Cumin (Curcumin)
Multiple studies show that curcumin both alone and in combination with other herbs (for example, boswelia and ginger) has beneficial effects on osteoarthritis (OA) and rheumatoid arthritis (RA). Curcumin mediates and interacts with many elements of the inflammatory cascade such as cytokines, growth factors, inflammatory transcription factors, protein kinases and enzymes (all promotoers of inflammation). In contrast, many medications used for RA and OA target just one of these pathways (hence making them more potent but also higher risk). For example, non steroidal anti-inflammatories (NSAIDS) inhibit the actions of prostaglandins and COX inhibitors target COX-2. Curcumin therefore has a more subtle influence with fewer risks. Its anti-inflammatory effects also may decrease cancer risk, act as an anti-depressant, and be neuroprotectant.
One study looked at groups with RA who took 500mg/d curcumin or 50mg/day diclofenac (NSAID medicaiton), or a combination of both. The group receiving curcumin only had the greatest amount of reduction of pain and swelling and no adverse effects.
A randomized double blind placebo control (RDBPC) study of 367 patients with knee osteoarthritis were randomized to Ibuprofen (NSAID) 1,200 mg/day or Curcuma domestica extract 1,500mg/day for 4 weeks. Curcuma domestica was found to be as effective as the NSAID for knee pain. Another study in Japan looked at 50 patients who were randomized to receive placebo or Theracumin 180mg/d for 8 weeks. Theracumin was found to be superior to placebo.
Additionally, curcumin has been found to be effective for depression. Three small and short term studies found that curcumin was beneficial either alone or in combination with pharmaceuticals in the treatment of depression. More studies need to confirm the effects of curcumin on depression but this is promising.
Curcumin should be combined with a black pepper alkaloid (piperine) in order to increase bioavailability. 5mg piperine leads to a 2 fold increase in curcumin concentrations. Piperine does have a powerful effect on the CYTP450 system though inhibition of CYP3A4. Doses greater than 10mg/d should be avoided among patients on multiple medications (especially those metabolized by this pathyway). Piperine’s effects are clinically relevant in many cases pf polypharmacy, especially when considering medications with a narrow therapeutic window. In this case, one would want to use nanoparticulated or phospholipid complex formulations of curcumin.
Also see curcumin in the digestive system section of this website.
eputable brands which have been recommended are Meriva (by Thorne).
Boswelia
Otherwise known as Frankincense (Indian frankinsense), boswelia is a gum resin (very hard to extract) which means one needs to use a standardized extract. Most studies have been done in the context of Ayerveda where it is combined with other herbs. Boswelia demonstrates many bioactitivies (AKBA is one of the primary boswelic acid) and impacts both autoimmunity and inflammation through many channels (much like curcumin). Standardized extracts are made with AKBA. This is also very hard to absorb (stays in the GI which may be the reason why it helps with inflammatory bowel). It can cause a lot of heartburn at higher doses, so it is usually standardized and concentrated.
Boswelia acts on the 5-LOX inflammatory cascade which is specific to bowel inflammation. Therefore, boswelia can influence both irritable bowel syndrome (IBS) as well as inflammatory bowel diseases such as Crohns disease. A combination of curcumin and boswelia would be an excellent combination for people with chronic inflammatory pain combined with bowel symptoms.
Recommended doses: 400-1200mg 3 times daily 40-65% boswelic acid. Himalaya Herbal Healthcare has a product with 60% boswelic acids.
The evidence for boswelia in Ayervedic preparations
RDBCT of 440 patients (ages 40-70) with knee OA received one of 4 treatments:
Celebrex (COX-2 inhibitor) OR Glucosamine 2g/day OR 400mg extracts SGCG Zingiber (ginger), Tinospora cordiflora (AKA guduchi or amrita), Phyllanthus emblica (Indian gooseberry) and B serrata (boswelia) OR 400mg extract SGC (same as prior but without the boswellia). This was the first ever head-to-head comparison between ayurvedic herbs and other known effective agents- these herbal preparations were found to be equivalent to Celexa and glucosamine in reducing pain and increasing functionality over 24 weeks of treatment. 7 patients in the Ayervedic group were withdrawn from the study d/t > 3 fold rise in transaminases, 3 pf these patients had Hep B. Although this outcome did not satisfy the FDA criteria for significant drug-induced injury, one may want to check liver panels on such patients 6 weeks after starting such herbal treatments. (Chopra A. et al. Rheumatology 2013; 52(8): 1408-17)
Similar combination called Rumalaya contains boswellia, guduchi, guggul (also used for lipids), Alpinia galangal (kind of ginger), licorice, and tribulus terrestris. One study found that this combination preserved cartilage and glycosaminoglycans and has anti-inflammatory activity.
(Kessler CS, et al Rheumatology Int 2014; Jul 26.)
Other potentially anti-inflammatory herbs
Tinospora cordiflora
A rasayana herb which is also used for fever, cough, allergies, possibly glucose regulation, anti-inflammatory, and immune modulator. This could be considered in people with arthritis, respiratory conditions.
Ginger
Ginger reduces pain and disability in several studies, but high rates of GI upset are reported. Compounds in ginger suppress several inflammatory markers in the inflammatory pathway. Compounds in ginger also suppress the expression of inflammatory genes linked to TLR mediated immunity- therefore auto-immunity may be regulated by ginger. It has been used in many countries in the treatment of RA. Given some of the GI issues at higher doses, it is often used in formulas. This could be considered for people that also have some GI issues such as sluggish digestion.
Ashwaganda
This has been recommended for patients with anxiety and burned out cortisol levels who need an anti-inflammatory. It is used in combinations such as with boswellia, ginger, and turmeric. This combination has been studied and found to have benefits but did not reach the significance seen with medications. Consider that people with chronic pain have fluctuations in cortisol (between resistance and exhaustive phase) and this may be useful in regards to its effects on the adrenals. When people are further along into the exhaustive phase, other more stimulating adaptogens would be more appropriate.
Cat’s Claw
From the Amazonian rainforest- 2 species used. Uncaria tomentosa (Central and South America) and U. guianensis (grows in Bangladesh and Burma). Known among Indigenous people to be useful for bone pain, cancer. Also used for asthma, gastric ulcers, bladder pain.
Inhibits TNF-a, prostaglandins, NF-kB (anti-inflammatory effect) and in studies helps to preserve cartilage (effect on OA); and also may have an effect on RA. Some of the constituents suggest that it may quiet an overactive immune system. There have been 3 small short term studies using it for OA; and it was found that they had improvement in joint pain. There is some data that there may be some joint sparing protection and protect the destruction of cartilage and therefore, could use in combination with glucosamine. A literature review of safety data found a low potential for acute or subacute oral toxicity (Valerio LG, et al. TOxicology Review 2005; 24(1): 11-35). The dose is 350 mg/day with standardized extract 4% alkaloid (isoteropodine) or 4-8% carboxy alkyl asters.
One study among RA patients were randomized to receive cats claw or placebo in addition to their usual medications (DMARDS). After 12 weeks 53% (compared to 24%) in study group (p = 0.044) had improved joint pain. (Mur E, et al. J Rheumatology 2002; 29 (4): 678-81.)
Thundergod vine (TwHF), Tripterygium wilfordii- root extract has been used in TCM for more than 2,000 years. It was used for conditions that we would consider auto-immune. It has constituents that strongly inhibit cytokines, pro-inflammatory genes, COX2, gamma interferon, prostaglandins, etc. It has been studied extensively. A study of 207 people with RA compared MTX, TwHF, and combination of both found that TxHF alone (55%) was similar in efficacy to MTX (46%) and the combination was far superior (76.8% met response criteria). The response criteria were the participants who report a 50% reduction in symptoms (this meets American College of Rheumatology guidelines for determining efficacy of interventions.) Lv QW, et al. Ann Rheum Dis 2014; April 14
Another study of 121 patients with RA were randomized to 180mg/d of thundergod vine or Sulfasalamine 2g/day and found that they were equally effective. Goldbach-Mansky R, et al. Ann Internal Medicine 2009; 151(4); 229-40.
It is very hard to find properly prepared and extracted products, but in China they are trying to make products with greater precision and it has been used in psoriasis and other auto-immune. Most common side effects are GI upset, menstruation disorders or amenorrhea have been reported in numerous trials. Mild liver enzyme increase. Mild prolongation of corrected QT interval. Triptolide is the major bioactive also suspected to be the component which causes toxicity.
Recommended dose: studies suggest that 360mg seems to be best dose for alleviating symptoms
Multiple studies show that curcumin both alone and in combination with other herbs (for example, boswelia and ginger) has beneficial effects on osteoarthritis (OA) and rheumatoid arthritis (RA). Curcumin mediates and interacts with many elements of the inflammatory cascade such as cytokines, growth factors, inflammatory transcription factors, protein kinases and enzymes (all promotoers of inflammation). In contrast, many medications used for RA and OA target just one of these pathways (hence making them more potent but also higher risk). For example, non steroidal anti-inflammatories (NSAIDS) inhibit the actions of prostaglandins and COX inhibitors target COX-2. Curcumin therefore has a more subtle influence with fewer risks. Its anti-inflammatory effects also may decrease cancer risk, act as an anti-depressant, and be neuroprotectant.
One study looked at groups with RA who took 500mg/d curcumin or 50mg/day diclofenac (NSAID medicaiton), or a combination of both. The group receiving curcumin only had the greatest amount of reduction of pain and swelling and no adverse effects.
A randomized double blind placebo control (RDBPC) study of 367 patients with knee osteoarthritis were randomized to Ibuprofen (NSAID) 1,200 mg/day or Curcuma domestica extract 1,500mg/day for 4 weeks. Curcuma domestica was found to be as effective as the NSAID for knee pain. Another study in Japan looked at 50 patients who were randomized to receive placebo or Theracumin 180mg/d for 8 weeks. Theracumin was found to be superior to placebo.
Additionally, curcumin has been found to be effective for depression. Three small and short term studies found that curcumin was beneficial either alone or in combination with pharmaceuticals in the treatment of depression. More studies need to confirm the effects of curcumin on depression but this is promising.
Curcumin should be combined with a black pepper alkaloid (piperine) in order to increase bioavailability. 5mg piperine leads to a 2 fold increase in curcumin concentrations. Piperine does have a powerful effect on the CYTP450 system though inhibition of CYP3A4. Doses greater than 10mg/d should be avoided among patients on multiple medications (especially those metabolized by this pathyway). Piperine’s effects are clinically relevant in many cases pf polypharmacy, especially when considering medications with a narrow therapeutic window. In this case, one would want to use nanoparticulated or phospholipid complex formulations of curcumin.
Also see curcumin in the digestive system section of this website.
eputable brands which have been recommended are Meriva (by Thorne).
Boswelia
Otherwise known as Frankincense (Indian frankinsense), boswelia is a gum resin (very hard to extract) which means one needs to use a standardized extract. Most studies have been done in the context of Ayerveda where it is combined with other herbs. Boswelia demonstrates many bioactitivies (AKBA is one of the primary boswelic acid) and impacts both autoimmunity and inflammation through many channels (much like curcumin). Standardized extracts are made with AKBA. This is also very hard to absorb (stays in the GI which may be the reason why it helps with inflammatory bowel). It can cause a lot of heartburn at higher doses, so it is usually standardized and concentrated.
Boswelia acts on the 5-LOX inflammatory cascade which is specific to bowel inflammation. Therefore, boswelia can influence both irritable bowel syndrome (IBS) as well as inflammatory bowel diseases such as Crohns disease. A combination of curcumin and boswelia would be an excellent combination for people with chronic inflammatory pain combined with bowel symptoms.
Recommended doses: 400-1200mg 3 times daily 40-65% boswelic acid. Himalaya Herbal Healthcare has a product with 60% boswelic acids.
The evidence for boswelia in Ayervedic preparations
RDBCT of 440 patients (ages 40-70) with knee OA received one of 4 treatments:
Celebrex (COX-2 inhibitor) OR Glucosamine 2g/day OR 400mg extracts SGCG Zingiber (ginger), Tinospora cordiflora (AKA guduchi or amrita), Phyllanthus emblica (Indian gooseberry) and B serrata (boswelia) OR 400mg extract SGC (same as prior but without the boswellia). This was the first ever head-to-head comparison between ayurvedic herbs and other known effective agents- these herbal preparations were found to be equivalent to Celexa and glucosamine in reducing pain and increasing functionality over 24 weeks of treatment. 7 patients in the Ayervedic group were withdrawn from the study d/t > 3 fold rise in transaminases, 3 pf these patients had Hep B. Although this outcome did not satisfy the FDA criteria for significant drug-induced injury, one may want to check liver panels on such patients 6 weeks after starting such herbal treatments. (Chopra A. et al. Rheumatology 2013; 52(8): 1408-17)
Similar combination called Rumalaya contains boswellia, guduchi, guggul (also used for lipids), Alpinia galangal (kind of ginger), licorice, and tribulus terrestris. One study found that this combination preserved cartilage and glycosaminoglycans and has anti-inflammatory activity.
(Kessler CS, et al Rheumatology Int 2014; Jul 26.)
Other potentially anti-inflammatory herbs
Tinospora cordiflora
A rasayana herb which is also used for fever, cough, allergies, possibly glucose regulation, anti-inflammatory, and immune modulator. This could be considered in people with arthritis, respiratory conditions.
Ginger
Ginger reduces pain and disability in several studies, but high rates of GI upset are reported. Compounds in ginger suppress several inflammatory markers in the inflammatory pathway. Compounds in ginger also suppress the expression of inflammatory genes linked to TLR mediated immunity- therefore auto-immunity may be regulated by ginger. It has been used in many countries in the treatment of RA. Given some of the GI issues at higher doses, it is often used in formulas. This could be considered for people that also have some GI issues such as sluggish digestion.
Ashwaganda
This has been recommended for patients with anxiety and burned out cortisol levels who need an anti-inflammatory. It is used in combinations such as with boswellia, ginger, and turmeric. This combination has been studied and found to have benefits but did not reach the significance seen with medications. Consider that people with chronic pain have fluctuations in cortisol (between resistance and exhaustive phase) and this may be useful in regards to its effects on the adrenals. When people are further along into the exhaustive phase, other more stimulating adaptogens would be more appropriate.
Cat’s Claw
From the Amazonian rainforest- 2 species used. Uncaria tomentosa (Central and South America) and U. guianensis (grows in Bangladesh and Burma). Known among Indigenous people to be useful for bone pain, cancer. Also used for asthma, gastric ulcers, bladder pain.
Inhibits TNF-a, prostaglandins, NF-kB (anti-inflammatory effect) and in studies helps to preserve cartilage (effect on OA); and also may have an effect on RA. Some of the constituents suggest that it may quiet an overactive immune system. There have been 3 small short term studies using it for OA; and it was found that they had improvement in joint pain. There is some data that there may be some joint sparing protection and protect the destruction of cartilage and therefore, could use in combination with glucosamine. A literature review of safety data found a low potential for acute or subacute oral toxicity (Valerio LG, et al. TOxicology Review 2005; 24(1): 11-35). The dose is 350 mg/day with standardized extract 4% alkaloid (isoteropodine) or 4-8% carboxy alkyl asters.
One study among RA patients were randomized to receive cats claw or placebo in addition to their usual medications (DMARDS). After 12 weeks 53% (compared to 24%) in study group (p = 0.044) had improved joint pain. (Mur E, et al. J Rheumatology 2002; 29 (4): 678-81.)
Thundergod vine (TwHF), Tripterygium wilfordii- root extract has been used in TCM for more than 2,000 years. It was used for conditions that we would consider auto-immune. It has constituents that strongly inhibit cytokines, pro-inflammatory genes, COX2, gamma interferon, prostaglandins, etc. It has been studied extensively. A study of 207 people with RA compared MTX, TwHF, and combination of both found that TxHF alone (55%) was similar in efficacy to MTX (46%) and the combination was far superior (76.8% met response criteria). The response criteria were the participants who report a 50% reduction in symptoms (this meets American College of Rheumatology guidelines for determining efficacy of interventions.) Lv QW, et al. Ann Rheum Dis 2014; April 14
Another study of 121 patients with RA were randomized to 180mg/d of thundergod vine or Sulfasalamine 2g/day and found that they were equally effective. Goldbach-Mansky R, et al. Ann Internal Medicine 2009; 151(4); 229-40.
It is very hard to find properly prepared and extracted products, but in China they are trying to make products with greater precision and it has been used in psoriasis and other auto-immune. Most common side effects are GI upset, menstruation disorders or amenorrhea have been reported in numerous trials. Mild liver enzyme increase. Mild prolongation of corrected QT interval. Triptolide is the major bioactive also suspected to be the component which causes toxicity.
Recommended dose: studies suggest that 360mg seems to be best dose for alleviating symptoms