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Health See other Health Articles Title: Early RA: Fish Oil Reduces Risk for Triple-DMARD Failure Medscape Medical News Editors' Recommendations Glucosamine, Chondroitin, Fish Oil May Reduce Inflammation Prednisone/MTX Tight Control Best First Step for Early RA Omega-3 Supplements May Lower Anxiety Fish oil doses high enough to provide 3.7 g/day of eicosapentaenoic acid plus docosahexaenoic acid significantly improved the efficacy of a "treat-to-target" protocol of combination disease-modifying anti-rheumatic drugs (DMARDs) in patients with early rheumatoid arthritis (RA), researchers report in an article published online September 30 in the Annals of the Rheumatic Diseases. Susanna, M. Proudman, MBBS, from the Rheumatology Unit at Royal Adelaide Hospital in Australia, and colleagues conducted the first randomized controlled study to examine the effects of fish oil in patients with recent-onset RA treated according to contemporary treat-to-target protocols with triple DMARD therapy. "Fish oil should be considered part of standard care for early RA," Dr. Proudman told Medscape Medical News. "In addition to symptomatic benefits and [nonsteroidal anti-inflammatory drug]-sparing effects in early RA, use of fish oil is associated with greater success rates with triple therapy and reduced need for additional DMARDs. It is safe and has additional collateral benefits of particular relevance to patients with RA, including reduced cardiovascular risk." The researchers randomly assigned 140 patients with RA of less than 12 months' duration and no exposure to DMARDs to receive either high-dose fish oil (n = 87) or control, low-dose fish oil (n = 53). Patients in the high-dose group were assigned to take 5.5 g/day of eicosapentaenoic acid plus docosahexaenoic, but because of compliance issues, they only managed an average of 3.7 g/day. The patients in the control group were assigned to receive 0.4 g/day (for masking). All patients were also treated with methotrexate, sulfasalazine, and hydroxychloroquine, adjusted according to a rules-based algorithm to achieve disease suppression. Leflunomide was added once maximal tolerated doses of triple DMARD therapy were reached, and progression to leflunomide (a marker of failure of triple DMARD therapy) was the primary outcome measure. Fish Oil Decreased Triple-DMARD Failure by More Than Half At 1-year follow-up, 10.5% of participants in the high-dose fish oil group and 32.1% of those in the control group needed treatment with leflunomide. The triple DMARD failure hazard ratio, adjusted for smoking history, shared epitope, and baseline anticyclic citrullinated peptide, was 0.24 for patients in the high-dose group compared with the control group. Moreover, the high-dose fish oil group was more than twice as likely as the control group to achieve American College of Rheumatology remission. "Because a structured treatment algorithm that was responsive to disease activity and tolerance was used, drug use could be used as an outcome measure for the effects of fish oil. Rather than using the disease activity in each group at the end of the study, the primary outcome measure is the number of increases in DMARDs required to reach the disease activity target; specifically, whether leflunomide needs to be added as initial triple therapy has failed to achieve the target disease activity. This is one of the novel features of this study, as the study design allows for a [randomized controlled trial] to be performed on a background of treat-to-target therapy, now considered a best practice approach to the treatment of RA. Furthermore, although the mean disease activity achieved in the high- and low-dose fish oil groups was no different, more patients taking [the] high dose had disease suppression to the level of [American College of Rheumatology] remission," Dr. Proudman said. "The decreased intensity of DMARD use for effective disease control in the fish oil group is an important finding because their failure can lead to use of costly biological agents," she added. How to Get Patients to Swallow 2 Teaspoons of Fish Oil Dr. Proudman said that to make the high dose of fish oil tolerable, patients took it as 10 mL (about 2 teaspoons) of liquid oil layered on a small volume (25 mL) of orange juice. "Patients were advised to swallow it in one gulp on an empty stomach and to wash it down with a small glass of orange juice before consuming a solid meal, preferably at the end of the day. These strategies minimize the time the oil spends floating in the stomach and, hence, repeating of the fishy taste. Other strategies to improve tolerability include reducing the volume further by using a double concentrate of oil, using a citrus-flavored oil, and encapsulating the oil, although the same volume of oil is required to provide the same dose, so the total number of capsules required is 7 to 12, depending on the concentration of the oil," Dr. Proudman said. Adequate Doses of Fish Oil May Become Adjuvant to DMARDs "Previous studies of fish oil in patients with established [RA] have demonstrated only modest benefit. However, in this study of patients with [RA] of less than 1 year's duration, high-dose fish oil given in combination with triple therapy using a "treat-to-target" approach increased the proportion of responders, as compared to the administration of low-dose fish oil. Thus, adequate doses of fish oil may be an effective adjunct to traditional [DMARD] therapy in patients with [RA] of recent onset," said Jonathan Kay, MD, director of clinical research in rheumatology and professor of medicine at the University of Massachusetts Medical School in Worcester. Dr. Kay was not involved in the study. The study was supported by the National Health Medical Research Council of Australia, the Royal Adelaide Hospital Research Committee, and Melrose Health. The authors, Dr. Kay, and Dr. Matteson have disclosed no relevant financial relationships. Post Comment Private Reply Ignore Thread
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