Q I am crippled with arthritis. I have heard about a new drug called rituximab, but I am worried about the possible side-effects. Are there any supplements that I could take for my arthritis instead? - H.P., London
A Rituximab, a monoclonal antibody, was originally developed by the drug company Hoffmann-LaRoche as an anticancer drug - in particular, non-Hodgkin's lymphoma. Its major mode of action is to suppress B-lymphocyte antibodies made by the immune system, and this is believed to interrupt a key part of the mechanism that causes arthritis.
However, the actual evidence for rituximab's benefits in arthritis is pretty thin. The first trial to be published was conducted on only five patients, all of whom had very advanced arthritis. They were given the drug for two months. Although four showed some initial improvement, it was relatively short-lived, and only one patient found any benefit 12 months after treatment (Arthritis Rheum, 2002; 46: 1984-5, 2029-33).
Another larger trial has recently got the tabloids buzzing with the prospect of rituximab being a 'a new cure' for arthritis. This British study was involved over a hundred arthritis suffers, and 20 per cent of them were claimed to have 'an exceptional level of improvement' after just two drug infusions. However, the study has not yet been published, so the results are difficult to assess.
What's not difficult to assess are the drug's potential side-effects. Because rituximab has been used in cancer chemotherapy for some years, its hazards are now well documented - and new ones are being discovered all the time. Flu-like symptoms, nausea, muscle pain and low blood pressure are just the beginning. What are described as 'severe pulmonary events' such as bronchospasm, dyspnoea (difficulty breathing), hypoxia (insufficient oxygen to body tissues) and acute respiratory failure can occur within one or two hours of starting the first infusion. These may need 'aggressive symptomatic treatment' (Hoffmann-LaRoche. Rituxan product monograph, 21 June, 2000).
Longer-term deaths have occurred as a result of severe side-effects affecting the skin (Hoffmann-LaRoche, Rituxan - important drug warning; 17 May 2001). In all fairness, such severe side-effects are unlikely in arthritis treatment because much lower doses of rituximab are used.
Given these problems with the drug and the lack of clinical trials, it is unlikely that rituximab will be licensed for use in arthritis before 2005.
The fact that doctors are now turning to potentially hazardous cancer treatments to combat arthritis shows just how desperate is the need to find anything that may work. As many sufferers like you will have discovered, medicine's track record in arthritis has been at best disappointing, at worst an abject failure. It has been a long history of hyped-up hopes followed by painful climb-downs as one new drug after another has been glowingly brought to market, only to be revealed to be no better than its predecessors.
Fortunately, there are many alternative treatments to choose from, some of them supported by good scientific evidence. The most popular alternative approach is manipulating food intake. Top of the list are fish oil supplements such as cod liver oil. Clinical trials have conclusively shown that taking cod liver oil for three months 'significantly' reduces joint pain and stiffness - with no side-effects (J Clin Epidemiol, 1995; 48: 1379-90).
A second line of attack is to check for food allergy or intolerance. Sixteen years ago, a major study clearly showed that arthritis symptoms improved on fasting, but worsened when patients began to eat certain foods (Lancet, 1986; 1 Feb: 236-8). One of the authors of that landmark study was Dr John Mansfield, who has a large practice treating arthritis through diet. He is convinced that most arthritis is caused by adverse reactions to just a few foods or chemicals. The culprit foods differ from person to person, but the most common ones are cereals and dairy products. In Dr Mansfield's experience, eliminating problem foods from the diet will cure 75 per cent of rheumatoid arthritis and about 50 per cent of osteoarthritis cases.
Two nutritional supplements are also beginning to revolutionise alternative treatments for arthritis. These are glucosamine and chondroitin, now recognised to be of major importance in the growth of cartilage, the spongy material that covers the ends of bones in the joints and protects them from wear.
The evidence for their beneficial effects is impressive. To date, there have been over 14 clinical trials, all showing a significant reduction in pain and joint stiffness. Virtually all the research has been done on osteoarthitis, the most common form of the disease. A recent major study has shown that 1500 mg of glucosamine a day protects against joint damage in osteoarthritis and may even reverse it (Lancet, 2001; 357: 251-6).
Other, more usual nutritional supplements may also be of benefit as people who develop rheumatoid arthritis have been found to have low levels of vitamin E, beta-carotene, selenium (Br J Nutr, 2001; 85: 251-69) and zinc (J Rheumatol, 1998; 25: 187-8).
Three herbs have been found to be particularly useful in arthritis: Boswellia, Devil's claw and white willow bark. A herbal formula based on Boswellia was recently tested in over 40 osteoarthritis patients in a double-blind trial, with highly significant effects on pain and joint mobility (J Ethnopharmacol, 1991; 33: 91-5).