|Also listed as: Autoimmune disease||Integrative Therapy Quick Links:|
- Addison's disease, allergic, allergy, ankylosing spondylitis, antibody, antigen, apoptosis, blood vessels, celiac disease, connective tissue, c-reactive protein, dermatomyositis, erythrocyte sedimentation rate, ESR, FANA, fluorescent antinuclear antibody, Grave's disease, Hashimoto's thyroiditis, histocompatibility, hypersensitivity, immune, immune disease, immune disorder, immune system, immunity, immunoglobulin, immunosuppressants, immunosuppression, inflammation, intravenous immunoglobulin, IVIG, major histocompatibility complex, leukocytes, lupus, lymphocytes, MHC, MS, multiple sclerosis, myasthenia gravis, pernicious anemia, programmed cell death, red blood cells, Reiter's syndrome, rheumatoid arthritis, sensitized, sensitized lymphocytes, Sjögren's syndrome, systemic lupus erythematosus, type I diabetes, white blood cells.
- The immune system protects the body from potentially harmful substances (antigens), such as microorganisms, toxins and foreign blood or tissues from other organisms.
- When an antigen enters the body, the immune system produces antibodies that bind to the antigen. Then sensitized lymphocytes (specialized white blood cells that recognize and destroy specific antigens) engulf the foreign substance in a process called phagocytosis.
- Autoimmune disorders are conditions caused by an immune response against the body's own tissues. The immune system mistakes its own cells for antigens. Autoimmunity is present in all healthy individuals, to some extent. However, healthy individuals are able to suppress defective lymphocytes (immune system cells) that mistakenly destroy body cells.
- Autoimmune disorders can destroy body tissues, cause abnormal organ growth or impair organ function. Autoimmune disorders commonly affect blood components (like red blood cells, connective tissues and blood vessels), endocrine glands (like the thyroid or pancreas), as well as muscles, joints and the skin.
- A person may experience more than one autoimmune disorder at the same time. Researchers estimate that at least 10 million Americans suffer from at least one of the more than 80 illnesses caused by autoimmunity. Examples of some of the most prominent autoimmune disorders include, Hashimoto's thyroiditis (inflamed thyroid that often causes underactive thyroid function), pernicious anemia (lack of vitamin B12 absorption), Addison's disease, type I diabetes, rheumatoid arthritis, systemic lupus erythematosus, dermatomyositis, Sjögren's syndrome, lupus erythematosus, multiple sclerosis (MS), myasthenia gravis, Reiter's syndrome, Grave's disease and celiac disease.
- The prognosis for individuals with autoimmune disorders depends on the specific disorder. Most autoimmune disorders are chronic (long-term). However, many disorders can be managed with treatment, including immunosuppressants and anti-inflammatories.
- This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).
- American Association for Clinical Chemistry. . Accessed March 2, 2009.
- Johns Hopkins Medical Institutions. Autoimmune Disease Research Center. . Accessed March 16, 2007. Accessed March 2, 2009.
- National Institute of Arthritis and Musculoskeletal and Skin Diseases. . Accessed March 2, 2009.
- National Women's Health and Information Center. Autoimmune Diseases: Overview. . Accessed March 2, 2009.
- Natural Standard: The Authority on Integrative Medicine. . Copyright © 2009. Accessed March 2, 2009.
- The exact cause of autoimmune disorders remains unknown. However, researchers believe that certain individuals are genetically predisposed to autoimmune conditions. It has also been suggested that sex steroids play a role since females are more susceptible to most autoimmune disorders.
- Autoimmune disorders occur when the immune system destroys normal body tissues instead of antigens. This is caused by a hypersensitivity reaction similar to allergies. The immune system reacts to a substance that it would normally ignore.
- Healthy immune systems are able to differentiate between "self" and "non-self" tissues. Healthy individuals have some lymphocytes (immune system cells) that are sensitized against "self" tissue cells. However, these defective lymphocytes are suppressed by other lymphocytes.
- Autoimmune disorders occur when the body is unable to destroy the defective lymphocytes. Disorders may also occur if normal body tissue is changed so that it is no longer recognized as "self" tissues. Some researchers believe that certain microorganisms or drugs may trigger some of these changes, especially in individuals who have a genetic predisposition for an autoimmune disorder. However, the exact mechanisms that prevent the body from destroying defective lymphocytes or change normal body tissues are unknown.
- Symptoms of autoimmune disease vary widely depending on the specific disease. There are more than 80 autoimmune disorders, which all have unique symptoms.
- Autoimmune disorders typically lead to the destruction of an organ or tissue, which results in decreased function of the affected organ or tissue. For instance, cells in the pancreas are destroyed in diabetic patients. Many autoimmune disorders also cause the organ or tissue to enlarge. For instance, Grave's disease causes thyroid enlargement (goiter formation).
- A group of nonspecific symptoms, including fatigue, dizziness, malaise (general feeling of discomfort) and fever, often accompany autoimmune diseases.
- General: Autoimmune disorders can be difficult to diagnose because signs and symptoms vary widely, depending on the specific disease. In some cases a specific diagnosis cannot be made, and the patient must consult a qualified healthcare professional regularly to monitor the condition. However, an autoimmune disease may be suspected when abnormalities are detected in routine laboratory tests, like elevated levels of C-reactive protein (a protein in the blood that is a marker for inflammation). If an autoimmune disorder is suspected, the patient will undergo diagnostic tests for diseases that correlate with symptoms.
- Fluorescent antinuclear antibody test (FANA): The fluorescent antinuclear antibody test (FANA) is considered a reliable first step for identifying systemic lupus erythematosus and other autoimmune disorders, including scleroderma, Sjögren's syndrome, Raynaud's disease, juvenile chronic arthritis, rheumatoid arthritis and antiphospholipid antibody syndrome. The FANA test is a blood test used to detect abnormal antibodies, called autoantibodies. The autoantibodies bind to components of and individual's own cells and cause the immune system to attack the body.
- To measure results, human tissue culture cells (HEp-2 cell line) are grown in culture and applied to a microscope slide. The slides are then treated with methyl alcohol to make the cells permeable before they are combined with the patient's blood. The cells are incubated with fluorescent antibodies that detect the binding of human antibodies to the cells. The slide is then viewed with a fluorescence microscope. Staining intensity and the pattern of binding are scored at various dilutions.
- A positive test result may suggest an autoimmune disease, but further testing is needed to make a specific diagnosis. FANA test results can be positive in people who do not have autoimmune disease. While a false positive result is uncommon, the frequency increases as people get older. A false negative result is also possible, but it is uncommon.
- C-reactive protein (CRP) test: The C-reactive protein (CRP) test can be used to monitor inflammation, which is associated with autoimmune disorders. A high or increasing amount of CRP in the blood suggests that the patient has an acute infection or inflammation. In a healthy person, CRP is usually less than 10mg/L. Most infections and inflammations result in CRP levels above 100mg/L.
- While the test is not specific enough to diagnose a particular disease, it can be used to help physicians monitor inflammation and determine if current treatments are effective.
- Erythrocyte sedimentation rate (ESR): An erythrocyte sedimentation rate (ESR) test may be conducted to measure and monitor inflammation. This blood test measures the rate in which red blood cells settle to the bottom of a test tube. During an inflammatory response, the high proportion of fibrinogen in the blood causes red blood cells to stick together. The red blood cells form stacks called rouleaux, which settle faster than normal. Normal values are 15mm/hr for men younger than 50 years old, less than 20mm/hr for men older than 50 years, less than 20mm/hr for women younger than 50 years old and less than 30mm/hr for women older than 50 years. Elevated levels usually occur in patients who have autoimmune disorders.
- While an ESR test is not diagnostic, it is useful in detecting and monitoring, tissue necrosis (death), rheumatologic disorders or other diseases that present vague and minimal physical symptoms.
- General: The prognosis for patients with autoimmune disorders varies, depending on the specific disease. Most autoimmune disorders are chronic, but many symptoms can be alleviated with treatment. Most autoimmune disorders are treated with immunosuppressive agents and/or anti-inflammatories. Other treatment options vary, depending on the symptoms associated with the specific disease.
- Immunosuppressants: Autoimmunity is controlled through balanced suppression of the immune system. The goal is to reduce the immune response against normal body tissue while leaving intact the immune response against foreign microorganisms and abnormal tissues. Corticosteroids and immunosuppressant medications (including cyclosporine and azathioprine) are commonly used to reduce the immune response. Immunomodulatory therapies, like etanercept, have been shown to be useful in treating rheumatoid arthritis. Side effects of immunosuppressants may lead to severe infections because they weaken the immune system.
- Anti-inflammatories: Anti-inflammatories are often used to treat autoimmune disorders. Non-steroidal anti-inflammatory drugs like ibuprofen (Motrin® or Advil®) have been used to relieve pain and reduce inflammation in patients suffering from autoimmune disorders like rheumatoid arthritis.
- Intravenous immunoglobulin transfusion (IVIG): Intravenous immunoglobulin transfusion (IVIG) has been used to reduce symptoms of autoimmune diseases, and to control the autoimmune process while maintaining the ability to fight disease. IVIG injections like Gamimune N®, Gammagard S/D® or Sandoglobulin® have been administered to boost the body's immune response and decrease the risk of infections. During the procedure blood products containing immunoglobulins are injected into the bloodstream.
- Other: Disorders that affect the blood components (like systemic lupus erythematosus) may require blood transfusions. Measures to assist mobility or other functions may be needed for disorders like rheumatoid arthritis, which affect the bones, joints or muscles. Individuals who have celiac disease (inability to digest and absorb gluten) may require dietary manipulation. Hormones or other substances normally produced by the affected organ may need to be supplemented. This may include thyroid supplements, vitamins, insulin injections or other supplements. For instance, hormone replacement therapy has been used to treat Hashimoto's thyroiditis (inflamed thyroid that often causes underactive thyroid function).
- Good scientific evidence:
- Borage seed oil: Preliminary evidence suggests that gamma linolenic acid (GLA) may have anti-inflammatory effects that may make it beneficial in treating rheumatoid arthritis. Additional research is needed to determine the optimal dose and administration.
- Avoid if allergic or hypersensitive to borage, its constituents, or members of the Boraginaceae family. Use cautiously in patients with bleeding disorders or in those taking warfarin or other anticoagulant or antiplatelet (blood thinning) agents. Use cautiously in patients with epilepsy or in those taking anticonvulsants. Avoid in patients with compromised immune systems or similar immunological conditions. Avoid during pregnancy and breastfeeding.
- DHEA: The majority of clinical trials investigating the effect of DHEA (dehydroepiandrosterone) for systemic lupus erythematosus support its use as an adjunctive treatment. Additional studies are needed to confirm these results.
- Avoid if allergic to DHEA. Avoid with a history of seizures. Use cautiously with adrenal or thyroid disorders. Use cautiously with anticoagulants, or drugs, herbs or supplements for diabetes, heart disease, seizure or stroke. Stop use two weeks before surgery/dental/diagnostic procedures that pose a bleeding risk, and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.
- Omega-3 fatty acids, fish oil, alpha-linolenic acid: Multiple randomized controlled trials report improvements in rheumatoid arthritis, including morning stiffness and joint tenderness, with the regular intake of fish oil supplements for up to three months. Benefits have been reported as additive with anti-inflammatory medications such as NSAIDs (like ibuprofen or aspirin). However, because of weaknesses in study designs and reporting, better research is necessary before a strong favorable recommendation can be made. Effects beyond three months of treatment have not been well evaluated.
- People who are allergic to fish should avoid fish oil or omega-3 fatty acid products derived from fish. People who are allergic or hypersensitive to nuts should avoid alpha linolenic acid or omega-3 fatty acid products that are derived from the types of nuts to which they react. Avoid during active bleeding. Use cautiously with bleeding disorders, diabetes, low blood pressure or drugs, herbs or supplements that treat any such conditions. Use cautiously before surgery. The Environmental Protection Agency (EPA) recommends that intake be limited in pregnant/nursing women to a single six-ounce meal per week and less than two ounces per week in young children. For farm-raised, imported or marine fish, the U.S. Food and Drug Administration (FDA) recommends that pregnant/nursing women and young children avoid eating types with higher levels of methylmercury and less than 12 ounces per week of other fish types. Women who might become pregnant are advised to eat seven ounces or less per week of fish with higher levels of methylmercury or up to 14 ounces per week of fish types with about 0.5 parts per million (such as marlin, orange roughy, red snapper or fresh tuna).
- Psychotherapy: Although group therapy may somewhat decrease pain in people with rheumatoid arthritis and depression, individual therapy coupled with anti-depressants may be more effective.
- Psychotherapy cannot always fix mental or emotional conditions. Psychiatric drugs are sometimes needed. In some cases symptoms may worsen if the proper medication is not taken. Not all therapists are qualified to work with all problems. Use cautiously with serious mental illness or some medical conditions because some forms of psychotherapy may stir up strong emotional feelings.
- Yoga: There is promising early evidence that yoga therapy may help treat rheumatoid arthritis. More research is needed to confirm these results.
- Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Certain yoga breathing techniques should be avoided in people with heart or lung disease. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction (the popular Lamaze techniques are based on yogic breathing). However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.
- Unclear or conflicting scientific evidence:
- Acupuncture: Further research is needed before acupuncture can be recommended for the treatment of rheumatoid arthritis or Raynaud's disease.
- Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, or neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.
- Arginine: Early study in humans has looked at the effect of arginine on blood vessel activity in Raynaud's disease. However, the effects of arginine are not clear. Large, well-designed trials are needed.
- Avoid if allergic to arginine, or with a history of stroke, liver, or kidney disease. Avoid if pregnant or breastfeeding. Use cautiously if taking blood-thinning drugs (like warfarin or Coumadin®), blood pressure drugs, or herbs or supplements with similar effects. Blood potassium levels should be monitored with use of arginine. L-arginine may worsen symptoms of sickle cell disease. Caution is advised in patients taking prescription drugs to control sugar levels.
- Astaxanthin: More well-designed clinical trials are necessary before astaxanthin can be recommended for the treatment of rheumatoid arthritis.
- Avoid if allergic/hypersensitive to astaxanthin, related carotenoids, or astaxanthin algal sources. Use cautiously if taking 5-alpha-reductase inihibitors, hypertensive agents, asthma medications, cytochrome P450 metabolized agents, menopause agents or oral contraception, or Helicobacter pylori agents. Use cautiously with hypertension, parathyroid disorders, and osteoporosis. Avoid with hormone-sensitive conditions, immune disorders, or if taking immunosuppressive therapies. Avoid with previous experience of visual changes while taking astaxanthin and with low eosinophil levels. Avoid if pregnant or breastfeeding.
- Ayurveda: There is some evidence that a traditional Ayurvedic herbal formula RA-1 may reduce joint swelling but not other symptoms in rheumatoid arthritis. RA-1 contains Withania somnifera (ashwagandha), Boswellia serrata (gugulla), Zingiberis officinale (ginger) and Curcuma longa (turmeric). A resin that is extracted from Boswellia serrata (H15, indish incense) is regarded in Ayurvedic medicine as having anti-inflammatory properties. However, evidence from one study showed no benefit in patients with rheumatoid arthritis. More studies are needed to determine efficacy of these treatments for rheumatoid arthritis.
- Ayurvedic herbs should be used cautiously because they are potent and some constituents can be potentially toxic if taken in large amounts or for a long time. Some herbs imported from India have been reported to contain high levels of toxic metals. Ayurvedic herbs can interact with other herbs, foods and drugs. A qualified healthcare professional should be consulted before taking.
- Beta sitosterol: Beta-sitosterol and beta-sitosterol glucoside have been observed to lower blood levels of IL-6 and, therefore, have been studied for possible as a treatment for rheumatoid arthritis. Larger populations of patients with rheumatoid arthritis should be evaluated in well-conducted clinical study if conclusions are to be made.
- Avoid if allergic or hypersensitive to beta-sitosterol, beta-sitosterol glucoside, or pine. Use cautiously with asthma or breathing disorders, diabetes, primary biliary cirrhosis (destruction of the small bile duct in the liver), ileostomy, neurodegenerative disorders (like Parkinsonism or Alzheimer's disease), diverticular disease (bulging of the colon), short bowel syndrome, celiac disease and sitosterolemia. Use cautiously with a history of gallstones. Avoid if pregnant or breastfeeding.
- Black cohosh: There is not enough human research to make a clear recommendation regarding the use of black cohosh for rheumatoid arthritis pain.
- Use cautiously if allergic to members of the Ranunculaceaefamily such as buttercups or crowfoot. Avoid with hormone conditions (breast cancer, ovarian cancer, uterine cancer, endometriosis). Avoid if allergic to aspirin products, non-steriodal anti-inflammatories (NSAIDs, Motrin®, ibuprofen, etc.), blood-thinners (like warfarin) or with a history of blood clots, stroke, seizures, or liver disease. Stop use before surgery/dental/diagnostic procedures with bleeding risk and avoid immediately after these procedures. Avoid if pregnant or breastfeeding.
- Black currant: Early study shows promise for the use of black currant seed oil in reducing the signs and symptoms of rheumatoid arthritis. However, additional study is needed to confirm these findings.
- Avoid if allergic or hypersensitive to black currant, its constituents, or plants in the Saxifragaceae family. Avoid in patients with hemophilia or those on blood thinners unless otherwise recommended by a qualified healthcare provider. Use cautiously with venous disorders or gastrointestinal disorders. Use cautiously if taking MAOIs (antidepressants) or vitamin C supplements. Avoid if pregnant or breastfeeding.
- Boswellia: Boswellia has been noted in animal and laboratory studies to possess anti-inflammatory properties. Based on these observations, boswellia has been suggested as a potential treatment for rheumatoid arthritis. However, data is conflicting, and combination products were used in some studies. Therefore, there is currently insufficient evidence to recommend for or against the use of boswellia for rheumatoid arthritis.
- Avoid if allergic to boswellia. Avoid with a history of stomach ulcers or stomach acid reflux disease (GERD). Use cautiously if taking lipid-soluble medications, agents metabolized by the liver's cytochrome P450 enzymes, or sedatives. Use cautiously with impaired liver function or liver damage or lung disorders. Use cautiously in children. Avoid if pregnant due to potential abortifacient effects or if breastfeeding.
- Bromelain: Bromelain cannot be recommended for the treatment of rheumatoid arthritis until further research is conducted.
- Avoid if allergic to bromelain, pineapple, honeybee, venom, latex, birch pollen, carrots, celery, fennel, cypress pollen, grass pollen, papain, rye flour, wheat flour, or members of the Bromeliaceaefamily. Use cautiously with history of a bleeding disorder, stomach ulcers, heart disease, or liver or kidney disease. Use caution before dental or surgical procedures or while driving or operating machinery. Avoid if pregnant or breastfeeding.
- Cat's claw: Several laboratory and animal studies suggest that cat's claw may reduce inflammation, and this has led to research of cat's claw for conditions such as rheumatoid arthritis. Large, high-quality human studies are needed before a conclusion can be drawn.
- Avoid if allergic to cat's claw, Uncaria plants, or plants in the Rubiaceae family such as gardenia, coffee, or quinine. Avoid with a history of conditions affecting the immune system. Use cautiously with bleeding disorders or with a history of stroke, or if taking drugs that may increase the risk of bleeding. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Cat's claw may be contaminated with other Uncaria species. Reports exist of a potentially toxic Texan grown plant, Acacia gregii, being substituted for cat's claw. Avoid if pregnant, breastfeeding, or trying to become pregnant.
- Chlorophyll: Diets high in chlorophyll have been hypothesized to modify intestinal flora resulting in improved management of immune disorders including rheumatoid arthritis. More evidence is needed to support the use of chlorophyll in autoimmune diseases.
- Avoid if allergic or hypersensitive to chlorophyll or any of its metabolites. Use cautiously with photosensitivity, compromised liver function, diabetes or gastrointestinal conditions or obstructions. Use cautiously if taking immunosuppressant agents or antidiabetes agents. Avoid if pregnant or breastfeeding.
- Copper: Preliminary study suggests that copper offers no benefit to individuals with systemic lupus erythematosus (SLE). Further research is required before recommendations can be made.
- Avoid if allergic/hypersensitive to copper. Avoid use of copper supplements during the early phase of recovery from diarrhea. Avoid with hypercupremia, occasionally observed in disease states including cutaneous leishmaniasis, sickle-cell disease, unipolar depression, breast cancer, epilepsy, measles, Down syndrome, and controlled fibrocalculous pancreatic diabetes (a unique form of secondary diabetes mellitus). Avoid with genetic disorders affecting copper metabolism such as Wilson's disease, Indian childhood cirrhosis, or idiopathic copper toxicosis. Avoid with HIV/AIDS. Use cautiously with water containing copper concentrations greater than 6mg/L. Use cautiously with anemia, arthralgias, and myalgias. Use cautiously if taking oral contraceptives. Use cautiously if at risk for selenium deficiency. The United States Recommended Dietary Allowance (RDA) is 1,000?g for pregnant women. The United States Recommended Dietary Allowance (RDA) is 1300?g for nursing women.
- DHEA: Preliminary evidence suggests that DHEA (dehydroepiandrosterone) may not offer benefit to individuals with rheumatoid arthritis or Sjögren's syndrome. Further research is needed in this area.
- Avoid if allergic to DHEA. Avoid with a history of seizures. Use with caution in adrenal or thyroid disorders or anticoagulants, or drugs, herbs or supplements for diabetes, heart disease, seizure or stroke. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.
- DMSO (dimethyl sulfoxide): Applying DMSO to the skin may help treat rheumatoid arthritis. More research is needed before a conclusion can be drawn.
- Avoid if allergic or hypersensitive to DMSO. Use caution with urinary tract cancer or liver and kidney dysfunction. Avoid if pregnant or breastfeeding.
- Evening primrose oil: Benefits of evening primrose oil in the treatment of rheumatoid arthritis or Raynaud's disease have not clearly been shown. More research is needed before a conclusion can be made.
- Avoid if allergic to plants in the Onagraceae family (willow's herb, enchanter's nightshade) or gamma-linolenic acid. Avoid with seizure disorders. Use cautiously with mental illness drugs. Stop use two weeks before surgery with anesthesia. Avoid if pregnant or breastfeeding.
- Feverfew: There is currently not enough evidence to support the use of feverfew for rheumatoid arthritis. Further research is warranted.
- Avoid if allergic to feverfew and other plants of the Compositaefamily (chrysanthemums, daisies, marigolds, ragweed). Stop use prior to surgery and dental or diagnostic procedures. Avoid with drugs that increase bleeding risk. Avoid stopping feverfew use all at once. Avoid if history of heart disease, anxiety or bleeding disorders. Caution is advised with a history of mental illness, depression and headaches. Avoid if pregnant or breastfeeding.
- Flaxseed and flaxseed oil: There is currently a lack of strong evidence available to support the use of flaxseed (not flaxseed oil) for lupus nephritis. More research is needed before a firm recommendation can be made.
- Flaxseed has been well-tolerated in studies for up to four months. Avoid if allergic to flaxseed, flaxseed oil or other plants of the Linaceae family. Avoid large amounts of flaxseed by mouth and mix with plenty of water or liquid. Avoid flaxseed (not flaxseed oil) with a history of esophageal stricture, ileus, gastrointestinal stricture or bowel obstruction. Avoid with a history of acute or chronic diarrhea, irritable bowel syndrome, diverticulitis or inflammatory bowel disease. Avoid topical flaxseed in open wounds or abraded skin surfaces. Use cautiously with a history of a bleeding disorder or with drugs that cause bleeding risk (like anticoagulants and non-steroidal anti-inflammatories (like aspirin, warfarin, Advil®), high triglyceride levels, diabetes, mania, seizures or asthma. Avoid if pregnant or breastfeeding. Avoid with prostate cancer, breast cancer, uterine cancer or endometriosis. Avoid ingestion of immature flaxseed pods.
- Gamma linolenic acid (GLA): Several clinical studies indicate significant therapeutic improvements in rheumatoid arthritis symptoms with use of gamma linolenic acid (GLA).
Currently, there is limited evidence showing that GLA is effective in treating Sjogren's syndrome. Additional study is needed before a conclusion can be made.
- Use cautiously with drugs that increase the risk of bleeding like anticoagulants and anti-platelet drugs. Avoid if pregnant or breastfeeding.
- Ginger: Well-designed clinical trials are necessary before ginger can be recommended for the treatment of rheumatoid arthritis.
- Avoid if allergic to ginger or other members of the Zingiberaceaefamily. Avoid with anticoagulation therapy. Avoid large quantities of fresh cut ginger with inflammatory bowel disease or a history of intestinal obstruction. Use cautiously prior to surgery and with gastric or duodenal ulcers, gallstones, cardiovascular disease, and diabetes. Use cautiously long-term and in underweight patients. Use cautiously if taking heart medications or sedatives and if driving or operating heavy machinery. Use cautiously if pregnant or breastfeeding.
- Ginkgo (Ginkgo biloba): Results from limited available clinical study suggest that Ginkgo biloba may effectively reduce the number of attacks in patients suffering from Raynaud's disease. In order to confirm these results, further clinical trials are required.
- Avoid if allergic or hypersensitive to members of the Ginkgoaceaefamily.
If allergic to mango rind, sumac, poison ivy or oak or cashews, then allergy to ginkgo is possible. Avoid with blood-thinners (like aspirin or warfarin (Coumadin®)) due to an increased risk of bleeding. Ginkgo should be stopped two weeks before surgical procedures. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Do not use ginkgo in supplemental doses if pregnant or breastfeeding.
- Glucosamine: Preliminary human research reports benefits of glucosamine in the treatment of joint pain and swelling in rheumatoid arthritis patients. However, additional research is needed before a conclusion can be made.
- Avoid if allergic or hypersensitive to shellfish or iodine. Some reports suggest a link between glucosamine/chondroitin products and asthma. Use caution with diabetes or a history of bleeding disorders. Avoid if pregnant or breastfeeding.
- Guggul: There is currently insufficient evidence to support the use of guggul or guggul derivatives for the management of rheumatoid arthritis.
- Avoid if allergic to guggul. Avoid with a history of thyroid disorders, anorexia, bulimia, or bleeding disorders. Signs of allergy to guggul may include itching and shortness of breath.
Avoid if pregnant or breastfeeding.
- Guided imagery: Cognitive-behavioral interventions for pain may be an effective adjunct to standard pharmacologic interventions for pain in patients with juvenile rheumatoid arthritis. Further research is needed to confirm these results.
- Guided imagery is usually intended to supplement medical care, not to replace it, and should not be relied on as the sole therapy for a medical problem. Contact a qualified health care provider if mental or physical health is unstable or fragile. Never use guided imagery techniques while driving or doing any other activity that requires strict attention. Use cautiously with physical symptoms that can be brought about by stress, anxiety or emotional upset because imagery may trigger these symptoms. Speak with a qualified health care provider before practicing guided imagery if feeling unusually anxious while practicing guided imagery, or with a history of trauma or abuse.
- Hops: Early clinical research suggests that a combination formula containing hops may help reduce symptoms of rheumatic diseases. However, well-designed human trials using hops alone are needed to determine if these positive effects are specifically the result of hops.
- Avoid if allergic to hops, its constituents, members of the Cannabaceae family, peanuts, chestnuts, or bananas. Use cautiously if driving or operating heavy machinery. Use cautiously with hormone-sensitive conditions (e.g. breast cancer, uterine cancer, cervical cancer, prostate cancer, or endometriosis) and diabetes. Use cautiously if taking hormonal agents (e.g. contraceptives or fertility agents). Use cautiously if pregnant or breastfeeding; some hops preparations contain high levels of alcohol and should be avoided during pregnancy.
- Hypnotherapy: Although multiple trials report diminished pain levels or requirements for pain-relieving medications after hypnotherapy, there is limited research for rheumatoid arthritis pain specifically. Other signs of rheumatoid arthritis, such as joint mobility or blood tests for rheumatoid factor, have not been adequately assessed.
- Use cautiously with mental illnesses like psychosis/schizophrenia, manic depression, multiple personality disorder or dissociative disorders. Use cautiously with seizure disorders.
- Lavender: Early human studies have found conflicting results on the use of massage with lavender aromatherapy for rheumatoid arthritis pain. More research is needed to make a conclusion.
- Avoid if allergic or hypersensitive to lavender. Avoid with a history of seizures, bleeding disorders, eating disorders (anorexia, bulimia) or anemia (low levels of iron). Avoid if pregnant or breastfeeding.
- Magnet therapy: Initial evidence has failed to show improvements in rheumatoid arthritis pain with the use of magnet therapy. However, due to methodological weaknesses of this research, the conclusions cannot be considered definitive.
- Avoid with implantable medical devices like heart pacemakers, defibrillators, insulin pumps, or hepatic artery infusion pumps. Avoid with myasthenia gravis or bleeding disorders. Avoid if pregnant or breastfeeding. Magnet therapy is not advised as the sole treatment for potentially serious medical conditions, and should not delay the time to diagnosis or treatment with more proven methods. Patients are advised to discuss magnet therapy with a qualified healthcare provider before starting treatment.
- Massage: Massage may be of benefit for rheumatoid arthritis, but there is currently not enough scientific data on which to base a strong conclusion for this indication.
- Avoid with bleeding disorders, low platelet counts, or if on blood-thinning medications (such as heparin or warfarin/Coumadin®). Areas should not be massaged where there are fractures, weakened bones from osteoporosis or cancer, open/healing skin wounds, skin infections, recent surgery, or blood clots. Use cautiously with a history of physical abuse or if pregnant or breastfeeding. Massage should not be used as a substitute for more proven therapies for medical conditions. Massage should not cause pain to the client.
- Moxibustion: There is preliminary evidence suggesting that patients suffering from rheumatoid arthritis may experience improved immune function as a result of acupuncture and moxibustion. However, evidence is insufficient at this time for making conclusions.
- Use cautiously over large blood vessels and thin or weak skin. Avoid with aneurysms, any kind of "heat syndrome," cardiac disease, convulsions or cramps, diabetic neuropathy, extreme fatigue and/or anemia, fever, inflammatory conditions, over allergic skin conditions or ulcerated sores, or skin adhesions. Avoid if pregnant or breastfeeding. Avoid areas with an inflamed organ, contraindicated acupuncture points, face, genitals, head, inflamed areas in general, nipples, and skin adhesions. Avoid in patients who have just finished exercising or if taking a hot bath or shower. Caution with elderly people with large vessels. It is advised to not bathe or shower for up to 24 hours after a moxibustion treatment.
- Omega-3 fatty acids: More research is necessary to determine whether omega-3 fatty acids can effectively treat lupus erythematosus.
- Avoid if allergic or hypersensitive to fish, omega-3 fatty acid products that come from fish, nuts, linolenic acid or omega-3 fatty acid products that come from nuts. Avoid during active bleeding. Use cautiously with bleeding disorders, diabetes, low blood pressure or drugs, herbs or supplements that treat any such conditions. Use cautiously before surgery. The Environmental Protection Agency (EPA) recommends that intake be limited in pregnant/nursing women to a single 6-ounce meal per week, and in young children to less than 2 ounces per week. For farm-raised, imported, or marine fish, the U.S. Food and Drug Administration recommends that pregnant/nursing women and young children avoid eating types with higher levels of methylmercury and less than 12 ounces per week of other fish types. Women who might become pregnant are advised to eat 7 ounces or less per week of fish with higher levels of methylmercury or up to 14 ounces per week of fish types with about 0.5 parts per million (such as marlin, orange roughy, red snapper, or fresh tuna).
- Pantothenic acid (vitamin B5): It has been reported that pantothenic acid levels are lower in the blood of rheumatoid arthritis patients than healthy individuals. However, it is not clear if this is a cause, effect or a beneficial adaptive reaction. There is currently insufficient scientific evidence in this area in order to form a clear conclusion.
- Avoid if allergic or hypersensitive to pantothenic acid or dexpanthenol. Avoid with gastrointestinal blockage. Pantothenic acid is generally considered safe in pregnant and breastfeeding women when taken at recommended doses.
- Papain: Review study found that proteolytic enzymes, including papain, may reduce pain and inflammation in rheumatic disorders. Additional research is needed to confirm these results.
- Use cautiously in patients sensitive to papain, being treated for prostatitis, with bleeding disorders or taking anticoagulants or antiplatelets. Use cautiously as an adjuvant to radiation therapy. Avoid in patients with gastroesophageal reflux disease or in those using immunosuppressive therapy.
- Para-aminobenzoic acid: Para-aminomethylbenzoic acid (PAMBA), a derivative of PABA, has been studied for use in autoimmune disorders such as pemphigus vulgaris. Potassium para-aminobenzoate (KPAB) has been proposed as a treatment for scleroderma. Additional high quality trials are needed.
- Pharmaceutical doses of PABA and its derivatives should only be taken under appropriate medical supervision. Avoid oral use in children and pregnant or nursing women. Avoid with known hypersensitivity to PABA or its derivatives. Use cautiously in patients with renal disease, liver disorders, diabetes, hypoglycemia, bleeding disorders, or in those taking anticoagulants.
- Peony: Peony's anti-inflammatory effects may benefit patients with rheumatoid arthritis. However, there is currently not enough evidence for or against this use of peony.
- Avoid if allergic or sensitive to peony. Avoid with bleeding disorders or if taking drugs, herbs, or supplements that increase bleeding risk. Use cautiously with estrogen-sensitive cancers or if taking drugs, herbs, or supplements with hormonal activity. Avoid if pregnant or breastfeeding.
- Physical therapy: Several studies have indicated that treatment of rheumatoid arthritis with physical therapy may help improve morning stiffness and grip strength. Treatment should be conducted by a specially trained physical therapist and that physical therapy. Some experts have suggested a long-term, high-intensity exercise program. Beneficial effects may last up to one year. Despite promising early evidence, better-designed studies are needed to draw a firm conclusion.
- Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with a qualified healthcare professional before beginning any treatments. Physical therapy may aggravate pre-existing conditions. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the physical therapy literature although causality is unclear. Erectile dysfunction has also been reported. Physical therapy has been used in pregnancy and although reports of major adverse effects are lacking the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.
- Podophyllum: Preliminary research suggests that podophyllum may be helpful for rheumatoid arthritis. Research is limited due to the possible adverse effects like severe diarrhea associated with oral podophyllum. Additional research is needed before a firm conclusion can be drawn.
- Avoid if allergic/hypersensitive to podophyllum or to members of the Berberidaceae family. Podophyllum, when applied topically, may be absorbed through the skin and cause irritation of the stomach and intestines. Podophyllum toxicity may cause heart palpitations and blood pressure changes, muscle paralysis, difficulty walking, confusion, and convulsions. Using podophyllum and laxatives may result in dehydration and electrolyte depletion. Use cautiously with arrhythmia, Crohn's disease, cardiovascular problems, gallbladder disease or gallstones, high blood pressure, irritable bowel syndrome, liver insufficiency, muscular, and neurologic disorders, psychosis, or kidney insufficiency. Use cautiously if taking antimiotic agents like vincristine, anti-psychotic agents, or laxatives. Avoid if pregnant or breastfeeding.
- Prayer, distant healing: Initial research suggests that in-person intercessory prayer (praying by others in the presence of patients) may reduce pain, fatigue, tenderness, swelling and weakness in rheumatoid arthritis when it is used in addition to standard care. Better quality research is necessary before a firm conclusion can be drawn.
- Prayer is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time it takes to consult with a healthcare professional or receive established therapies. Sometimes religious beliefs come into conflict with standard medical approaches, and require an open dialog between patients and caregivers. Based on limited clinical study, patients certain that they were receiving intercessory prayer had a higher incidence of complications following cardiac bypass surgery than those who did not know they were being prayed for.
- Probiotics: In limited study, Lactobacillus GG was associated with improved subjective well-being, as well as reduced symptoms of rheumatoid arthritis. However, these findings were not statistically significant. More studies on the effects of probiotics in rheumatoid arthritis are needed.
- Probiotics are generally considered safe and well-tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant. Caution is advised when using probiotics in neonates born prematurely or with immune deficiency.
- Propolis: Based on anti-inflammatory action observed in laboratory research, propolis has been proposed as a possible treatment for rheumatic diseases. However, there is currently not enough scientific human study to make a conclusion.
- Avoid if allergic or hypersensitive to propolis, black poplar (Populas nigra), poplar bud, bee stings, bee products, honey, and Balsam of Peru. Severe allergic reactions have been reported. Use cautiously with asthma or gastrointestinal disorders. Avoid if pregnant or breastfeeding because of the high alcohol content in some propolis products.
- Psychotherapy: There is conflicting evidence as to whether or not brief supportive-expressive group psychotherapy reduces psychological distress and medical symptoms and improves the quality of life of women with systemic lupus erythematosus (SLE). Further studies are needed to draw clear conclusions.
- Psychotherapy cannot always fix mental or emotional conditions. Psychiatric drugs are sometimes needed. In some cases, symptoms may worsen if the proper medication is not taken. Not all therapists are qualified to work with all problems. Use cautiously with serious mental illness or some medical conditions because some forms of psychotherapy may stir up strong emotional feelings.
- Pycnogenol: Pycnogenol® may be useful as a second line therapy to reduce inflammatory features of systemic lupus erythematosus (SLE). Further research is needed before a recommendation can be made.
- Avoid if allergic/hypersensitive to pycnogenol, its components, or members of the Pinaceae family. Use cautiously with diabetes, hypoglycemia, bleeding disorders. Use cautiously if taking hypolipidemics, medications that may increase the risk of bleeding, hypertensive medications, or immune stimulating or inhibiting drugs. Avoid if pregnant or breastfeeding.
- Reishi mushroom: A combination of reishi mushroom and San Miao San (a mixture of several Chinese herbs) may help reduce the pain of rheumatoid arthritis. However, these herbs did not reduce swelling. More research with reishi mushroom alone is needed.
- Avoid if allergic or hypersensitive to any constituents of Ganoderma lucidum or any member of its family. Use cautiously with diabetes, blood disorders (including hemophilia), low blood pressure, or ulcers. Avoid if pregnant or breastfeeding.
- Relaxation therapy: Limited preliminary research reports that muscle relaxation training may improve function and well being in patients with rheumatoid arthritis. Additional research is necessary before a conclusion can be reached.
- Avoid with psychiatric disorders like schizophrenia/psychosis. Jacobson relaxation (flexing specific muscles, holding that position, then relaxing the muscles) should be used cautiously with illnesses like heart disease, high blood pressure, or musculoskeletal injury. Relaxation therapy is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time to diagnosis or treatment with more proven techniques.
- Selenium: Selenium supplementation has been studied in rheumatoid arthritis patients with mixed results. Additional research is necessary before a clear conclusion can be drawn.
- Avoid if allergic or sensitive to products containing selenium. Avoid with history of nonmelanoma skin cancer. Selenium is generally regarded as safe for pregnant or breastfeeding women. However, animal research reports that large doses of selenium may lead to birth defects.
- Shark cartilage: Chondroitin sulfate, a component of shark cartilage, has been shown to benefit patients with osteoarthritis. However, the concentrations of chondroitin in shark cartilage products may be too small to be helpful. The ability of shark cartilage to block new blood vessel growth or reduce inflammation is suggested to be helpful in rheumatoid arthritis. However, there is limited research in these areas, and more studies are needed before a recommendation can be made.
- Avoid if allergic to shark cartilage or any of its ingredients (including chondroitin sulfate and glucosamine). Use cautiously with sulfur allergy. Avoid with a history of heart attack, vascular disease, heart rhythm abnormalities (arrhythmias) or heart disease. Use cautiously with a history of liver or kidney disorders, tendency to form kidney stones, breast cancer, prostate cancer, multiple myeloma, breathing disorders (like asthma), cancers that raise calcium levels (like breast, prostate, multiple myeloma or squamous cell lung cancer) and diabetes. Avoid if pregnant or breastfeeding.
- Spiritual healing: There is currently not enough evidence that spiritual healing adds any benefit to conventional treatment in rheumatoid arthritis. Spiritual healing should not be used as the only treatment approach for medical or psychiatric conditions, and should not delay the time it takes to consider more proven therapies.
- Stinging nettle: Stinging nettle is widely used as a folk remedy to treat arthritis and rheumatic conditions throughout Europe and Australia. Pre-clinical evidence suggests that certain constituents in the nettle plant have anti-inflammatory and/or immunomodulatory activity and may be of benefit in rheumatoid arthritis. Well-designed, randomized controlled trials are needed to further support its use in humans.
- Avoid if allergic or hypersensitive to nettle, members of the Urticaceae family, or any ingredient of nettle products. Use cautiously with diabetes, bleeding disorders, or low sodium levels in the blood. Use cautiously with diuretics and anti-inflammatory drugs. The elderly should also use nettle cautiously. Avoid if pregnant or breastfeeding.
- Tai chi: There is not enough scientific evidence showing that tai chi reduces rheumatoid arthritis symptoms, although tai chi may help improve range of motion of the lower extremities.
- Avoid with severe osteoporosis or joint problems, acute back pain, sprains, or fractures. Avoid during active infections, right after a meal, or when very tired. Some believe that visualization of energy flow below the waist during menstruation may increase menstrual bleeding. Straining downwards or holding low postures should be avoided during pregnancy, and by people with inguinal hernias. Some tai chi practitioners believe that practicing for too long or using too much intention may direct the flow of chi (qi) inappropriately, possibly resulting in physical or emotional illness. Tai chi should not be used as a substitute for more proven therapies for potentially serious conditions. Advancing too quickly while studying tai chi may increase the risk of injury.
- TENS (Transcutaneous Electrical Nerve Stimulation): Preliminary studies of TENS in rheumatoid arthritis report improvements in joint function and pain. However, most research is not well designed or reported, and better studies are necessary before a clear conclusion can be reached.
- Avoid with implantable devices, like defibrillators, pacemakers, intravenous infusion pumps, or hepatic artery infusion pumps. Use cautiously with decreased sensation, like neuropathy, and with seizure disorders. Avoid if pregnant or breastfeeding.
- Thymus extract: Preliminary results indicate that articular and cutaneous symptoms associated with systemic lupus erythematosus may be improved with thymus extract use. Well designed clinical trials are required before thymus extract can be recommended for this use.
- Avoid if allergic or hypersensitive to thymus extracts. Use bovine thymus extract supplements cautiously due to potential for exposure to the virus that causes "mad cow disease." Avoid use with an organ transplant or other forms of allografts or xenografts. Avoid if receiving immunosuppressive therapy, with thymic tumors, myasthenia gravis (neuromuscular disorder), untreated hypothyroidism, or if taking hormonal therapy. Avoid if pregnant or breastfeeding; thymic extract increases human sperm motility and progression.
- Turmeric: Turmeric has been used historically to treat rheumatoid arthritis. Laboratory and animal studies show anti-inflammatory activity of turmeric and its constituent curcumin, however, reliable human research is lacking.
- Avoid if allergic or hypersensitive to turmeric, curcumin, yellow food colorings, or plants belonging to the Zingiberaceae (ginger) family. Use cautiously with a history of bleeding disorders, immune system deficiencies, liver disease, diabetes, hypoglycemia, or gallstones. Use cautiously with blood-thinners, such as warfarin (like Coumadin®), and blood sugar-altering medications. Avoid in medicinal amounts if pregnant or breastfeeding. Turmeric should be stopped prior to scheduled surgery.
- Zinc: The majority of trials do not show significant improvements in rheumatoid arthritis symptoms following zinc treatment. Interpretation of some data is difficult because patients in the studies were permitted to continue their previous arthritis medication and most studies used a small number of participants. Well-designed clinical trials are needed before a definitive conclusion can be made.
- Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride since studies have not been done on its safety or effectiveness. Avoid with kidney disease. Use cautiously if pregnant or breastfeeding.
- Fair negative scientific evidence:
- DMSO (dimethyl sulfoxide): DMSO does not seem to help treat scleroderma, and therefore, it is not recommended. Avoid if allergic or hypersensitive to DMSO. Use caution with urinary tract cancer or liver and kidney dysfunction. Avoid if pregnant or breastfeeding.
- Green lipped mussel: There is conflicting evidence of the effect of green-lipped mussel supplementation for treating rheumatoid arthritis. Overall, the evidence does not support this use.
- Green-lipped mussel is generally considered safe. Use cautiously with anti-inflammatory agents. Use cautiously with asthma. Avoid in patients with liver disease. Avoid with allergy or sensitivity to green-lipped mussel or other shellfish. Avoid if pregnant or breastfeeding.
- Willow bark: Based on limited clinical study, willow bark extract has not shown efficacy in treating rheumatoid arthritis. More high-quality studies of larger design are needed to make a conclusion.
- Avoid if allergic/hypersensitive to aspirin, willow bark (Salix spp.), or any of its constituents, including salicylates. Use cautiously with gastrointestinal problems, such as ulcers, hepatic disorders, diabetes, gout, hypertension, hyperlipidemia, history of allergy or asthma, and leukemia. Use cautiously if taking protein-bound medications, antihyperlipidemia agents, alcohol, leukemia medications, beta-blockers, diuretics, Phenytoin (Dilantin®), probenecid, spironolactone, sulfonylureas, valproic acid, or methotrexate. Use cautiously if pre-disposed to headaches. Avoid operating heavy machinery. Avoid in children with chickenpox and any other viral infections. Avoid with blood disorders, and renal disorders. Avoid if taking other NSAIDs, acetazolamide or other carbonic anhydrase inhibitors. Avoid with elevated serum cadmium levels. Avoid if pregnant or breastfeeding.
- Zinc: In limited study, zinc supplementation did not seem to have a beneficial effect on symptoms of patients with chronic inflammatory rheumatic disease.
- Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride since studies have not been done on its safety or effectiveness. Avoid with kidney disease. Use cautiously if pregnant or breastfeeding.
- Currently, there is no known method of prevention of autoimmune disorders.
- Genetics: Certain individuals have a genetic predisposition to autoimmune disorders, which are usually associated with more than one gene. Some researchers suggest that certain major histocompatibility complex (MHC) class II allotypes are strongly correlated with specific autoimmune diseases. The MHC encodes proteins called human leukocyte antigens (HLA), which are found on the membrane of all cells. The HLA molecules help the body's immune system distinguish between self and non-self cells.
- For instance, HLA-DR2 (specific type of HLA) is positively correlated with systemic lupus erythematosus (chronic inflammatory connective tissue disease) and multiple sclerosis, and negatively correlated with diabetes type I. HLA DR3 is correlated with myasthenia gravis (neuromuscular disease), systemic lupus erythematosus and diabetes type I. HLA DR4 is correlated with rheumatoid arthritis, diabetes type I and pemphigus vulgaris (skin disorder characterized by blistering of the skin and mucus membrane). However, not all genetically susceptible individuals develop the disorder.
- Gender: Women are more likely to develop autoimmune disorders than men. In fact, researchers estimate that about 75% of all patients suffering from autoimmune disorders are female. However, the most prominent exception is ankylosing spondylitis, which has a male preponderance. The reasons for gender preponderance are unclear. Several animal studies suggest that sex steroids may play a role in gender susceptibility. Other researchers suggest that the exchange of cells between mother and child during pregnancy may cause autoimmunity.
Copyright © 2011 Natural Standard (www.naturalstandard.com)
The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.