The Evaluation Of Concurrent Supplementation With Vitamin E And Omega- 3 Fatty Acids On Plasma Lipid Per Oxidation And Antioxidant Levels In Patients With Rheumatoid Arthritis
S Kolahi, J Hejazi, J Mohtadinia, M Jalili, H Farzin
antioxidant, lipid peroxidation, omega- 3, rheumatoid arthritis, vitamin e
S Kolahi, J Hejazi, J Mohtadinia, M Jalili, H Farzin. The Evaluation Of Concurrent Supplementation With Vitamin E And Omega- 3 Fatty Acids On Plasma Lipid Per Oxidation And Antioxidant Levels In Patients With Rheumatoid Arthritis. The Internet Journal of Rheumatology. 2010 Volume 7 Number 1.
Rheumatoid Arthritis (RA) is a chronic inflammatory disorder which can cause oxidative stress . The prevalence of RA among adults is 1 to 2% worldwide and it is three times more prevalent in females than males [2, 3]. The main characteristic of the disease is inflammation of synovial membrane with swelling and pain that ultimately leads to the destruction of cartilage and bone .Routine clinical practices in management of rheumatoid arthritis aim at reducing the patients’ pain and joint inflammation, minimizing loss of function and decrease the progression of joint damage. However, some pharmacological therapies such as non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids have the potential to cause side-effects and rarely effective . As a result, many studies have focused on finding some complementary methods to reduce the dose of drugs or to improve the outcomes. One of these complementary treatments is supplementation with omega 3 fatty acids [4, 5].Previous studies have shown Eicosapentaenoic acid (EPA) and Decosahexaenoic acid (DHA) effects on reduction of inflammatory cytokines . In meta-analysis of randomized- controlled clinical trials (RCTs), it has been suggested that Omega-3 fatty acids can reduce pain, stiffness and the number of painful and swelling joints for 3 months . However, the effect of these fatty acids on serum antioxidant levels is not well defined. In a study assessing the effect of Omega-3 fatty acids fed mice, a significant reduction of plasma vitamin E levels has been detected . Another study on healthy people, who took the Omega-3 fatty acids supplements, showed an increase in serum malondialdehyde (MDA) levels which is an indicator of lipid peroxidation . Thus, combined supplementation with Omega-3 fatty acids and vitamin E can be a solution. In RA patients, reactive oxygen species (ROSs) such as superoxide, hydrogen peroxide and hydroxyl radicals are increased due to augmentation of inflammatory cytokines transcription. The antioxidant micronutrients like vitamin E are a part of antioxidant defense system in the body and can reduce ROSs which can result in integrity of cells and improvement of clinical outcomes of RA . A recent molecular study reported an anti-inflammatory role for vitamin E supplements and the need for higher doses of analgesics was reduced when alfa-tocopherol supplements in addition to aspirin, were used .In the present study, the effect of omega-3 fatty acids and vitamin E supplements were assessed on clinical outcomes, plasma lipid peroxidation and antioxidant levels of RA patients.
Material and Methods
This randomized double-blinded placebo controlled trial was conducted in a 12-week period on female patients with active RA, between April 2008 and November 2008. The study population was selected from 400 registered female RA patients in outpatient clinics of Sina and Sheikh Al- Raees educational clinics of Tabriz University of Medical Sciences in Tabriz, Iran. The inclusion criteria were ages between 20 -70 years, having RA based on 1987 American College of Rheumatology criteria and having stable treatment protocols during the past 2 months.
The demographic characteristics and medical drug use history were obtained by face-to-face interview. Body mass index (BMI) of the patients was determined using Quetelet’s index [BMI= Weight (Kg)/Height (m2)].The exclusion criteria were no desire to participate in the study, history of diabetes mellitus, hypothyroidism, nephritic syndrome, abnormal hepatic or renal function, Cushing’s syndrome, obesity, gastrointestinal disorders and fat mal absorption, taking vitamin E or Omega-3 fatty acids supplements and drugs such as blockers, Angiotensin converting enzyme inhibitors (ACEI), Oral contraceptives and smoking. Ninety patients were randomly assigned to one of three groups receiving Omega-3 (group O, n = 30), vitamin E- Omega-3 (group EO, n = 30) or placebo (group P, n = 30). 1 g Omega-3 capsules were prescribed daily (180 mg EPA and 120 mg DHA). The daily dose of vitamin E (Alfa-tocopherol acetate) was 400 international units (IU).The participants didn’t change their usual diet, physical activity and medications throughout the study. All of the patients were examined by the same rheumatologist in every visit. Pain was measured by visual analog scale (VAS) using a 0-100 mm scale. The disease activity was determined by physical exams (morning stiffness, joint pain, tenderness and swelling) and biochemical analysis [high-sensitive C-reactive protein (hs-CRP) levels]. Disease activity score (DAS 28) was determined by LN-63 calculator, made by Bristol-Myers Squibb company. Plasma total antioxidant (TAO) of the patients was estimated by using Randox Total Anti Oxidant Status test kit in serum (Randox Laboratories Ltd, UK) , Plasma superoxide dismutase (SOD) enzyme activity by Ransod spectrophotometric kit (Ransod, Randox Laboratories Ltd. UK), Plasma Glutathione peroxidase (GPX) enzyme activity by Ransel spectrophotometric kit (Ransel, Randox Laboratories Ltd. UK). Serum C-reactive protein was measured by two point immunoturbidimetric method using a kit produced by Parsazmun (Lot. No.83001). All of these procedures were completed using auto analyzer apparatus (Alcgon-Abbott, USA). Malondialdehyde (MDA) concentration was measured using MDA reaction with thiobarbituric acid followed by extraction with butanol. The optic density (OD) of the aqueous extract was measured spectrophotometrically at 532 nm wavelength and compared with standard curve .Energy and nutrient intakes were measured using a 3-day 24-h recall (two week days and one weekend day). The information was obtained through face to face interview and standard food models. A variety of measuring tools were used to evaluate intake. Nutrients were analysed by Nutritionist III software, version 7.0 (N-Squared computing, Salem, OR, USA), which was modified for Iranian foods. A written informed consent was obtained from all participants. The research proposal was approved by both the institutional review board and the ethics committee of Tabriz University of Medical Sciences (ethics committee approval number 8071). The omega-3, vitamin E and placebo capsules did not have any side effects. Statistical analyses were done using SPSS Software
Of the 90 patients involved in the present study, 82 persons completed the study. Eight patients were excluded from the study due to either Unrelated medical problems (1 patients) or inaccessibility to rheumatologist’s office (5 patients) or lack of desire to complete the task (2 patients)(fig. 1). There were no significant differences among the three groups at the beginning of the study regarding age, disease duration, use of medication and body mass index (BMI). The used type and dose of medications were not significantly different between the three groups. Also, there were no significant difference in clinical outcomes (DAS-28, joint pain and swelling and VAS) between the three groups at the base line. After that intervention was completed, the changes in clinical outcomes were not significantly different among the three study groups and none of the interventions could improve the signs and symptoms (Table 2).The biochemical markers used in this study were SOD , GPX activity and TAC to assess anti oxidant capacity of plasma, MDA to test lipid peroxidation and CRP to evaluate inflammation. Among these biochemical markers, only MDA levels were significantly decreased in EO group comparing to two other groups after completion of the intervention. After intervention,
1- BMI: body mass index * - the data are expressed in mean ± SD ** - the data are expressed in percentage (number) †-OE: omega-3-vitamin E ‡-O: omega-3 •-P: placebo
- DAS: disease activity scale 2- VAS: visual analog scale * - The data are expressed in mean ± SD. †-OE: omega-3-vitamin E ‡-O: omega-3 •-P: placebo **- The p-values refer to differences between the EO, O and P groups concerning the change from baseline to week 12. Differences between the groups were analysed by ANOVA or Kruskal-Wallis tests. There was no statistically significant change from baseline to week 12. Withingroup differences at week 12 compared to baseline were evaluated by Paired t-test or Wilcoxon signed ranks test.
To the best of our knowledge, this randomized, double-blind, placebo controlled clinical trial was the first study to assess the effect of both omega-3 and vitamin E supplements on plasma antioxidant capacity in RA patients. In the present study intake of several nutrients such as vitamin E and C, selenium, PUFA, etc. which could have confounding effect on the data interpretation was assessed. Also we assessed the effects of omega-3 and vitamin E supplements on clinical outcomes and lipid peroxidation of RA patients. Although , the clinical outcomes of the patients were not improved significantly in any of groups, we found a significant reduction in MDA levels of EO group comparing with other groups.There are many types of reactive oxygen species (ROS) in the cellular environment of RA patients which can lead to lipid peroxidation and production of MDA. A recent study showed that vitamin E levels in RA patients were lower and MDA levels were higher than healthy control group . Another study also showed that 2.4 g/d of fish oil consumption for 3 months in healthy women could decrease vitamin E levels after 1 month and increase lipid peroxidation and MDA production after 2 months . Similar to other studies, the patients in this study had high levels of serum MDA and EO group was the only group with reduced MDA levels. A study by Palozza
In conclusion, concurrent supplementation with Omega-3 fatty acids and vitamin E reduced oxidative stress , lipid peroxidation compared with fish oil alone or placebo in female RA patients. However, it did not affect the activity of antioxidant enzymes, TAC, clinical outcomes and disease activity score.