A presentation by Dr. Swamy Venuturupalli, MD, FACR from Lupus LA's annual patient education conference at Cedars Sinai Medical Center in Los Angeles, CA. Dr. Swamy Venuturupalli is a board-certified rheumatologist practicing in Los Angeles. He is Clinical Chief of the Division of Rheumatology at Cedars Sinai Medical Center and Associate Clinical Professor of Medicine at UCLA as well as being Editor-in-Chief of Current Rheumatology Reports. Dr. Venuturupalli grew up in Bombay, India, the son of two physicians. In 1995, he received his medical degree from the prestigious Topiwala National Medical College in Bombay. Dr. Venuturupalli completed his residency in Internal Medicine, with distinction, at the Upstate Medical University in Syracuse, NY. Following his residency, he was appointed Chief Resident in the department of medicine at Syracuse University, where he was in charge of managing and training 65 residents. In 1999, Dr. Venuturupalli moved to Los Angeles for a combined fellowship in health services research with UCLA's School of Medicine, the RAND Corporation, and the Greater Los Angeles Veteran's Administration Medical Center. Along with his cohort, he conducted research on complementary and alternative medicine, publishing studies on Ayurvedic medicine, dietary supplements, and mind-body medicine. Dr. Venuturupalli then completed a rheumatology fellowship at the UCLA-Olive View medical program in 2002. Dr. Venuturupalli's role as research investigator includes over a hundred clinical trials involving conditions such as lupus, rheumatoid arthritis, inflammatory muscle diseases, ankylosing spondylitis, etc. He participates in ongoing rheumatology research with Dr. Daniel Wallace, a leading physician in the field, at the Cedars Sinai Division of Rheumatology. Dr. Venuturupalli lectures frequently to the general public and to the staff and faculty at Cedars Sinai Hospital on various topics in rheumatology, including alternative and complementary medicine. He was also recently invited to give grand rounds at Cedars on topics such as antiphospholipid syndrome and myositis. Dr. Venuturupalli has authored numerous text-book chapters, is published in peer-reviewed journals, and is currently the Editor-in-Chief of the journal Current Rheumatology Reviews. For the past eight years, Dr. Venuturupalli has held a private practice in association with a group of 4 rheumatologists. Dr. Venuturupalli is highly regarded by his colleagues and is a sought-after teacher in his field of expertise. He has served as the past president of the Southern California Rheumatology Society, a non-profit professional organization of rheumatologists focusing on professional education. Areas of expertise: Inflammatory Muscle disease, Systemic Lupus Erythematosus, Anti- Phospholipid syndrome, Sjogren's syndrome, Osteoporosis, Vasculitis.

1. Complementary and Alternative
Therapies for Lupus
Swamy Venuturupalli, MD, F.A.C.R
Attending Physician, Cedars Sinai Medical Center
Asst. Clinical Professor of Medicine, UCLA.
8737 Beverly Blvd, Los Angeles, CA. 90048

2. Definition
• Complementary and Alternative medicine
includes all those types of medicine that,
when mentioned by a patient, elicit a blank
look from their physicians, and cause the
physician to leave the room in a hurry.

3. NCCAM Definition
• Complementary and alternative medicine,
as defined by the National Center for
Complementary and Alternative Medicine
(NCCAM), is a group of diverse medical
and health care systems, practices, and
products that are not presently considered to
be part of conventional medicine.

4. Classification of Alternative medical
modalities
Alternative Medical
Systems
Alternative medical systems are built
upon complete systems of theory and
practice.
Homeopathy, Ayurvedic
medicine and Traditional
Chinese Medicine.
Mind-Body
Interventions
Mind-body medicine uses a variety of
techniques designed to enhance the
mind's capacity to affect bodily
function and symptoms
meditation, prayer, mental
healing, and therapies that
use creative outlets such as
art, music, or dance
Biologically Based
Therapies
Biologically based therapies in CAM
use substances found in nature, such
as herbs, foods, and vitamins
dietary supplements, herbal
products and neutraceuticals
Manipulative and
Body-Based Methods
Based on manipulation and/or
movement of one or more parts of the
body
chiropractic, massage
therapy or osteopathic
manipulations
Energy Therapies Energy therapies involve the use of
energy fields. They are of two types:
biofield therapies, and biomagnetic
based therapies
qi gong, reiki, and
therapeutic touch

5. Usage
• 4 out of 10 Americans used CAM for chronic
conditions
• 629 million visits with $27 billion being spent in
year
• Estimated that 60-90% of patients with Arthritis
have used CAM.

6. CAM usage in SLE
• About 65% of SLE patients have been reported to
have used CAM in some studies
• Lupus patients who use CAM tend to be younger
and better educated
• They seem to report poorer self-rated health status,
and less satisfaction with healthcare. However,
when objective measures of disease activity are
looked at, these patients are not sicker.

7. CAM therapies used by lupus
patients
• Relaxation techniques
• Massage therapy
• Herbal medicine
• Lifestyle diets
• Self-help groups
• Imagery
• Folk remedies
• Spiritual healing
• Chiropractic
• Megavitamin therapy
• Homeopathy
• Energy healing
• Acupuncture
• Hypnosis
• Copper bracelets/magnets

8. Topics of discussion
• Appeal of alternative approaches
• Difference between approaches
• How does one choose- Role of Science
• CAM therapies that have some clinical trial data
for use in lupus patients
• Other therapies
• How does one choose- the way forward
• Resources

9. Appeal of Alternative therapies
• Recent research has shown the following
reasons associated with seeking alternative
therapies
– Offer hope
– Lifestyle choice
– Psychological distress

10. Difference between approaches
• Case 1: Ms. A who has SLE
• Naturopath’s opinion
• Traditional Chinese medicine
• Rheumatologist’s opinion

11. How does one choose-the role of
science
• 1992- establishment of office of alternative
medicine
• The Randomized Controlled Trial- Gold standard
of measurement
• Criticism of this approach
– Only western medicine can be tested using this
approach
– What about experience gained over thousands of
years?
– How do you deal with thousands of therapies out
there which have no scientific data, but are popular or
have shown benefit in someone you know?

12. Evidence Based Medicine
• Grades of evidence
– Case reports
– Case series
– Case controlled studies
– Cohort studies
– Randomized controlled trials

13. Nutritional studies
• Protein and caloric restriction has beneficial effects
– Severe caloric restriction delays the onset of
glomerulonephritis in rats
– Protein restriction especially of casein, phenylalanine,
and tryptophan have a beneficial effect on lupus in rats
– diets rich in saturated fats and omega-6 fatty acids, and
L-canavarine (alfalfa) have a deleterious effect on lupus
in mice
– Diets deficient in zinc were found to be beneficial in
lupus rats
– No human studies to date have confirmed these
findings

14. Nutritional studies
• Vitamin E has been advocated for lupus patients
since the 1940’s.
• Several positive studies have been reported
• A closer look at the literature shows several
negative studies as well
• A recent meta-analysis of literature showed that
high dose vitamin over 400IU per day was
associated with a higher mortality and higher
incidence of heart attacks and strokes.

15. Nutritional studies
• Vitamin A has been reported to have beneficial
effects in SLE
• 3 patients with skin lesions were given vitamin A
in high doses. In 1 week all lesions cleared up
• Other researchers have reported an improvement
in immune function parameters with vitamin A
supplementation
• Caution advised to patients using vitamin A from
animal sources as these are fat soluble and can
accumulate and cause toxicity

16. Nutritional studies
• Selenium supplementation has been
reported to be beneficial in lupus mice.
• No human studies
• Caution advised as excess selenium can
cause diarrhea, vomiting, hair loss, skin
lesions and nervous system dysfunction

17. Omega 3 fatty acids

23. Omega-3 in lupus
• Majority of mice studies show that fish oils retard the
development of lupus in mice.
• Human studies show only modest results
• In 1 RCT, 8/17 lupus patients given 6-8 grams of fish oil per
day improved compared with 2/17 given placebo
• In 2 other uncontrolled studies, patients given large doses of
fish oil, did not show any improvements in DNA, immune
complexes, or renal parameters
• In a double blind study of 26 lupus patients who were
followed for 2 years, there was no improvement in renal
parameters or DNA antibodies. However, lipids did improve
in the treated group.
• In a small uncontrolled study of 9 patients with lupus, 30
grams of flax seed oil seem to confer some beneficial effects
on renal parameters and atherogenesis.

25. HERBS
• Considered to be safe because they are
natural
• Not regulated- are you getting what your
supposed to be getting?
• In traditional systems of medicine, these are
given as part of a multi-modality treatment

26. Clinical data
• Encouraging data in Arthritis (not lupus) was found for:
– Gamma Linolenic Acid (GLA)
• Evening primrose
• Borage seed oil
• Black currant seeds
– Devils claw
– Phytodolor
– Willow bark extract.
• Additional data for Trypterigium Wilfordii Hook
F. (thunder god vine)

27. Tripterygium Wifordii Hook F
(TWHf)
• Herb known as “thunder god vine”
• Used for over 2000 years in Chinese medicine
• Thousands of patients have reportedly been successfully
treated in China.
• Been used in 5 open trials- total of 249 patients with lupus
• Improved fever, rash, fatigue, lymphadenopathy and
laboratory abnormalities
• Some serious side effects such as gastrointestinal upset,
infertility, and suppression of lymphocyte proliferation. A
young man reportedly died from cardiac toxicity, and
teratogenicity has also been reported.

28. Herbs- conclusions
• Phytomedicines are multi-component systems, thus
defining potential mechanisms of action is not easy.
• They have weaker pharmacological effects on the
inflammatory mediator pathway, thus ADR’s are low.
• They cannot compete with synthetic drugs in severe cases
of pain, but they have a role in:
– mild to moderate chronic pain
– As a replacement for more toxic drugs
– More data on side effects and interactions needed: from
pts and PCP’s.

29. DHEA
• Naturally occurring adrenal steroid that is
secreted mainly as DHEA-sulfate
• Works as a substrate for androgens and
estrogens.
• Also has immunomodulatory effects,
primarily upregulation of IL-2 and
downregulation of IL- 6

30. DHEA
• Van Vollenhoven RF, Engleman EG, McGuire JL.
Dehydroepiandrosterone in systemic lupus erythematosus. Results of a
double-blind, placebo-controlled, randomized clinical trial. Arthritis
Rheum 1995; 38:1826-31.
• Petri MA, Lahita RG, Van Vollenhoven RF, et al. Effects of prasterone
on corticosteroid requirements of women with systemic lupus
erythematosus: a double-blind, randomized, placebo-controlled trial.
Arthritis Rheum 2002; 46:1820-9.
• Chang DM, Lan JL, Lin HY, Luo SF. Dehydroepiandrosterone
treatment of women with mild-to-moderate systemic lupus
erythematosus: a multicenter randomized, double-blind, placebo-controlled
trial. Arthritis Rheum 2002; 46:2924-7.

31. Dehydroepiandrosterone treatment of women with mild-to-moderate
systemic lupus erythematosus: a multicenter
randomized, double-blind, placebo-controlled trial.
• Large RCT, multi-center.
• 200mg prasterone per day
• 381 women enrolled
• 86/147 in the prasterone group v/s 65/146 in placebo group
had either stabilization or improvement in their disease
• Muscle aches and oral ulcers were less frequent in the
prasterone group
• The lipid profile improved significantly and complement
levels decreased
• Acne and hirsutism were the most frequent side effects, but
these were not severe
• In my practice I use it for symptoms of severe fatigue and for
cognitive difficulties
Arthritis Rheum 2002; 46:2924-7

32. Stress and Lupus
• Hard to define- major stress and minor stress.
• Psychological anxiety, high demand of self and job, poor
control of life, poor social support- these are surrogates that are
used to measure stress in scientific studies.
• There is a connection between stress and hormones- e.g. cortisol
• Stress has not been shown to cause lupus in multiple studies
• Stress can exacerbate lupus- shown in multiple studies
• Stress usually causes a worsening in the quality of life of lupus
patients
• Psychosocial factors can affect disease activity and quality of
life but not cause organ damage
• Coping with stress is associated with improvement in quality of
life.
Neuroimmunomodulation 2006;13:283–293

33. Psychosocial factors that might
positively affect adaptation
• Self-efficacy: A belief that one can perform
specific behaviors to achieve specific health
related goals
• Optimism: A stable tendency to believe that one
will experience good rather than bad outcomes
• Acceptance: Acceptance that one has a chronic
disease that may not completely get better

34. Psychosocial interventions
• Patient education
• Coping skills training
• Relapse prevention:
– Identification of early signs of relapse
– Rehearsal of cognitive and behavioral skills for
coping
– Provision of self-rewards for effective
performance of coping responses

35. The Effects of Daily Stress and Stressful Life Events on the
Clinical Symptomatology of Patients With Lupus Erythematosus
• 46 patients with lupus were followed for 6
months. They kept a daily diary of events and had
measurements of their lupus activity through
complement and DNA levels
• High intensity stressful events were not associated
with an increase in symptomatology
• On the other hand, daily stress was associated with
worse symptoms and when objective measures
were performed, a worsening of disease activity
was noted.
Psychosomatic Medicine 66:788-794 (2004)

37. Fatigue in systemic lupus
erythematosus: a randomized
controlled trial of exercise
• 93 patients with lupus were randomly
assigned to a graded exercise program,
relaxation program or usual care
• 16/33 in the exercise group were “very
much better”, compared with 8/29 in
relaxation group and 5/32 in the usual care
group.
• These results were statistically significant
Tench, CM. Rheumatology, 2003 - 171.66.120.158

38. Acupuncture
• What is Acupuncture?
• Qi and meridians- 12 primary and 8 extra-ordinary
meridians.
• Practitioners may use heat, pressure, friction, suction or
electric stimulation and lasers.
• Concept of Te qi or Te chi.
• Problems with a control group for acupuncture trials.
• Modern Acupuncture- incorporates pain mechanisms by
way of nervous, endocrine and immune mechanisms rather
than meridians.

39. Treatment of systemic lupus erythematosus by acupuncture. A
preliminary report of 25 cases.
• Acupuncture cannot alter the course of the
disease, though for some patients, certain
symptoms can be helped.
Feng, SF. Chin Med J (Engl). 1985 Mar;98(3):171-6.

40. CAM therapies used by lupus
patients
• Relaxation techniques
• Massage therapy
• Herbal medicine
• Lifestyle diets
• Self-help groups
• Imagery
• Folk remedies
• Spiritual healing
• Chiropractic
• Megavitamin therapy
• Homeopathy
• Energy healing
• Acupuncture
• Hypnosis
• Copper bracelets/magnets

41. Conclusions- Choosing the right
practitioner
– Get an accurate diagnosis
– Ask your doctor.
– Get information.
– Check references.
– Check qualifications.
– Consider the cost.

42. Conclusions- Danger signs
about a practitioner
• promises you can be "cured."
• tells you to stop or decrease prescription medications.
• advises a severely restricted diet
• insists you pay in advance for a series of expensive treatments
• cannot show you a license or a certificate from an approved
school or organization in his or her specialty
• advises you to keep the treatment a secret from your doctor, or
anyone else

43. Resources for more information
• Arthritis foundation: www.arthritis.org
• National Center for Complementary and
Alternative Medicine: www.nccam.nih.gov
• The arthritis foundation’s guide to
alternative therapies
• Johns Hopkins review of alternative
therapies for arthritis