Home' Australian Pharmacist : October 2011 Contents Vol.30–October#10,2011
The articles in this series are independently researched and compiled by PSA commissioned authors and peer reviewed.
in osteoarthritis highlighted a number
of methodological flaws in the current
body of research. Nevertheless it
reported that data from the higher
quality studies suggested that devil’s
claw was effective in reducing pain.35
Further studies are required to
In animal experiments an extract of
devil’s claw showed a dose-dependent
suppression of inflammatory
cytokines [interleukin-1beta (IL-1beta),
interleukin-6 (IL-6), and tumour necrosis
factor-alpha (TNF-alpha)].36 In addition,
in vitro research has determined that
harpagoside (an iridoid glycoside) is
the main constituent responsible for
the inhibition of COX-1, COX-2 and NO
production however there are other
constituents that may antagonise or
increase the synthesis of inflammatory
mediators.37 The relative amount of
various anti- and pro-inflammatory
constituents in devil’s claw and the
mode of administration may affect the
anti-inflammatory potential of different
preparations.38,39 For instance the
increased penetration of harpagide
from topical preparations using ethanol
may counteract the anti-inflammatory
activity of the other constituents.
Products from reputable manufacturers
are often standardised for harpagoside
content; while this is not a guarantee
of the ratios of other constituents it
may be preferable to non-standardised
Longer term treatment may be
required as some studies indicate that
maximum pain relief occurs after 3 to
A minimum of 2,400 mg
(corresponding to 50 mg harpagoside)/
day may be required for optimal
Minor adverse events (mostly
gastrointestinal) have been reported in
around 3% of patients.
On the whole
devil’s claw appears to be associated
with relatively minor risk (compared
to NSAIDs), but further long-term
assessment is required.35
Rare unconfirmed case reports
suggest possible potentiation of
warfarin.44 Despite earlier concerns,
recent data from screening assays
suggest that devil’s claw preparations
are unlikely to have a clinically relevant
effect on CYP function.
preparations may inhibit P-glycoprotein
activity and expression to various
extents suggesting the possibility of
herb-drug interactions, although the
harpagoside content does not appear
to be responsible.33 Caution should be
exerted with concomitant medications
until more is known.
Use in pregnancy and lactation
There is currently insufficient evidence
to confirm the safety or otherwise of
devil’s claw in pregnancy and lactation
although low doses have been used
Use with caution in those with
oesophageal reflux or hyperacidity.46
Cautions and counselling points
• A minimum of 2,400 mg
(corresponding to 50 mg
harpagoside)/day for three to
four months may be required
for optimal effects.
• Mild gastrointestinal effects may
occur but these are likely to be less
pronounced than NSAIDs.
• Use with caution in those with
oesophageal reflux or hyperacidity,
and monitor use if taking warfarin or
More research is required but the
generally good safety profile of
turmeric and devil’s claw suggests that
a therapeutic trial may be warranted in
certain individuals with inflammatory
conditions such as RA and IBD. The
effects appear to be largely due to the
contribution of the active constituents,
such as curcumin and harpagoside, in
inhibiting pro-inflammatory mediators.
Newer formulations of turmeric
with improved bioavailability should
be considered and a standardised
formulation of devil’s claw (for
harpagoside content) should be
purchased from a reputable distributor.
Key learning points
• Turmeric and its active constituent
curcumin are promising anti-
inflammatory agents but more
research is required.
• Requirements for other anti-
inflammatory medications should be
monitored as these may be reduced
or ceased if the CAM treatment is
1. Joos S. Review on efficacy and health services
research studies of complementary and alternative
medicine in inflammatory bowel disease. Chin J Integr
Med 2011;17(6):403–9 .
2. Lakatos PL, Czegledi Z, David G, Kispal Z, Kiss LS,
Palatka K, et al. Association of adherence to therapy
and complementary and alternative medicine use with
demographic factors and disease phenotype in patients
with inflammatory bowel disease. J Crohns Colitis
3. Wong AP, Clark AL, Garnett EA, Acree M, Cohen
SA, Ferry GD, et al. Use of complementary medicine
in pediatric patients with inflammatory bowel
disease: results from a multicenter survey. J Pediatr
Gastroenterol Nutr 2009;48(1):55–60.
4. Efthimiou P, Kukar M. Complementary and alternative
medicine use in rheumatoid arthritis: proposed
mechanism of action and efficacy of commonly used
modalities. Rheumatol Int 2009;30(5):571–86 .
5. Rispler D, Sara J, Davenport L, Mills B, Iskra C.
Underreporting of complementary and alternative
medicine use among arthritis patients in an orthopedic
clinic. Am J Orthop (Belle Mead NJ) 2011;40(5):E92–5.
6. Unsal A, Gozum S. Use of complementary and
alternative medicine by patients with arthritis. J Clin
7. Sikora-Polaczek M, Bielak-Zmijewska A, Sikora E.
[Molecular and cellular mechanisms of curcumin
action--beneficial effect on organism]. Postepy Biochem
8. Taty Anna K, Elvy Suhana MR, Das S, Faizah O, Hamzaini
AH. Anti-inflammatory effect of Curcuma longa
(turmeric) on collagen-induced arthritis: an anatomico-
radiological study. Clin Ter 2011;162(3):201–7 .
9. White B, Judkins DZ. Clinical Inquiry. Does turmeric
relieve inflammatory conditions? J Fam Pract
10. Khajehdehi P, Zanjaninejad B, Aflaki E, Nazarinia M,
Azad F, Malekmakan L, et al. Oral Supplementation
of Turmeric Decreases Proteinuria, Hematuria, and
Systolic Blood Pressure in Patients Suffering from
Relapsing or Refractory Lupus Nephritis: A Randomized
and Placebo-controlled Study. J Ren Nutr 2011.
11. Jurenka JS. Anti-inflammatory properties of curcumin,
a major constituent of Curcuma longa: a review of
preclinical and clinical research. Altern Med Rev
12. Mito S, Watanabe K, Harima M, Thandavarayan
RA, Veeraveedu PT, Sukumaran V, et al. Curcumin
ameliorates cardiac inflammation in rats with
autoimmune myocarditis. Biol Pharm Bull
13. Zhong F, Chen H, Han L, Jin Y, Wang W. Curcumin
attenuates lipopolysaccharide-induced renal
inflammation. Biol Pharm Bull 2011;34(2):226–32.
14. Xie L, Li XK, Takahara S. Curcumin has bright
prospects for the treatment of multiple sclerosis. Int
15. Mythri RB, Veena J, Harish G, Shankaranarayana
Rao BS, Srinivas Bharath MM. Chronic dietary
supplementation with turmeric protects against
neurotoxicity in vivo: implications for Parkinson’s
disease. Br J Nutr 2011;106(1):63–72.
16. Banji D, Pinnapureddy J, Banji OJ, Saidulu A, Hayath
MS. Synergistic activity of curcumin with methotrexate
in ameliorating Freund’s Complete Adjuvant induced
arthritis with reduced hepatotoxicity in experimental
animals. Eur J Pharmacol 2011.
17. Deodhar SD, Sethi R, Srimal RC. Preliminary study on
antirheumatic activity of curcumin (diferuloyl methane).
Indian J Med Res 1980;71:632–4.
18. Holt PR, Katz S, Kirshoff R. Curcumin therapy in
inflammatory bowel disease: a pilot study. Dig Dis Sci
19. Hanai H, Iida T, Takeuchi K, Watanabe F, Maruyama
Y, Andoh A, et al. Curcumin maintenance therapy for
ulcerative colitis: randomized, multicenter, double-
blind, placebo-controlled trial. Clin Gastroenterol
the complementary approach
Enquires » Email: email@example.com » Phone 1300 369 772 » Fax: 1300 369 771
It’s time to leave university and start
your career as a registered pharmacist
National Intern Training
Benefits of PSA NITP
• Exceptional support, helping you
• Content and connections to get
your career off to a flying start.
• A one-stop shop for your CPD.
• $1,000 of additional extras.
The NITP is a comprehensive, high quality
program with a flexible delivery method.
PSA’s experience has ensured NITP is in tune
with your needs, supporting you to achieve
your goal of becoming a competent and
Visit www.psa.org.au/intern to find out more.
Links Archive November 2011 September 2011 Navigation Previous Page Next Page