CAM and arthritis – the ARC report

The Arthritis Research Council produced a report last month on Complementary and alternative medicines for the treatment of rheumatoid arthritis, osteoarthritis and fibromyalgia. The report was limited to various supplements and looked at over 40 substances from antler velvet to willow bark.  In the introduction the report comments:

There is little data on how they compare with other available conventional treatments. We also rarely know what is the most effective dose. One key area of ignorance is how they interact with other medications which could change the effectiveness of such medicines. Interactions may be particularly important since many patients taking complementary medicine do not tell their doctor.
Finally, despite the frequent assumption that by being ‘natural’ such compounds are not harmful, we often know little about how safe some of the complementary medicines really are. Underlying these issues is that unlike medically qualified doctors, most practitioners who prescribe complementary medicine are currently not subject to any government regulation.

It is a very glossy reader friendly document (nowt wrong with that) written by Professor Gary Marfarlane from the Epidemiology Group at Aberdeen University.

So is there any evidence that Prof Macfarlane is some CAM stooge determined to spread the message of CAM to the world? Well you can read his bio here and I can’t see any evidence that is anything other than a Jobbing Epidemiologist with no axe to grind. So no conspiracy theory there.

The Report

There are hours of entertainment in this document for nerdy types who want to haggle over the evidence. In essence this is a document which tries to mix accessibility to the public with a more scholarly approach to the literature. They have used a simple scoring system to give an overall impression for the evidence behind any substances. I am not a big fan of simplified scoring systems – it strikes me as far too simplistic and all this evidence has to be interpreted with care. They have used a traffic light system to score the safety of the medications. I don’t like these either. I do accept that this may be a personal bias toward any system that involves colour given my red-green colour blindness. However, I prefer to think it is because traffic light systems applied to medicine are embarrassingly naive and grotesquely simplified parodies of the complexity of clinical practice. I also find it difficult to believe it would be the chosen method of an academic epidemiologist. This is the ideal point for me to deploy the cliche: it is a bit more complicated than that.

Having made those criticisms I have to admit a sneaking admiration for the underlying aims of this project. (And I have to applaud them for including safety data – an area so often glossed over by the CAM fans.) It has taken a sprawling subject, allied it to a grown-up sensible approach to evidence-based medicine and then tried to present the findings in a way that remains accessible to a wider audience.

Rather revealingly, using their fantabulous scoring system only two substances out of the forty scored the maximum 5 points. To hit the top score these substances needed to show:

There is consistent evidence across several studies to suggest that this compound is effective.

What were the two? Capsaicin - a topical gel containing stuff extracted from chilli peppers and fish oil in rheumatoid arthritis.

I think the capsaicin is an interesting inclusion and somewhat blurs the distinction between alternative therapies and ones that have a ‘natural’ origin. I don’t regard capsaicin as an alternative therapy. CAM practitioners can cling on to it as some irrefutable evidence that not all CAM is useless but it is widely used by GPs and it is in the BNF. There is nothing alternative or particularly complementary about it.

So that leaves one substance – fish oil in rheumatoid arthritis. I haven’t delved into the original papers but Prof Macfarlane suggests that there is evidence that fish oil can reduce the amount of NSAIDs required by arthritics and can give a modest improvement in pain. The good Prof does highlight some of the limitations in the studies. The patient numbers were still modest – only 97 in total and interestingly there was poor retention in the trial. Only 65% were still taking the fish oil at the end (54% of placebo).  There had also been a re-hash of the data from 10 trials (with low to moderate quality) in a meta-analysis which also suggested some improvement. This is when meta-analysis starts to make me worry – smooshing together dubious data and applying complex statistics makes me nervous. The whole thing looks like fertile ground for a decent size trial.

The Reaction

The BBC reported on the study but overall it seemed to have had a very minimal splash. I haven’t seen it covered on the usual blogs and I don’t think this study pleased anybody all that much. The CAM fringe wouldn’t like it as it has largely been reported as showing treatments as ’ineffective’ treatments. Any science-based medicine reaction has perhaps been muted by the way the study was reported in the media.

Personally, I feel slightly uneasy about the whole exercise – there is clearly a need to give people decent information and the conclusions seem reasonable. Could the money have been better spent on a more scholarly and purely academic review? I am just not sure how thrilled I would be if I had given money to a charity such as ARC.

Even the Medical Director of ARC seemed to have a slightly apologetic tone:

Professor Alan Silman, the Arthritis Research Campaign’s medical director, added: “We didn’t start this saying this was our opportunity to knock complementary medicines.

“The message is not ‘don’t take them’. The message is ‘if you are going to take them, be aware of what the level of evidence is’.”

Though he seems more concerned that ARC may alienate any patrons that do support and use complementary medicines. And what was the CAM response to all this?

Dr Peter Fisher, clinical director of the Royal London Homeopathic Hospital, said the report focused on tablets and preparations applied to the skin, missing out therapies such as acupuncture and osteopathy.

Not the most convincing defence for the lack of evidence of homeopathy and other alternative supplements is it?