When high-dose fish oil is added to traditional “triple therapy” in early rheumatoid arthritis (RA), patients are more likely to have good outcomes, according to an Australian study published recently online in the Annals of the Rheumatic Diseases.

RA is an inflammatory, autoimmune disease in which the body mistakenly attacks the lining of the joints, resulting in inflammation, pain and joint destruction. To control symptoms and stop joint damage, rheumatologists usually try one or a combination of disease-modifying antirheumatic drugs (DMARDs). One effective and often-used combination is methotrexate, sulfasalazine and hydroxychloroquine – dubbed “triple therapy” – but it doesn’t work for everybody.

Fish oil, which contains anti-inflammatory omega-3 fatty acids has been shown in previous studies to reduce inflammation and pain associated with RA – and to allow patients to cut back on the use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen.

“We wanted to determine whether fish oil, in appropriate anti-inflammatory doses, had additional benefits in terms of disease modifying capabilities beyond the symptomatic benefits such as reduced joint swelling and pain,” says lead study author Susanna M Proudman, a clinical associate professor at the University of Adelaide, in Australia. “The effect [of fish oil] on traditional disease-modifying antirheumatic drugs was unknown.”

For this randomized, double-blind study, the researchers focused on patients with “early” RA (those who had had RA symptoms for less than 12 months) but had not yet been treated with DMARDs. Patients were divided into two groups: those in the high-dose fish oil group got 5.5 grams of fish oil per day while those in the low-dose group (which served as the control group) got 0.4 grams per day.

Patients also received triple therapy in a “treat-to-target” approach. Treat-to-target means that medication is adjusted at doctor visits if a patient doesn’t reach a predetermined treatment target of remission or low disease activity (as measured by blood tests and the number of tender/swollen joints). Patients were assessed every three weeks for the first 12 weeks and every six weeks thereafter. 

The study found that at one year, just more than 10 percent of patients in the high-dose fish oil group had “failed” triple therapy compared to 32 percent of patients in the control group. The time to achieving remission was also significantly less in the high-dose fish oil group than in the control group. Additionally, significantly more patients in the high-dose fish oil group than the control group had tapered off NSAIDs (which was discouraged during the study) by 12 weeks.

“We’ve have many patients who went into remission from the disease with the treat-to- target approach,” says Dr. Proudman. “Adding a high dose of fish oil on top of it meant patients needed fewer steps and fewer DMARDs to control it.” The reason, Dr. Proudman explains, is that omega-3 fatty acids act like NSAIDs in the body.  

The results are good news for RA patients who now have another way to be proactive and manage their disease in a more natural way. “RA patients always ask about dietary and lifestyle changes that they can make, and the study highlights that fish oil that can be an attractive adjunct to traditional DMARD therapy,” says Linda Mileti, MD, a rheumatologist at Cleveland Clinic, in Ohio.  

“I would caution patients not to replace DMARD therapy with fish oil,” she adds. “But when used together, supplementing with 3 or 4 grams of fish oil looks like it can be helpful, especially since it can diminish NSAID use.” NSAIDs can have cardiovascular and gastrointestinal side effects.

There could be an extra bonus to taking fish oil as well. RA patients are at increased risk of cardiovascular problems, points out Dr. Mileti. “Fish oil is already known to confer additional cardiovascular protections.”

But just eating fish won’t be enough to get a therapeutic dose of fish oil; a supplement will be necessary. “Fish oil is readily available, but the key is to take a sufficiently high dose to get therapeutic benefits,” says Dr. Proudman.