BACKGROUND:A good friend of the family asked me over Christmas if there were any herbal remedies for gout. This condition is characterised by hot, tender, swollen joints due to high levels of uric acid. Gout used to be called the rich man's disease because it was more prevalent in those with diets high in meat, seafood and alcohol. It can have a genetic component or be triggered by certain medications.
Very few herbal remedies are recommended for gout. Gloriosa superba, a tropical vine, is the source of a drug called colchicine, which is used to treat the condition. The plant’s scientific name captures some of the beauty of its flowers. It is also called the flame lily or glory lily and the spectacular flowers have six separate flame-shaped parts with yellow, orange and red sections.
Gloriosa is the national flower of Zimbabwe and is increasingly popular as an ornamental bloom. Products containing the herb are becoming more available, especially traditional Indian or ayurvedic remedies.
The flame lily is used in many different ways in Africa and India, from killing lice to treating cancer. In India, a paste made from the roots is applied to inflamed joints and other painful conditions.
This is what led to the discovery that Gloriosa superba contains colchicine, which has been used to treat gout for thousands of years. Colchicine was originally isolated from the autumn crocus, but since the 1950s the flame lily has been regarded as a better source. The wild plant was over-harvested to the point that it became endangered. In Zimbabwe, it remains a protected plant. In India, it is cultivated commercially and the country supplies much of the world’s colchicine.
EVIDENCE FROM STUDIES
No studies were found using flame lily preparations. Colchicine purified from Gloriosa has been shown to be effective in animal studies. Several alkaloids with similar structures to colchicine have been found in Gloriosa and have similar effects. However, their activities and toxicities have not been studied extensively. Even colchicine has been examined in only a few controlled studies. The European League Against Rheumatism recommends colchicine and non-steroidal anti-inflammatory drugs, such as aspirin, as first-line treatments for acute gout flare-ups. However, the US Food and Drug Administration (FDA) did not formally approve colchicine for gout until 2009. Using legislation to encourage clinical trials of older drugs, the FDA granted a pharmaceutical company exclusive rights to market colchicine in the US for three years on condition that it conduct two randomised controlled trials.
In previous research on the product called Colcrys, the company had found preliminary evidence that lower doses over one hour could prevent many of the adverse effects and be as effective.
At the end of last year, the FDA ordered all other colchicine-only products off the market in the US. At the same time, the cost of colchicine went from $9 (€7) per 100 tablets to $485. The company says this is the only way to develop high-quality evidence for the safest ways to take colchicine. Others argue this is asking patients to pay for the research that private corporations should conduct. The company has provided a mechanism for US patients to be reimbursed if the higher costs impose financial hardship.
PROBLEMATIC ASPECTS
In traditional ayurvedic medicine, Gloriosa is one of the seven upavishas. These are semi-poisonous plants that are important as treatments, but toxic if used incorrectly. All parts of Gloriosa can be poisonous, causing diarrhoea, vomiting, stomach pain and burning. Ingesting large amounts can lead to seizures and death.
Colchicine and related compounds are blamed for these problems. The FDA received reports of more than 150 deaths and numerous adverse effects suspected to be due to colchicine. The problem appears to be that doses causing adverse effects are only slightly higher than those required to relieve gout.
RECOMMENDATIONS
Colchicine is available in Ireland on prescription only. In spite of its long traditional use, it can have serious side effects. As an older remedy, the research required to understand its strengths and weaknesses has not been conducted. Such studies are now under way through innovative, but controversial, FDA regulation.
Although colchicine is produced commercially from Gloriosa superba, using the herb to treat gout or any other condition could be dangerous. The amount of colchicine and its related alkaloids in any herbal remedy will be uncertain and variable. Colchicine in any formulation should be taken only under medical direction.
Dónal O’Mathúna has a PhD in pharmacy, researching herbal remedies, and an MA in bioethics. He is a senior lecturer in the school of nursing, Dublin City University
