Memorandum submitted by the Arthritis Research Campaign HO 28
1.0 Brief introduction to the organisation and the submitter
1.1 The mission of the Arthritis Research Campaign is to improve the lives of people with arthritis by: funding high quality research into the cause, treatment and cure of arthritic conditions, translating the outcomes of research to benefit patients, educating health professionals and providing information to the general public. The charity was founded in 1936 and is the fourth largest medical research charity in the UK and the only charity in the UK solely dedicated to investigating arthritis in all its forms. The charity invests an average of £30million pounds every year in research, education and training.
1.2 The Arthritis Research Campaign does not receive any government or statutory funding and is therefore totally dependent on voluntary donations. Fundraising in the community is organised through a combination of voluntary fundraising branches, paid staff and charity shops. The charity has no conflict of interests to declare.
1.3 Professor Alan Silman, the Medical Director of Arthritis Research Campaign, makes this submission on behalf of the charity. In addition to his remit of developing and directing the research strategy for the Arthritis Research Campaign, he covers the charity's educational role which ranges from patient information to ensuring training for all health professionals. Prior to joining the charity in 2007 he was the director of the Epidemiology Unit in Manchester and had research interests in several areas of rheumatology. He has published over 500 original articles and several books, including being one of the five joint editors of the major international reference work 'Rheumatology'. He serves on several national and international committees which include, among others, membership of the Expert Advisory Group to the MHRA and Chair of the Op Telic Health Review Board, the MoD committee responsible for overseeing research on the health of servicemen and women in Iraq and Afghanistan.
2.0 Factual information
2.1 Some facts on arthritis: more than 6 million people in the UK have painful osteoarthritis in one or both knees. Prevalence increases with age with 1 in 5 adults aged 50-59 to almost 1 in every 2 adults aged 80+ having painful osteoarthritis in one or both knees.[i] It is thought that over 10 million people in the UK have a form of arthritis. The Arthritis Research Campaign is currently re-evaluating the prevalence of arthritis in the UK and hopes to publish the results by the end of 2009. In terms of the cost of arthritis, research has shown that 10 million working days were lost in 2006/7 due to musculoskeletal conditions, second only to stress, depression and anxiety.[ii] The cost to the UK of musculoskeletal conditions is £5.7billion annually[iii] and arthritis is the most common condition for which people receive Disability Living Allowance*.[iv]
* Disability Living Allowance (DLA) is a benefit for people who are so disabled, they have personal care needs, mobility needs or both. Claimants must be under 65.
2.2 Arthritis and alternative treatments: over 60% of people with arthritis or other aches and pains use some form of complementary and alternative medicine[v] - and claim different things work for them. Under this broad heading are included care from alternative practitioners such as chiropractic and osteopathy as well as the use of over the counter herbal and other ingested agents. Overall 46% of the UK population use complementary medicines at some point in their lives spending over £450 million per year.[vi] People with arthritis and musculoskeletal conditions, whose symptoms are often chronic, are particularly attracted to try such medicines and therefore need guidance to help them decide if such treatments may or may not be suitable for their arthritis and associated rheumatic conditions.
2.3 An evidence-based approach to homeopathy: in February 2009, the Arthritis Research Campaign published the first evidence-based report on the use of homeopathy and complementary medicines in arthritis using evidence from randomised controlled trials. A second report is underway on the use of complementary practitioners. A section within this report, written by the Arthritis Research Campaign in conjunction with national experts, is dedicated to homeopathy, which is defined by the Society of Homeopaths in England as "treating like with like" and based on an observation that symptoms of an illness are identical to those experienced by a healthy person treated for that illness. Homeopathic remedies are produced by a sequence of dilutions of an active substance causing similar symptoms in the belief that this will reduce the likelihood of harm.[vii] The report is a summary of existing published studies which indicates whether or not there is scientific evidence to support the clinical effectiveness and safety of certain named products for people with arthritis. The report also considered issues such as biological plausibility and ease of obtaining the treatments.
2.4 A simple way of communicating the information to the general public: the Arthritis Research Campaign score medicines according to their effectiveness with 1 indicating that there is no evidence that the compound works and 5 indicating that the compound is effective. It also grades the medicines according to safety, providing traffic light classifications for each.
2.4.1 Based on the evidence available from clinical trials with other supporting information, the Arthritis Research Campaign categorised each medicine into one of five categories:
1 = There is, overall, no evidence to suggest that the compound works or only a little evidence which is outweighed by much stronger evidence that it does not work.
2 = There is only a little evidence to suggest the compound might work. The evidence from studies in this category often come from only a single study which has reported positive results and there are therefore important doubts about whether it works.
3 = There is some promising evidence to suggest that the compound works. The evidence will be from more than one study. However there may also be some studies showing that it does not work. For a compound in this category however we are still uncertain whether it works or not.
4 = There is some consistency to the evidence, which will come from more than one study, to suggest that the compound works. Although there are still doubts from the evidence that it works, on balance we feel that it is more likely to be effective than not.
5 = There is consistent evidence across several studies to suggest that this compound is effective.
2.4.2 The research also included a categorisation of all compounds according to their safety profile. For many compounds it was not easy to do this because there was relatively little information available on safety. Where information was available, it was categorised, assuming that it is taken within the range of recommended doses. Compounds which are safe at the recommended doses may have serious adverse effects when taken at higher doses. Again, it should be emphasised that most conventional medicines have adverse effects, some serious. However, there is generally greater information available on conventional drugs in order to determine the frequency and range of such adverse effects. The categorisation used was:
Traffic light at Green Compounds with reported adverse effects which are mainly minor symptoms and infrequent. A classification of Green does not mean that the compound has no reported adverse effects and patients should check in the product information leaflet what these are.
Traffic light at Amber Compounds with adverse effects reported as common (even if they are mainly minor symptoms) or with more serious adverse effects.
Traffic light at Red Compounds with serious adverse effects reported. Patients should carefully consider these before deciding whether to take these medicines.
There were some compounds on which there was very little information on adverse effects and it was therefore not possible to classify them. Such examples are therefore indicated by traffic light at Amber together with "No information" written alongside.
2.5 Conclusion from the review of the evidence: homeopathic remedies are widely available over-the-counter in pharmacies and health food shops throughout the UK. The mechanism of action of these remedies is not clear. There is no evident safety risk with the use of these remedies, and interactions with other drugs are unlikely. Even though isolated reports have suggested positive effects of homeopathy in the treatment of fibromyalgia, evidence is still not conclusive. Trials which investigated the role of these remedies in osteoarthritis and rheumatoid arthritis yielded inconsistent results.
2.6 Relationship to Conventional Medicine: The Arthritis Research Campaign review also made clear that the effectiveness of homeopathic and other complementary medicines needs to be evaluated in part against that of conventional remedies for the same condition. Furthermore, as many patients take both kinds of treatment there is a need to consider interactions both in terms of effectiveness and safety.
3.1 That the Committee welcomes an evidence-based approach to homeopathy, (as well as other non conventional therapies available over the counter), that can be communicated directly with lay audiences, and that the Committee actively encourages further evidence-based assessments of homeopathic remedies in arthritis as well as other diseases, so that more information is available to assess any real benefits from homeopathy. This is particularly important in chronic, progressive diseases.
3.2 That the Committee considers the straightforward 1 - 5 categorisation process for efficacy and the traffic light system for safety used in the Arthritis Research Campaign's review described above, for all areas of homeopathy, so that patients can make better informed decisions.
3.3 That the Committee agrees that the efficacy and safety of homeopathic and other complementary medicines available over the counter need be evaluated against the conventional remedies for the same condition as well as potential interactions of other remedies that could be taken at the same time.
4.0 Supplementary material
Please find attached a pdf of the report, Complementary and alternative medicines for the treatment of Rheumatoid Arthritis, Osteoarthritis and Fibromyalgia, 2009. The report was written national experts in conjunction with the Arthritis Research Campaign.
[i] Peat G, Duncan R, Thomas E. Data from CAS-K study. Personal communication 2008
[ii] Health and Safety Executive. Estimated days (full-day equivalent) off work and associated average days lost per (fulltime equivalent) worker and per case due to a self-reported work-related illness or workplace injury. http://www.hse.gov.uk/statistics/tables/0607/swit1.htm [Date accessed: 13-5-2008]
[iii] Health and Safety Executive. Musculoskeletal disorders - Why tackle them? http://www.hse.gov.uk/healthservices/msd/whytackle.htm [Date accessed: 1-7-2008].
[iv] Department for work and pensions. Disability Living Allowance - cases in payment Caseload (Thousands): Main Disabling Condition by Gender of claimant. http://184.108.40.206/100pc/dla/disabled/ccsex/a_carate_r_disabled_c_
ccsex_nov07.html [Date accessed: 1-5-2008].
[v] Arthritis Research Campaign website (accessed December 2008) http://www.arc.org.uk/arthinfo/patpubs/6007/6007.asp
[vi] Thomas KJ, Coleman P. Use of complementary or alternative medicine in a general population in Great Britain. Results from the National Omnibus Survey. J Public Health 2004;26:152-7