Herbs and supplements

Herbal medicine involves the therapeutic use of plant preparations with the aim to prevent disease, enhance health and alleviate suffering. Herbal remedies have been used in many cultures since ancient times. Today about one-quarter of pharmaceutical preparations contain at least one active ingredient extracted from plant sources. Herbal medicine as practiced today is a blend of traditional herbal knowledge and modern medical science. There is evidence of synergistic effects when different herbs are combined so herbs are more often prescribed as mixtures than a single herb.

Safety of herbal medicine

Generally speaking, herbal remedies are safe but can sometimes cause side effects. These can include stomach upsets, sleeplessness and muscle or joint pain. Some herbal remedies may also interact with your prescribed medication. Some herbs may be beneficial for arthritis, but the evidence is inconclusive. It is best to avoid self-prescribing and consult with a suitably qualified practitioner and check with your doctor before starting the treatment to avoid any side effects and herb-drug interactions.

Visit New Zealand Association of Medical Herbalists

Supplements are used to supplement, not replace, a healthy diet. There is more to your nutritional requirements than single nutrients and these are usually best consumed packaged in their wholefood source. Food comes with a whole lot of other vitamins, minerals, fibre, fats, protein, carbohydrates and other compounds that are good for your health. Chewing and digesting real food is an important part of feeling full and keeping our teeth strong too.

Some people need to supplement their diet for various reasons, and some people try supplements as a complementary therapy for their health condition. We’ve put together a guide to herbal medicine and supplements commonly taken by people living with arthritis.

Origins
From the French maritime pine tree, Pinus pinaster, the extract is pycnogenol. The active phenolic compounds are also present in other plants such as cranberries, blueberries, green and black tea, grape seed extract, sorghum grains, cinnamon and cocoa.

Claims
Antioxidant and anti-inflammatory effects. There are many claims for the benefits that antioxidants may have in the body, including on the brain, eyes, cardiovascular system, blood vessels, glucose control, and chronic inflammation in autoimmune diseases.

Be aware
Different nutraceutical companies are patenting their own version of pine bark extract and conducting studies on the patented version. So, while some conclusions may be drawn for one specific extract, these may not always carry over to the various other pine bark extracts. This also means that most research is funded by industry. This doesn’t mean all results are invalid, but it is something to be aware of when considering the studies that have been selected for publishing and what you are reading. This awareness goes for any study on a commodity that the research funders can sell. Pycnogenol is French pine bark extract and Enzogenol is a New Zealand pine bark extract.

Evidence
A 2018 review concluded that treatment with pycnogenol had statistically but not clinically significant improvements in joint stiffness with osteoarthritis. 

Although not the most potent anti-inflammatory agent out there, pycnogenol has shown some efficacy in alleviating symptoms in patients with autoimmune disease. It won’t do much for you if you are in a flare, but it can help mediate chronic inflammation when in remission or non-flare state.

A 2018 industry-funded study has shown that pycnogenol may be effective for relieving dry eye and dry mouth symptoms associated with Sjogren’s syndrome.

Safety
There are no reported serious side effects of pine bark extract supplementation, but as it has the potential to lower blood pressure and blood sugar you should consult your doctor before starting supplementation.

Where to find it
Readily available in supplement form online and in health stores as capsules, tablets, and powder and as drinks that contain pine bark extract as one of multiple ingredients.

Origins
A flowering plant from the Zingiberaceae family, cultivated by humans for its commercial value. Originally from Maritime Southeast Asia and also native to China, West Africa and the Caribbean. Ginger has been used in both Ayurvedic and Traditional Chinese Medicine.

Claims
For centuries ginger has been used for a wide range of ailments, including allergic rhinitis, digestive issues, nausea, and arthritis. For arthritis, ginger is claimed to reduce inflammation and joint pain.

Evidence
Antioxidant and anti-inflammatory effects. Similar to non-steroidal anti-inflammatories (e.g. ibuprofen), ginger acts on the inhibition of cyclooxygenase enzymes 1&2. It also switches off certain inflammatory genes.

Rheumatoid Arthritis
There is promising evidence for ginger to play a role in the management of inflammation from rheumatoid arthritis. A human study in 2022 found that supplementation of 1.5 grams per day of ginger in 63 patients with rheumatoid arthritis obtained a significant reduction of inflammatory markers.

Systemic Lupus Erythematosus
A 2022 review of the effect of ginger on inflammatory diseases highlights that ginger has potential in the management of systemic lupus erythematosus as it has proven anti-oxidant and anti-inflammatory effects. One of ginger’s active compounds, 6-shoagol appears to be protective against lupus.

Psoriasis
The same review also highlights that ginger’s anti-oxidant and anti-inflammatory properties make it a candidate for a short-term alternative treatment in people with psoriasis.

Osteoarthritis
One trial in 2001 resulted in a significant difference in knee pain when standing for people who took a ginger extract supplement compared to placebo (63% ginger vs 50% placebo). But a review in 2020 on the effectiveness of ginger and pain in knee osteoarthritis concluded that there is insufficient evidence to support the use of a ginger supplement or topical application for pain relief and knee function improvement.

Safety
Ginger is a pretty safe herbal remedy with only mild side effects, including upset stomach, mouth irritation, and heartburn. If you are taking anticoagulant medication such as warfarin, ginger may increase the risk of bleeding. It should not be taken if you have gallstones.

Where to find it
The root of the ginger plant is used as a spice in cooking so you can find fresh ginger at your local supermarket, green grocer, or farmers market. You can buy ground, crystallised ginger and ginger tea from most places you buy your groceries. Online and at health stores you will find ginger liquid extract, syrup, and capsule supplements.

Origins
Withania somnifera known more popularly as Ashwagandha or Indian Ginseng, is a herb used in Ayurvedic medicine, the traditional medicine of India. Ashva means “horse” and gandha means “smell” in Sanskrit. It is said to have a “horsey” smell. It is part of the nightshade family of plants and grows in India, Middle East, and parts of Africa. The root extract is most commonly used in herbal medicine.

Claims
May help relieve stress, anxiety, and depression. May improve brain function and sleep.

Evidence
A 2020 review of the use of herbal medications for treatment of osteoarthritis and rheumatoid arthritis notes ashwagandha has anti-inflammatory and analgesic effects with significant decreases in self-reported pain scores in a study on people with knee OA. Significant reduction in scores for pain, stiffness, and disability were also observed.

Safety
Ashwagandha has been consumed for many years in the use of Ayurvedic medicine. It is a safe herbal supplement, but no studies have been done on long-term use. One study on the safety of ashwagandha found that consumption of the root extract for 8 weeks was safe in both males and females with no adverse events reported.

Where to find it
You can find ashwagandha in many forms. Readily available online and in stores are soft chews, capsules and powder supplements. Traditional ayurvedic remedies can use the leaves, seeds, or fruit.

A medicinal cannabis product is either dried cannabis or a pharmaceutical dosage form containing one or more ingredients extracted from the Cannabis plant.

What is CBD? (cannabidiol)

To be considered a ‘CBD product’ the tetrahydrocannabinol (THC) and other specified substances within the product must not exceed 2% of the total CBD, THC and other specified substances which naturally occur in cannabis. A CBD product cannot contain any other controlled drugs or psychoactive substances.

THC is the compound that produces an intoxicating effect.

Claims

The main claims relevant to arthritis involve pain perception, mood, inflammation and immunity, sleep, appetite and digestion.

Evidence

For arthritis: There is insufficient evidence to support routine use in patients with acute pain or nociceptive pain associated with rheumatic conditions (including osteoarthritis and back pain).

Other pain: There is low-quality evidence that medicinal cannabis may improve perceived levels of pain in patients with chronic neuropathic or malignant pain.

There is currently insufficient clinical trial evidence to support medicinal cannabis products being used as a first-line treatment for any condition. However, they may be suitable for some conditions if patients have ongoing symptoms despite optimal use of conventional treatments or where it might interact with the patient’s other medications, or other medications are not tolerated.

What is an approved medicinal product?

Medicinal cannabis products that are approved as meeting the minimum quality standards can be prescribed in Aotearoa New Zealand. This is NOT an indication of efficacy or safety and is NOT the same as being Medsafe approved. Medsafe approves the use of a medication based on evidence that it actually works for the condition it is being prescribed for, as well as taking into account the quality of the product.

There are two indications where medicinal cannabis is Medsafe approved:

1. Sativex is indicated as add-on treatment, for symptom improvement in patients with moderate to severe spasticity due to multiple sclerosis (MS) who have not responded adequately to other anti-spasticity medication and who demonstrate clinically significant improvement in spasticity-related symptoms during an initial trial of therapy.
2. Epidyolex is indicated for use as adjunctive therapy for seizures associated with Lennox-Gastaut syndrome (LGS) or Dravet syndrome (DS) for patients 2 years of age and older.

Safety

CBD is generally safe to take. It is a prescription medication so must be added to your treatment plan with the guidance and advice of a GP or other prescriber. Medical practitioners can prescribe medicinal cannabis products that are neither Medsafe approved nor verified by the Medicinal Cannabis Agency as meeting the minimum quality standard; however, these have no official New Zealand endorsement of efficacy, safety or quality.

Adverse effects are common but usually tolerable depending on the individual and the formulation

Toxicity is highly unlikely.

Situations in which to be cautious if using medicinal cannabis:

• Liver or kidney issues
• Children or adolescents
• History of falls
• Previous risk-associated behaviours with substances
• Psychosocial support considerations
• Financial position – medicinal cannabis products aren’t funded in Aotearoa
• Employment type such as operating heavy machinery
• Driving
• Drug testing

Origins
Gum resin from the bark of the Boswellia tree found in India, North Africa and the Middle East. Ayurvedic medicine.

Claims
The extract of Boswellia serrata can support the body in maintaining healthy joints via anti-inflammatory activity, pain relief, and anti-arthritic effects.

Evidence
Studies have mainly looked at the effect of Boswellia serrata on osteoarthritis. A 2017 review of dietary supplements for treating osteoarthritis found that Boswellia serrata showed clinically important improvements in joint stiffness in the short term. There is no evidence for medium or long-term benefits.

A 2019 study found that the topical application of Boswellia Carterii B. (oliban oil) was associated with a significant improvement in OA pain and symptoms compared to a control group and a group taking diclofenac. However, activities of daily living, sport and recreation, and knee-related quality of life did not improve significantly.

Safety
No serious adverse effects have been reported, but high doses may impact the liver. Do not start taking any supplement without consulting your doctor or specialist first.

Origins
Harpagophytum procumbens (Hp) is a plant from the sesame family that is native to Southern Africa. Also called grapple plant and wood spider. It has been used in traditional medicine throughout Southern Africa and is harvested in Namibia, Botswana and South Africa on a commercial level.

Claims
Can relieve pain, lower inflammation markers and protect joints through anti-inflammatory action.

Evidence
Has mainly been studied for pain relief for lower back pain and osteoarthritis. A review of the evidence in 2004 concluded that there is limited evidence in the treatment of knee and hip osteoarthritis for treatment with dosages below 30 mg and moderate evidence for the treatment of the same conditions plus lower back pain at 60mg and above.

A more recent review found evidence for the reduction of inflammation markers and protection of articular cartilage. The quality of evidence isn’t ideal, and more robust trials need to be done to make any recommendations to treat arthritis with devil’s claw.

Safety
Devil’s claw has been reported to interact with anticoagulants, painkillers, heart drugs (for example, digoxin) and stomach acid drugs (for example, famotidine). It may also cause diarrhoea. There are reported adverse effects in high doses, so lower effective doses are recommended. Only take this herb with the guidance of a health professional.

Origins
St John’s wort (SJW), also known as Hypericum perforatum, is a yellow flowering plant from which extracts are used to make teas, liquid extracts, and supplements. It has been used in Traditional Chinese Medicine for centuries.

Claims
Acts as an anti-depressant and reduces inflammation and pain

Evidence
There are promising animal studies that demonstrate pain relief and the ability to work in tandem with opioids for pain relief. However, a 2017 review of the evidence concluded that clinical research in this field is still scarce, and the few studies available on chronic pain produced negative results. Prospective randomised controlled clinical trials performed at low doses are needed to validate its potential efficacy in humans.

A large-scale meta-analysis of SJW for depression in 2017 concluded that for patients with mild-to-moderate depression, St John’s wort has comparable efficacy and safety when compared to SSRIs (standard prescribed medication for depression). The studies were limited to 12 weeks duration at the most so evidence is unclear for longer term, and was lacking for more severe depression.

Safety
Taken at the recommended dose, St John’s wort has few adverse effects (for example nausea, rash). However, research has shown that SJW altered the pharmacokinetics of drugs such as digoxin, tacrolimus, indinavir, warfarin, alprazolam, simvastatin, and oral contraceptives. Hyperforin is one of the active ingredients in an SJW extract and is the main culprit for interactions with prescription medicines. A 2020 review of SJW drug interactions recommended a safety threshold of a maximum 1-mg of hyperforin per day is recommended.

Talk to your doctor if you are taking prescribed medications before you start SJW.

Contact your doctor immediately if you are reading this and taking St John’s wort and notice signs or symptoms indicating that your medicine is less effective than usual.

Origins
Curcumin (curcuma longa) is an active compound from turmeric, a plant belonging to the ginger family Zingiberaceae, native to tropical South Asia. Turmeric originates from the Vedic culture in India and south Asia; it is also used in Traditional Chinese Medicine and throughout Africa and Jamaica in traditional medicine.

Claims
In Ayurvedic medicine, turmeric is a well-documented treatment for rheumatism and swelling. Unani practitioners use turmeric to improve blood circulation, and in both Ayurvedic and traditional Chinese medicine, turmeric is used to improve digestion. Claims also include reducing inflammation and pain and improving function in arthritis.

Evidence
A 2021 systematic review of the therapeutic effects of curcumin on pain and function for knee osteoarthritis concluded that compared with placebo, there appears to be a benefit for pain and function. Based on several studies, the effects are similar to that of NSAIDs. Optimal dosing, frequency and formulation remain unclear at this time.

Markers of inflammation are reliably reduced with supplementation in inflammatory conditions.

Piperine, a compound in black pepper, enhances the ability to absorb curcumin, so it should be taken together for the best results.

Safety
Turmeric and curcumin are safe when used in cooking but this is generally in low quantities, so it is unlikely to have therapeutic effects. Ground turmeric has been found to be contaminated with lead from Bangladesh and Indian sources through processing methods. No amount of lead ingestion is safe. Do your research and only buy trusted brands. For more information about lead in herbs and spices in NZ: Do your herbs and spices contain arsenic, cadmium or lead? – Consumer NZ

Therapeutic levels of curcumin in supplements are generally considered safe.

Where to find it
You can buy fresh turmeric root at most fruit and vegetable stores in New Zealand. Ground turmeric is available at most supermarkets and food stores. Curcumin supplements are available at most health stores.

Origins
Bromelain is a group of proteolytic enzymes found in pineapple. It is most highly concentrated in the core and stem from where it is extracted and made into a supplement. Indigenous people of Central and South America have long used pineapple in traditional medicine.

Claims
Has promising anti-inflammatory and pain relief effects.

Evidence
A 2021 review of bromelain processing, pharmacokinetics and therapeutic uses notes that for rheumatoid and osteoarthritis, bromelain has the potential to act as an NSAID treatment. But the poor quality of studies means there is not enough evidence for recommendations.

Safety
There seems to be good tolerability and safety in the lower doses that have been studied, around 500mg/day and comparable in symptom relief to standard pain medication. It also appears safe and well tolerated with no relevant side effects with higher doses of up to 2000mg/kg body weight. Remember that it is up to your health provider to work out the dosage for you.

Care should be taken in;

• long-term supplementation
• People with kidney issues
• People taking anticoagulants and antibiotics.

Origins
Extracted oil from the fruits and seeds of avocado and soybean. ASU is generally one-third avocado oil and 2-thirds soybean oil.

Claims
Reduces pain, improves function, and slows progression in osteoarthritis. It is also used for back pain.

Evidence
ASU has antioxidant, anti-inflammatory and chondroprotective effects. It is involved in the protection of the cartilage matrix and can be tried as a natural alternative to NSAIDs.

A 2020 review of the potential treatment benefits of ASU concluded that considering its effect on OA and its role in providing positive structural changes, ASU seems to be a promising drug for OA.

There may be some potential for ASU in treating scleroderma, but large studies need to be done.

A systematic review and meta-analysis of randomised placebo-controlled trials published in 2019 concluded that there is a beneficial effect of ASU treatment in symptomatic knee OA but not in hip OA.

Safety
ASU supplementation is generally regarded as safe. Some minor and rare side effects have been reported in some people, such as smelly breath, diarrhoea, and stomach pains. Some rare and more severe side effects have also been reported. However, in clinical trials, adverse events are similar in ASU supplementation as placebo.

Where to find it
Sold as capsules alone and in combination with other nutrients online and at any store selling supplements in New Zealand. It has been studied in specific formulations, so combining these commercial oils yourself will not be the same.

Origins
Chondroitin is a naturally occurring carbohydrate in humans and animals that is integral in the structure of cartilage, the connective tissue that cushions joints. As a supplement, it is sold as chondroitin sulfate, which is derived from cows, pigs, and marine life, mainly sharks.

Claims
Relief of joint symptoms from osteoarthritis and slows down osteoarthritis progression.

Evidence
Chondroitin sulfate is strongly recommended against in patients with knee and/or hip OA as are combination products that include glucosamine and chondroitin sulfate, but is conditionally recommended for patients with hand OA. A single trial suggested analgesic efficacy of chondroitin sulfate, without evidence of harm, in hand OA.

Safety
It’s safe to take, with only minor side effects reported.

Dose
A standard dose is 1000-1200mg daily in either one dose or two to three divided doses taken with food.

Where to find it
You can buy chondroitin sulfate supplements at pharmacies and supermarkets. It is usually sold in combination with glucosamine and has similar benefits taken alone or in combination.

References

2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee

Origins
Glucosamine is a naturally occurring carbohydrate substance in connective tissue. Commercially it is derived from shellfish and comes in glucosamine sulfate, hydrochloride, and often in combination with chondroitin.

Claims
Glucosamine has the potential to slow cartilage deterioration in the joints and reduce pain in the process.

Evidence
Meta-analyses suggest that glucosamine (as sulfate, not hydrochloride) may lead to a slight reduction in symptoms of osteoarthritis, although the results are somewhat inconsistent. It should be noted that the reduction in symptoms is minor, comparable to paracetamol, but not as consistent.

Safety
You can safely supplement with glucosamine; the most common side-effect is flatulence.

Dose
A standard dose is 300-500 mg three times a day, which adds up to a total daily dose of 900-1,500 mg. The effectiveness of glucosamine is dose-dependent, and some studies suggest taking up to 2,000-3,000 mg daily, divided into multiple doses.

The most effective forms of glucosamine supplementation are glucosamine sulfate salts, followed by glucosamine sulfate. Glucosamine hydrochloride is ineffective, and N-Acetylglucosamine is a distinct supplement that should not be confused with glucosamine.

It is advisable to take glucosamine supplements with food.

Where to find it
You can buy glucosamine supplements at pharmacies and supermarkets. It is usually sold in combination with chondroitin and has similar benefits taken alone or in combination.