Alternative and Complementary Medicine in the Treatment of Lupus

This site is intended for healthcare professionals as a useful source of information on the diagnosis, treatment and support of patients with lupus and related connective tissue diseases.

Introduction

In most of the world, alternative, or complementary, medicine is widely accepted and in the United Kingdom there is a growing interest in its use. It is thought that almost four billion people globally use plants as medicines, predominantly because nothing else is either affordable or accessible. Estimates worldwide suggest that less than 30% of health care is provided by allopathic (Western-style) medicine. The American College of Rheumatology statement on ‘complementary’ and ‘alternative’ therapies for rheumatic disease defines such therapies as ‘being outside of the prevailing mainstream and may be safe and effective, unsafe and ineffective or questionable’. It is important to emphasise that ‘alternative’ medicine is frequently called ‘complementary’ medicine because the majority of Western patients use this therapy along with, not instead of, allopathic medical care. In the United Kingdom, it is estimated that 20% of the general population visit alternative care practitioners. In the chronic rheumatic diseases, the use of alternative medical therapies is higher than in the general population and ranges from 40-94%. A study published in 2000 showed that nearly 50% of British lupus patients had used alternative medical therapies, the most popular forms being relaxation techniques, massage and herbal medicine (Table 1).

Whilst it is apparent that a large number of patients are using alternative and complementary treatments, the reasons for this are less clear. One explanation for this health seeking behaviour in Western patients is not secondary to a disillusionment with conventional allopathic medicine but, rather, a result of patients’ perceptions of a lack of holistic care shown by their medical practitioners. This hypothesis is supported by the fact that in America, where the data is available, over 70% of patients using alternative care are unlikely to disclose this potentially vital information to their regular physicians. The major reason reported for not sharing this information is the belief that mainstream doctors disapprove of alternative therapies and may even refuse to treat them once they discover that their patients are using complementary therapies. Another study suggests that the widespread use of alternative therapies is because allopathic medicine is simply ‘unable to comprehensively treat chronic illness’ whereas, in addressing the connection between mind and body, complementary medicine can fill a void left by allopathic medicine.

The scope of alternative therapies is vast, and ever increasing. More than 350 practices have been described and in the year 2000 the Food and Drug Administration (FDA) of America estimated that there are more than 29,000 herbal, vitamin or supplement therapies available with approximately 1000 more added each month. In order to provide a structure for this chapter, the various alternative and complementary therapies have been sub-divided according to their classification as defined by the American National Institute of Health. The classification system and sub-grouping of treatment modalities which are covered in this chapter, are found in Table 2.

The aim of this chapter is to serve as a reference in exploring the evidence both for, and against, the principal alternative and complementary therapies used in the treatment of lupus. As a quick guide, at the end of each section there is a brief summary of the preceding evidence.

Table 1

The use of alternative medical therapies by lupus patients in the United Kingdom, Canada and the United States. The total refers to all patients using at least one alternative therapy and the numbers in brackets are the percentage (%) of patients in that category.



Relaxation techniques
Massage
Herbal Medicine
Lifestyle diets
Spiritual healing
Commercial weight loss
Homeopathy
Megavitamin therapy
Self-help groups
Acupuncture
Imagery
Energy healing
Folk remedies
Chiropractic
Hypnosis
Biofeedback
Other
Total
United Kingdom
(n=211)

45 (21.3)
40 (19)
32 (15.2)
27 (12.8)
14 (6.6)
14 (6.6)
13 (6.2)
10 (4.7)
10 (4.7)
8 (3.8)
7 (3.3)
6 (2.8)
4 (1.9)
4 (1.9)
3 (1.4)
0 (0)
13 (6.2)
102 (48.3)
Canada
(n=229)

51 (22.3)
36 (15.7)
28 (12.2)
26 (11.4)
16 (7)
8 (3.5)
14 (6.1)
14 (6.1)
21 (9.2)
7 (3.1)
18 (7.9)
11 (4.8)
18 (7.9)
15 (6.6)
3 (1.3)
8 (3.5)
10 (4.4)
116 (50.7)
United States
(n=267)

71 (26.6)
52 (19.5)
28 (10.5)
41 (15.4)
39 (14.6)
18 (6.7)
6 (2.2)
14 (5.2)
29 (10.9)
3 (1.1)
26 (9.7)
6 (2.2)
10 (3.7)
13 (4.9)
3 (1.1)
10 (3.7)
8 (3)
134 (50.2)

Table 2

Classification of Alternative Modalities and Therapies.
Fields of Practice – ANIH

Diet, nutrition and lifestyle changes






Herbal Medicine




Mind/body interventions and movement therapies



Alternative systems of medical practice


Manual healing methods



Bioelectromagnetics



Pharmacological and biological Interventions
Alternative Modalities/Therapies

Promotes study of effects of foods, vitamins and minerals on acute and chronic disease, with additional focus on health maintenance and disease prevention.



Includes herbal products for pharmacological use; derived from European, Asian and Native American traditions.


Includes therapies such as biofeedback, relaxation, imagery, meditation, hypnosis, psychotherapy, prayer, dance, music therapy and yoga.

Consists of traditional Oriental medicine.


Uses techniques such as osteopathy, massage, chiropractic, and therapeutic touch as diagnostic and therapeutic tools.

Explores the interaction of living organisms with electromagnetic fields for multiple healthcare applications.

Includes drugs and vaccines not yet endorsed by mainstream medical practice.
Examples covered in this chapter

Essential fatty acids
Vitamins A and E
Selenium
Evening Primrose Oil
Green tea products
Food elimination diets

Uncaria tomentosa
Uncaria guianensis (cats claw)
Meditation
Hypnosis

Cognitive behavioural therapy
Exercise
Aromatherapy

Acupuncture
Moxibustion

Massage
Reflexology


Electro-magnetic field devices



Diet

1.0 Diet and Nutritional Therapies

Attempts at symptom management can often leave patients feeling totally dominated by their disease. In their quest to regain some control, and with dietary modification and ‘fad diets’ becoming more frequently promoted to the general public, a number of patients try dietary modification and supplements with varying success. The following section outlines a number of diet and nutritional therapies, their benefits and potential deleterious effects.

1.1 Essential Fatty Acids

The role of essential fatty acids and dietary oils has been investigated with the omega-3 polyunsaturated fatty acids derived from fish oils being shown to have effective immunomodulatory activities.

Studies in humans have shown that prolonged treatment with omega-3 fatty acids in the form of fish oils can slow renal progression for high-risk patients with IgA nephropathy and lower plasma triglycerides, but it must be noted that these studies have small numbers. Other research has suggested that in patients who already exhibit disease, an increased consumption of omega-3 fatty acids is not necessarily beneficial, but it could potentially prevent relapse. In a number of randomized controlled clinical trials of rheumatoid arthritis, the use of omega-3 fatty acids has been shown to be beneficial and reduce NSAID requirements. Similarly, whilst the results of trials using fatty acids in patients with inflammatory bowel disease are variable, a number of studies have shown a significant benefit to both clinical activity and steroid-sparing effect.

Further research has also investigated the use of flaxseed oil (also known as linseed oil) in patients with lupus nephritis. Flaxseed contains high concentrations of the omega-3 fatty acid precursor a-linolenic acid and it is this which is thought to produce the beneficial effects. Results in humans indicate that flaxseed appears to be renoprotective in lupus nephritis and can reduce serum creatinine and improve creatinine clearance. However, these results should be interpreted with caution given the small numbers of patients in the trials.

Whilst there are some positive studies using fatty acids in humans with lupus, there is clearly the need for further carefully designed controlled trials into their therapeutic application in human autoimmune and inflammatory conditions. Before this research is available, there is no harm (unless the patient has an allergy) in patients increasing their intake of omega-3 fatty acids by using oils rich in these fatty acids and increasing their intake of oily fish to two to three times per week.

1.2 Vitamins A and E

Vitamin A products (retinoids) are already extensively used by dermatologists in the treatment of psoriasis and acne. Research in three women given vitamin A (beta-carotene) three times a day in 1976 showed a clearing of skin lesions within one week of commencing treatment. A further study of 10 women in 1988 showed beneficial responses to high doses of supplementary vitamin A given for two weeks. Whilst these studies showed no side effects of vitamin A, there is a lack of research into the long-term effects of Vitamin A and its impact. It is known that the ingestion of excess vitamin A from animal sources can have side effects including alopecia, nausea and anorexia and, therefore, at present it can only be recommended that patients have a balanced diet containing sufficient plant-based Vitamin A, e.g. from carrots and sweet potatoes.

Studies on lupus mice models have shown that treatment with vitamin E can delay the onset of autoimmunity and extend mean survival time. However, these findings have not been satisfactorily replicated in humans and treating lupus with vitamin E is still controversial, despite research into the topic first being available in the 1940’s. A more recent study looking at disease activity in 12 patients through recording oxidative DNA damage and autoantibodies suggests that vitamin E can be of benefit but older studies of vitamin E in the treatment of discoid skin lesions have given variable outcomes. There are some anxieties that vitamin E is only effective in the treatment of lupus at very high doses but that, even at high doses, patients still appear to have flares and that at these doses vitamin E can function as an anticoagulant. There is, therefore, a need for further research to investigate the clinical effectiveness of this vitamin in lupus patients, both as to its effects on skin lesions and on total disease activity.

1.3 Selenium

Free radical damage is known to play a significant role in the pathogenesis of lupus and research has shown that there are low levels of antioxidants in the serum of lupus patients. A number of studies have suggested that antioxidant supplementation may improve lupus disease activity. Selenium is a natural antioxidant. It appears that the supplementation of auto-immune mice models with selenium results in increased life expectancy and a significantly higher level of natural killer cell activity. The mechanisms behind these findings are not known. Dietary sources with high levels of selenium include fish such as pike, carp and herring. However, it must be noted that excess selenium can result in toxicity which may present with symptoms such as alopecia, gastrointestinal disturbance, sloughing of the nails and, in extreme cases, liver cirrhosis, pulmonary oedema and death. Patients must, therefore, be warned against taking excessive selenium supplementation.

1.4 Evening Primrose Oil

Research has shown that evening primrose oil supplementation can increase survival in autoimmune mice models. It is thought that this effect results from an increase in prostaglandin E1, and that the prostaglandin is derived from gamma-linolenic acid which constitutes 19% of the content of evening primrose oil. Prostaglandin E1 is thought to exert its beneficial activities in lupus models through decreasing lymphocyte proliferation and natural killer cell activity. These studies have not been replicated in humans and, therefore, evening primrose oil cannot be routinely recommended.

1.5 Green Tea Products

Epidemiological evidence indicates that in comparison to the United States and Britain, the incidence of lupus is considerably lower in China and Japan, the two leading green-tea consuming countries. It is hypothesized that green tea polyphenols (GTPs) may be at least partly responsible for this geographical difference in lupus severity and prevalence. To support this theory, a number of molecular, cellular and animal studies have indicated that GTPs can provide protective effects against autoimmune reactions in salivary glands (particularly important in Sjögren’s Syndrome) and in the skin by suppressing autoantigen expression and down-regulating inflammatory cytokines. These studies have not been replicated in humans but preliminary data appears promising. Further research would be needed to check out any beneficial effects of GTPs.

1.6 Dietary Considerations and Food Elimination Diets

Much of the research previously covered concerns diet modification and the potential inclusion of high vitamin, anti-oxidant or nutrient foods. The following section outlines a number of diet modifications which may help ameliorate lupus symptoms/signs.

1.6.1 Alfalfa Seeds

Alfalfa is primarily used in the United States,Australia and New Zealand for dairy production, beef and lamb. However, it is also used for human consumption, particularly as a salad ingredient in these countries. Over the past few decades there has been interest and research into alfalfa’s cholesterol lowering activities. Interestingly, researchers observed pancytopaenia and antinuclear antibody production in both primates and humans who were given alfalfa seeds and, in primates, symptoms such as lethargy, anorexia and a facial rash which resolved when the treatment was withdrawn and were exacerbated again on reintroduction of alfalfa seeds.

Further research examining the link between alfalfa and lupus concluded that the amino acid L-canavanine was the key constituent of alfalfa which exacerbated lupus, though a lack of control over autoantibody synthesis and lymphocyte proliferation. L-canavanine is found in many legumes including soyabean, alfalfa, clover and onions, however, cooking the food is meant to destroy the lupusprovoking effects whilst maintaining lipid-lowering properties. Therefore, it is recommended that lupus patients avoid alfalfa and cook foods which are rich in L-canavanine.

1.6.2 Excess Energy, Protein and Fat

A number of animal studies suggest that energy and calorie restriction reduces autoimmune disease. However, whilst it is known that lupus disease activity is associated with an increase in body mass index in pre-menopausal women, there do not appear to be any studies into caloric restriction in humans and the effects this has on lupus activity. Such studies would be impossible to directly repeat in humans given that in animal models scientists have reduced caloric intake by up to 60% in pre-adolescent mice.

High protein intake is known to be associated with an acceleration of kidney disease in both autoimmune-prone individuals and animal models and, therefore, it is widely accepted that low protein diets are the standard treatment for renal failure. The benefits of omega-3 polyunsaturated fatty acids in lupus have previously been outlined. Saturated or omega-6 polyunsaturated fats have been shown to have a detrimental effect on autoimmune disease activity and reduce survival in a number of animal models. Autoimmune-prone mice fed saturated fats appear to experience more severe nephritis and glomerular pathology, leading to the hypothesis that dietary fat, especially saturated fat, restriction may be an effective therapeutic approach to lupus nephritis. Research in humans is sparse, but one study followed patients with lupus who reduced their intake of omega- 6 polyunsaturated fats for one year. In this study, the number of patients with active disease fell from 11 to 3 but the study group was small, there was no control group and there was the additional possibility of spontaneous improvement and a placebo effect. Foods high in omega-6 fatty acids include oils such as sunflower oil, poppy seed oil, corn oil and foods such as mayonnaise, margarine and brazil nuts.

In addition to generic reduction diets of calories, fats and protein, a number of researchers have suggested that lupus patients may be more likely to have food allergies. A number of case studies indicate that lupus patients may benefit from the discovery and elimination of possible food triggers.

Summary

• Omega-3 fatty acids from fish oils (oily fish) and flaxseed oil (linseed oil) can, possibly, slow renal progression in lupus patients. Patients can be encouraged to increase their intake of omega-3 fatty acids to two or three times per week, unless they have an allergy.

• Vitamin A can help reduce lupus skin lesions. Long term effects of vitamin A are not known but patients should be encouraged to eat a balanced diet with sufficient plant based Vitamin A (good sources being carrots and sweet potatoes).

• The evidence regarding vitamin E and lupus is equivocal but, again, a balanced diet is advocated.

• Selenium (a natural antioxidant found in fish such as pike, carp and herring) may improve disease activity. Supplementation should not be excessive as this may lead to toxicity.

• The evidence regarding evening primrose oil in lupus is equivocal.

• The evidence regarding green tea products is equivocal, but patients should not be discouraged from drinking moderate amounts.

• As there is no harm in doing so, it is recommended that patients avoid alfalfa and cook foods rich in L-canavanine (onions, soya bean).

• There is currently insufficient evidence, but some research indicates that a low protein diet and reduction in consumption of foods rich in omega-6 polyunsaturated fats (e.g. sunflower oil, mayonnaise) may be beneficial in lupus patients.

2.0 Herbal Treatments

With the ‘natural products’ field growing at an increasing rate, both patients and healthcare workers need reliable information in order to make appropriate treatment choices. Patients may well have started taking herbal remedies on the subjective advice of enthusiastic but uninformed sales staff. Many sales suggestions come from anecdotal or personal experience and this can put patients at risk. Herbal products are classified as dietary supplements and the normal regulatory controls for medicines do not apply. The lack of regulation over herbal treatments is important both because as single agents the ‘natural products’ can cause toxicity and side-effects but also because they may interact in unexpected ways with other prescribed medication, particularly disease modifying anti-rheumatic drugs (DMARDs) such as methotrexate and mycophenolate. Therefore, if patients express an interest in herbal remedies, a qualified medical specialist should be consulted before any are taken.

2.1 Uncaria tomentosa and Uncaria guianensis

Uncaria tomentosa and Uncaria guianensis are Peruvian herbs commonly known as ‘cat’s claw’. Traditionally, the bark of ‘cat’s claw’ is prepared as a decoction (water which the plant has previously been boiled in) which is said to be beneficial in the treatment of arthritis, bursitis, chronic fatigue syndrome and disorders of the gastrointestinal tract as well as lupus. The mechanism of action of these two herbs is not currently known, but it is thought that perhaps U. tomentosa functions through inhibition of TNFa production. Whilst there are no animal or human trials of either of these herbs in lupus patients, there is a 52-week double blind placebo-controlled study of 40 patients with active rheumatoid arthritis who were randomized to U. tomentosa or placebo in addition to their standard treatment with sulfasalazine or hydroxychloroquine. Results showed a 53% reduction in the number of painful joints in patients receiving the U. tomentosa, in comparison to a 24% reduction in the placebo group. As a note of caution, there is one reported case of acute renal failure secondary to treatment with ‘cat’s claw’ in a patient who had lupus.

2.2 Other Herbal Remedies

A number of other herbs have also been investigated in lupus mice with the hope of reducing the necessity for steroids. Atractylodes ovata, Angelica sinensis, Cordyceps sinensis, Ligustrum ludidum and Codonopsis pilosula extracts were all tested, the most effective being C. sinensis which exhibited the greatest inhibition of anti double-stranded DNA antibodies and longest lifespan of affected mice. The mechanism of action of these remedies is not yet known. One human study of 61 lupus patients given C.sinensis over five years showed a slower deterioration in creatinine clearance, however, more research, human models and greater validation is needed.

Summary

• Natural remedies are not subjected to the same rigorous testing and licensing laws as drugs and, therefore, can have potentially serious and poorly documented side effects.

• Herbal remedies should not be used without specialist advice, particularly if patients are also taking DMARDs.

3.0 Mind/Body Interventions and Movement Therapies

The idea that the mind can influence the body and vice versa is not a new concept, for example, in clinical trials, the ‘placebo effect’ is well known. However, there is now an increasing body of evidence to support the psychoneuroimmunology theory which provides a conceptual framework for the brain’s ability to control all aspects of the immune system. If this connection between mind and body is accepted, then this can provide a key to treatment. The major categories of ‘mind/body’ treatments are outlined below.

3.1 Meditation

Meditation has its foundation in early religious practices and over the past few decades it has become more widely accepted as a treatment for chronic illness. In practicing meditation, individuals use particular awareness and concentration techniques to calm the mind and relax the body. There is no specific research into meditation in lupus, however, research in patients with fibromyalgia has shown that meditation can help relieve pain, anxiety, stress, depression and fatigue. Meditation instructors are not certified or licensed on a national level and it is, therefore, important that patients enquire about the training and qualifications of any individuals or organizations they wish to approach for care. Before meditation can be widely recommended further research is needed to validate its therapeutic potential.

3.2 Hypnosis

Hypnotherapy involves bringing a patient into a state where they are unaware of, but not blind to, their surroundings and they are in a state of focused and attentive concentration. Hypnotherapy has been studied as a tool for managing a variety of problems including chronic pain syndromes, irritable bowel, fibromyalgia and arthritis. There is one case report where hypnotherapy was used in conjunction with psychoanalytic psychotherapy to help a young female with lupus and there is a paper suggesting a protocol for use in hypnosis in patients with a variety of complaints, including lupus, but there does not appear to be any other published research in the therapeutic benefits of hypnosis specifically in lupus.

3.3 Cognitive Behavioural Therapy and Stress Reduction

Cognitive behavioural therapy is a multidisciplinary approach which involves teaching patients new thought and behaviour patterns for coping with chronic illness. A randomized controlled trial of a stress-reduction program using biofeedback-assisted cognitive-behavioural therapy in 92 patients who experienced pain with lupus found that patients who received the treatment showed improvements in pain, psychological function and perceived physical function. Although the study number was relatively small, these results are promising and, potentially, could offer a helpful intervention to reduce pain without additional medication. However, the treatment requires several clinic visits with a trained health professional and this is not only time consuming for the patient but could present funding issues.

Slightly different options which have been researched in lupus patients include self-help groups which are reported to improve depression, self-worth and self efficacy, or a person-centred telephone counselling system which can improve perceived physical functioning but not pain or psychological functioning.

3.4 Exercise

A recent review which focused on the relationship between lupus and exercise in patients with low to moderate disease activity, found that exercise can help patients with lupus in a number of ways. Exercise can help reduce cardiovascular mortality, obesity, osteoporosis, sleep disturbances, fatigue and improve quality of life. The authors advise that in order to avoid risks of exercise which come from a wide variation in resting heart rate and blood pressure in lupus patients, individuals should have exercise programs tailored to their personal needs. A major problem in suggesting to patients with chronic disease that they should participate in physical exercise is a lack of adherence and this is particularly the case if patients are exercising individually. Therefore, any exercise programs need to include motivating factors.

Whilst there is no specific evidence regarding Tai Chi or Yoga in lupus patients, these complementary therapies may be of benefit as they encourage patients to ‘increase levels of fitness and flexibility within his/her own limits’. It should be noted that, as with all the previously mentioned therapies, patients are advised to learn Tai Chi or Yoga from a teacher rather than simply a video or guidebook.

3.5 Aromatherapy

Aromatherapy is based around essential plant oils and their healing properties. Natural oils are diluted in a carrier oil and normally massaged into the body but they can also be inhaled or used in a cold compress or in a bath. Aromatherapy massages use techniques to relieve tension and improve circulation, the aim being to allow oil molecules to be absorbed into the bloodstream and pass through to the nervous system. There are no trials of aromatherapy in lupus patients, however, there is a paper which suggests that in rheumatoid and musculoskeletal autoimmune disorders aromatherapy is often of value, even if all it serves to do is relax the patient.

Summary

• Psychoneuroimmunology theories suggest that the brain can control all aspects of the immune system.

• The bulk of published information concerning mind/body interventions promotes cognitive behavioural therapy as helping to reduce pain and stress. Aromatherapy, hypnosis and meditation have additionally been promoted as treatment.

• Whilst rarely detrimental, psychological interventions are time consuming and there is a sparsity of information regarding cost effectiveness.

• Exercise should be promoted in patients with mild to moderate disease activity. Tailored exercise programs which include motivating factors are of particular benefit.

• Tai Chi or Yoga can be regarded as forms of exercise and stress reduction. Patients should be encouraged to attend professional training centres rather than teach themselves these techniques.

4.0 Alternative Systems of Medical Practice

Acupuncture is a technique which has been used as pain relief in traditional Chinese medicine for centuries. Acupuncture involves the insertion of fine needles into the skin at a number of specific points along particular channels or meridians. The theory behind acupuncture is that an essential life force flows through the body along these specific channels and that stimulation of these points can correct any misplaced flow and, therefore, reinstate maximum health. Interestingly, whilst some acupuncture points lie in ‘trigger points’ which are areas rich in nerve endings, a number of meridians do not correspond anatomically to the nervous or circulatory system. There is a lack of large randomized control trial evidence on the efficacy of acupuncture and this is as applicable to lupus as to any other disease. The best evidence using acupuncture is in the treatment of acute pain where it appears to be an effective treatment. There are a number of very small scale trials in patients with lupus, suggesting that acupuncture can possibly reduce the requirement for corticosteroids and help control skin flares in discoid lupus.

Research has also been carried out into moxibustion, another form of traditional Chinese medicine, that uses the heat generated by burning herbal preparations containing Artemisia vulgaris to stimulate acupuncture points. The largest published control study investigated 12 patients with lupus and 12 healthy controls. The study showed no significant alteration in disease activity between the lupus patients and control group. More research is needed to confirm or refute these preliminary findings.

Summary

• There is very little evidence supporting acupuncture therapy for lupus and, therefore, acupuncture cannot be routinely recommended. It may reduce skin flares in discoid lupus but more research is necessary.

5.0 Manual Healing Techniques

5.1 Massage and Reflexology

Despite massage being the second most commonly used alternative/complementary therapy for British lupus patients, there is no published evidence as to its therapeutic benefits in these patients. However, there are a number of studies highlighting the short term benefits of massage in arthritis pain and, for patients with lupus, there is anecdotal evidence that, as with aromatherapy, it can be useful even if all it serves to do is relax the patient.

Reflexology is a particular type of massage that is also widely practiced throughout the world. In reflexology, an individual's feet are viewed as a map of the body with reflexes corresponding to organs or glands. Practitioners promote reflexology on the basis that deals with the principle that there are reflexes in our hands and feet which correspond with every organ, gland and part of the body. Therefore, reflexologists believe that if the reflexes are worked on there will be relief of tension and stress which they consider are the causes of a significant proportion (70%) of today’s health problems. This process has not been scientifically validated and there are no studies of reflexology in patients with lupus.

Summary

• Despite a lack of evidence promoting its effectiveness, massage is commonly used by lupus patients.

• Patients should receive massage, chiropractic or reflexology from professionally certified practitioners.

6.0 Bioelectromagnetics

There have been studies investigating the use of pulsed electromagnetic field (EMF) devices in patients with fatigue as a complication of multiple sclerosis. EMF devices deliver low-level, pulsed electromagnetic fields and are worn for up to 24 hours daily on one or more acupressure points for 4 or 8 weeks. Results from two trials have been promising, showing improvement in fatigue levels, particularly in patients with moderate disability levels. However, there was no long term follow up of the patients after either of the trials ended and there do not appear to be any published studies in lupus patients. In spite of this, EMF may be a useful treatment in patients with fatigue as a presenting feature in lupus and this, therefore, warrants further investigation.

Summary

• Pulsed electromagnetic field (EMF) devices may help improve fatigue but more research is needed.

7.0 Other Points of Interest

7.1 Financial Implications of Alternative and Complementary Medicine

As with any treatments, there are cost implications both in the use of complementary medicines and in their evaluation. Two BMJ articles explored the pros and cons of a review by NICE into the effectiveness of alternative and complementary medicine. The principal argument against such an investigation was on financial grounds: ‘a strong argument can be made for NICE not having to spend time and money going through, yet again, evidence that we know to be inadequate’. In terms of the actual cost versus benefit of using alternative and complementary medicine, the evidence is not clear but sense would say that any clinically ineffective healthcare is unlikely to be cost-effective. An American study of general medical practice demonstrated that individuals who use complementary medical therapists additionally make more frequent visits to allopathic medical practitioners in comparison to non-users. A Canadian study showed that users of alternative medical therapies made less visits to general practitioners per annum but a similar number of visits to alternative specialists.

7.2 The ethics of alternative therapy

For the practicing clinician, the use of alternative medical therapy can create a number of ethical dilemmas. Physicians have a duty to their patients to respect their autonomy and, therefore, allow freedom of choice as to their desire to seek alternative treatments. However, as previously outlined, there are a number of unanswered questions regarding alternative treatments. Is the conventional approach clearly superior? What is the safety and efficacy of the proposed treatment? Justice could dictate that alternative treatments should be available to all, but at what cost? Nonmaleficence obliges all physicians to make their patients aware of the possible risks but many of the risks are theoretical and treatments may still be beneficial.

Conclusion

This chapter has outlined a number of therapies used in the treatment of specific symptoms in patients affected by lupus. Some treatments have reasonably good evidence for use and appear to be beneficial, even if the mechanism of action is not apparent and, for others, the evidence is less clear.

In order to advise patients about the use of complementary medicines, there are several guidelines that can be referred to, a particularly useful one being published by the department of health. Physicians need to ask their patients about selfmedication and complementary or alternative medication and encourage their patients to seek advice from themselves as to any doubts they may have about particular treatments. Physicians should additionally encourage patients to seek licensed practitioners (where available) such as for acupuncture and massage. The department of health provides details of how to contact qualified practitioners. Patients need to know which herbal remedies they are taking, be aware of possible side effects and purchase these from reputable sources with clear labelling. Patients should additionally be encouraged to obtain an accurate diagnosis from a qualified physician before exclusively using alternative treatments for serious conditions with proven conventional treatments.

Despite this chapter highlighting the fact that many alternative therapies need further research in order to determine their efficacy and safety profile, patients will continue to use these treatments regardless of whether this research is performed. Physicians must, therefore, be prepared to counsel and advise patients about all available options with the best available evidence. For an increasing number of patients ‘all available options’ will mean incorporating alternative medicine into their health care.

Summary

• The evidence for and against complementary and alternative medicine for lupus is mixed and varies with different treatments.

• The department of health has published useful guidelines for complementary medicine.

• It is essential that physicians ask their patients whether they are taking complementary medication and, if patients are keen to seek complementary care, to encourage them to visit qualified practitioners.
Dr Hannah Bainbridge
Royal Sussex County Hospital
Eastern Road
Brighton
East Sussex BN2 5BE
Dr Inam Haq
Brighton & Sussex Medical School
University of Sussex
Brighton
East Sussex BN1 9PX