The clinical approach to diagnosis and treatment of rheumatoid arthritis (RA) has dramatically shifted in the last 5-10 years. Most rheumatologists recognize the need for early intervention and aggressive management.

As a result, early institution of disease-modifying anti-rheumatic therapy and biologic drugs are currently the treatment approach adopted by most specialists.

However? while these new medications are extremely effective, they do have significant potential side effects. This is particularly true for patients who take non-steroidal anti-inflammatory drugs (NSAIDS) as part of their treatment program.

NSAIDS have been associated with the development of stomach and intestinal ulcers, kidney and liver dysfunction, bone marrow issues, and skin photosensitivity, among other problems.

As a result, many patients have elected to look for more ?natural? types of therapies.

Naturally occurring compounds with anti-inflammatory effects have been written about extensively. A number of herbs as well as foods with anti-inflammatory effects have been mentioned in the literature.

Unfortunately, many of these compounds have not been scrutinized using the classic scientific method of double-blind placebo controlled study design.

A recent study though, looking at the beneficial effects of cod liver oil has demonstrated effectiveness in a rigorously controlled study.

In the April, 2008 issue of Rheumatology, researchers evaluated the anti-inflammatory effects of cod liver oil in rheumatoid arthritis. (Galarraga B et al. - Cod liver oil supplements containing n-3 fatty acids can be used as NSAID-sparing agents in RA patients. Rheumatology 4:2008).

The study's purpose was to determine whether cod liver oil supplementation helped reduce daily non-steroidal-anti-inflammatory drug requirement of patients with RA.

Ninety-seven RA patients were randomized to take either 10 grams of cod liver oil containing 2.2 grams of omega-3 fatty acids or air-filled identical placebo capsules.

Documentation of NSAID daily requirement, clinical and laboratory measures of RA disease activity and safety checks were done at 0, 4, 12, 24 and 36 weeks.

At 12 weeks, patients were instructed to gradually reduce, and if possible, stop their NSAID intake.

Relative reduction of daily NSAID requirement by more than 30 per cent after nine months was the primary outcome measure.

Sixty per cent of patients completed the study.

Thirty-nine per cent in the cod liver oil group and 10 per cent in the placebo group were able to reduce their daily NSAID requirement by more than 30 per cent.

No differences between the groups were observed in the clinical measures of RA disease activity or in the side-effects observed.

While the response as far as symptoms was somewhat disappointing, other studies have shown an improvement in symptoms in patients taking cod liver oil.

The important issue here is that NSAID requirement was reduced and that can be presumptive evidence of the anti-inflammatory effects of cod liver oil.

The best treatment approaches involve a combination of conventional and natural. Close communication between the patient and the physician is required.