aspects of daily living, it is possible that some CAM may really work as‘complementary’ to orthodox medicine

Research agenda

� high-quality research on CAM effectiveness, consumer behaviour and safety isurgently needed


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