In part one, I explained the basics of why we have inflammation and why chronic inflammation occurs. But, a healthy, functioning immune system is vital to monitor the body constantly for invading toxins, damaged or ageing cells and especially cells that are turning cancerous through a variety of mutations. Thus, we do not want to suppress the immune response completely but it is the excessive, overreaction with chronic inflammation which is a key component in the generation of all of our major killers, cardiovascular disease, cancer, Alzheimer's disease, diabetes, chronic lung disease, osteoporosis and auto-immune disease.
There are simple ways to monitor inflammation in the body. The classic cardinal signs of acute inflammation are heat, which includes fever, swelling, redness and pain. To give the example of acute arthritis (any condition with-itis in the word means inflammation e.g. arthritis is inflammation of joints), acutely arthritic joints demonstrate these four cardinal signs.
Chronic inflammation of a particular organ or part of the body may also demonstrate these for cardinal signs but this is not vital to make the diagnosis of chronic inflammation. A history of any of the above diseases indicates that there is the scenario of chronic inflammation occurring in the body.
There is a very simple blood marker known as hs-CRP which is also an indication of inflammation. The normal range for hs-CRP is 0 to 5 mg/L, but a normally functioning immune system typically has chronic levels below 1.5 mg/L. A number of studies have shown that persistent levels above 3 mg/L may suggest chronic inflammation and certainly in patients with these types of levels, there is an increased risk for cardiac events, as one example.
In states of acute inflammation such as untreated widespread cancers or acute infections, the hs-CRP levels maybe closer to 100 mg/L or above, a sure sign that there is a serious condition somewhere in the body.
In 2008, one of the world’s leading experts in the area of inflammation and especially its place in cardiovascular disease, Professor Paul Ridker from Harvard University, published in the New England Journal of Medicine, the Jupiter trial which was a trial of 17,800 healthy men and women with low LDL levels but an hs-CRP level above 2 mg/L. The people in this trial were given either rosuvastatin 20 mg daily or placebo and then followed for cardiovascular events. The average follow-up of the trial was only 1.9 years. It was demonstrated that rosuvastatin reduced LDL levels by 50% and hs-CRP by 37%. The rates of cardiac events were reduced to around 50%, however there were very low numbers of events in both treatment & placebo groups. This was the first trial that highlighted the potential benefits for reducing inflammation, regardless of cholesterol levels in people at intermediate risk for heart disease.
In 2017, Professor Ridker’s group released yet another trial in the New England Journal of Medicine. The trial included just over 10,000 patients with a prior history of heart attack, again hs-CRPs above 2 mg/L but this time used a pure anti-inflammatory agent known as canakinumab. The study clearly showed significant reductions in hs-CRP with around a 15% reduction in further cardiac events with this treatment. Most importantly, from this trial, those people with the biggest reduction in hs-CRP with the treatment had the most robust reduction in further cardiac events. In other words, the better the targeted reduction in inflammation, the better the response to treatment.
Interestingly, one of the sub-studies of the trial showed a very significant reduction in lung cancer in the people given canakinumab. This prompted the drug company Novartis, who produce this agent, to shift their focus to lung cancer rather than making this drug available for heart disease. Many other studies are being conducted at present of a number of strong anti-inflammatory agents and the cardiovascular world is eagerly awaiting the results from these trials.
At present, however, there are more generic anti-inflammatory agents that I use routinely to suppress chronic inflammation, depending on the clinical circumstances. There are quite a few natural agents which are very safe but not particularly powerful, the best known being the curcumin based products and omega three fatty acids, especially in the form of krill. There are a number of other herbal products that do have well described anti-inflammatory benefits and a particularly effective widespread group of agents known as polyphenols (these are basically strong plant chemicals) which have more global benefits for health but also work as anti-inflammatory agents. The Calabrian bergamot based products being the best examples here.
There has been a pharmaceutical agent available for a number of years for the treatment of gout and more recently in cardiology for pericarditis which over the past few years has been shown to work very well as an anti-inflammatory for atherosclerotic cardiovascular disease such as heart attack or stroke. I am now routinely using this agent, colchicine, for all my patients with chronic ischaemic heart disease.
Over the next few years will see an explosion of pharmaceutical anti-inflammatory therapies, most of which will be given by injection. But, watch this space, as there are a number of companies throughout the world developing skin patches with micro needles which in my view will markedly reduce the need for any injectables whatsoever, including vaccinations.
The key message from this two part series on inflammation, is that although some degree of inflammation is important in controlling diseases, it is vital to have balance in our immune system. Using the variety of anti-inflammatories, both natural and pharmaceutical appropriately, has been increasingly shown to be very beneficial for the management of many modern diseases. This is yet another example of the vital need for ongoing scientific research and trials in this area.
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