Pomegranate (Punica granatum) as an adjunctive therapy in rheumatic diseases: A systematic review

Rheumatic diseases, including rheumatoid arthritis (RA) and osteoarthritis (OA), are characterized by chronic inflammation and oxidative stress, leading to joint destruction and disability. Conventional treatments, while effective, often present residual disease activity and adverse effects, prompting interest in complementary interventions. Pomegranate (Punica granatum), rich in bioactive polyphenols such as punicalagins and ellagitannins, has demonstrated anti-inflammatory and antioxidant properties that may benefit patients with rheumatic diseases.

To systematically review clinical and preclinical evidence regarding the effects of pomegranate supplementation in the management of rheumatic diseases.

A comprehensive search was conducted in PubMed, Scopus, Web of Science, Cochrane, SciELO, and gray literature up to December 2024 following PRISMA 2020 guidelines. Eligible studies included randomized controlled trials (RCTs), observational studies, and preclinical models assessing pomegranate in RA, OA, and other autoimmune rheumatic conditions. Study quality was assessed using RoB 2, NOS, AMSTAR 2, and GRADE tools.

Seven studies met the inclusion criteria: five clinical trials (one pilot and four randomized controlled trials), one preclinical animal study, and one in vitro study. In RA, supplementation with pomegranate extract or juice resulted in significant reductions in DAS28 scores, ESR, and CRP, accompanied by enhanced antioxidant activity. In OA, four randomized trials demonstrated significant improvements in WOMAC, KOOS, and VAS scores, decreased inflammatory biomarkers (IL-6, TNF-α), and enhanced antioxidant capacity. Preclinical and in vitro models confirmed inhibition of key pro-inflammatory cytokines (TNF-α, IL-1β, IL-6), suppression of NF-κB and MAPK pathways, and preservation of cartilage integrity. No serious adverse events were reported across clinical trials, and pomegranate supplementation was generally well tolerated. The overall certainty of evidence was graded as low to very low, primarily due to small sample sizes, heterogeneous interventions, and short follow-up durations.

Pomegranate demonstrates promising anti-inflammatory and antioxidant effects that may complement conventional therapies in rheumatic diseases. However, due to the limited number of high-quality studies, findings should be interpreted with caution. Larger, well-designed, multicenter randomized controlled trials are warranted to confirm both efficacy and safety before clinical recommendation.