Jonathan Kay, MD
December 20, 2013
Hello. I’m Jonathan Kay, Professor of Medicine and Director of Clinical Research in the Division of Rheumatology at UMass Memorial Medical Center and the University of Massachusetts Medical School, both in Worcester, Massachusetts. Welcome to my Medscape blog.
Patients often come to my office interested in alternative treatments — complementary and alternative medications. One of these is fish oil, which many patients are taking for cardiovascular purposes. Omega-3 fatty acids can suppress the production of proinflammatory eicosanoids and were studied in the 1980s and early 1990s as potential treatments for established rheumatoid arthritis. Fish oil showed minimal benefit in the treatment of established rheumatoid arthritis, and the doses required were enough to make a patient smell somewhat fishy.
In September, an interesting study was published online in Annals of the Rheumatic Diseases by Proudman and colleagues[1] from Australia. It compared high-dose with low-dose fish oil (5.5 g/day compared with 400 mg/day) in patients with early rheumatoid arthritis of less than 1-year duration and who used fish oil as an adjunctive treatment to triple therapy. They employed a treat-to-target strategy in which triple therapy was escalated, with the dose of methotrexate being increased gradually and then ultimately switching to leflunomide therapy and, if necessary, biologic agents. The requirement of a patient switching to leflunomide was considered failure of adjunctive fish oil therapy.
Interestingly, a statistically significantly smaller proportion of patients on high-dose fish oil ended up on leflunomide compared with those taking low-dose fish oil. Patients also seemed to do better in terms of achieving Disease Activity Score remission on fish oil compared with triple therapy or standard nonbiologic therapy alone. This approach to using fish oil as an adjunctive treatment rather than as a primary treatment in patients with early rheumatoid arthritis may be very appropriate in the therapeutic armamentarium that we now have for rheumatoid arthritis. Not only may it benefit patients and allow for less aggressive treatment with nonbiologic disease-modifying antirheumatic drugs, but it may also have cardiovascular benefits. Those will need to be determined in future studies. However, this initial study by Proudman and colleagues is very interesting and deserves notice.
I look forward to your comments and thank you very much for your attention. I look forward to seeing you again on Medscape.
References
Proudman SM, James MJ, Spargo LD, et al. Fish oil in recent onset rheumatoid arthritis: a randomised, double-blind controlled trial within algorithm-based drug use. Ann Rheum Dis. 2013 Sept 30. [Epub ahead of print]