Introduction
What should I know about Rheumatoid Arthritis?
Rheumatoid arthritis (RA) is an autoimmune condition, causing inflammation commonly in the small joints of the hands, wrists and feet leading to pain, stiffness and swelling. Causes of RA is unknown, but several risk factors identified include smoking, obesity and exposure to air pollution. Women and older people have a higher risk of developing RA although it might affect people at all age. It should not be mistaken as common joint pains suffered among elderly such as Osteoarthritis. RA often painful and disabling, requiring lifelong pharmacological management.
RA condition is chronic , systemic, and symmetric, causing persistent painful swelling of joint tissue, which eventually leads to bone erosion and deformity. As there is no cure, it may progressively worsen by affecting the heart, lung and nervous systems (51)
One distinguishing feature of RA is the appearance of prominent bony lumps called “nodules” over joints.
Rheumatoid arthritis is usually chronic, although people with the disease sometimes go into spontaneous remission. (1) The chronic inflammation of RA covers the synovial membrane with a mass of tissue called “pannus.” Filled with inflammatory cells and erosive substances, pannus eats away the underlying cartilage and bone, leading to destruction of the joint. While the exact cause of rheumatoid arthritis has not been determined, a number of factors can help trigger the inflammatory process including genetics, (2) stress, (3) poor nutrition, (4) and bacterial infection. (5)
Heavy metals such as mercury, cadmium, and lead are possible contributing factors in RA. One study reported that these toxic metals could interfere with the body’s ability to manufacture collagen, the tough, fibrous protein that acts like a steel girder in cartilage. Chelation therapy may be helpful for rheumatoid arthritis patients with elevated levels of heavy metals. This therapy consists of a series of treatments using EDTA, a synthetic amino acid that removes heavy metals from the body, administered intravenously. EDTA chelation, though controversial, has been tested and found at least partially beneficial in a number of diseases, including RA.
Stress is an important issue in rheumatoid arthritis. Chronic stress can exact a heavy toll on the immune system. Stress is linked to both the onset and worsening of RA, and flare-ups are often preceded by a stressful event. (6) Stress reduction can help. In one study, RA sufferers who followed a stress management program had less pain and feelings of helplessness, while their coping skills, sense of empowerment and overall health improved. These improvements were still evident 15 months later. This study underscores the value of learning stress management skills for individuals with rheumatoid arthritis. (7)
Statistic
World Health Organization, 2023.
- In 2019, 18 million people worldwide were living with rheumatoid arthritis
- About 70% of people living with rheumatoid arthritis are women, and 55% are older than 55 years
- 13 million people with rheumatoid arthritis experience severity levels (moderate or severe) that could benefit from rehabilitation
Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021.
- In 2020, an estimated 17·6 million people had rheumatoid arthritis worldwide, an increase of 121% since 1990
- Rheumatoid arthritis mortality has decreased globally over the past three decades
Arthritis Foundation, 2011.
The prevalence of Rheumatoid Arthritis (RA) in Malaysia is 5 in 1000 people
Signs and Symptoms
The symptoms of RA usually develop gradually over several weeks to months. Initial symptoms include fatigue, weakness, low-grade fever, loss of appetite, and joint pain. The hands, feet, and wrists are the most common places where RA joint pain is felt, although the elbows, shoulders, hips, knees, and ankles may also be involved. Joint pain and stiffness often precede any noticeable swelling. Joint stiffness is typically worse in the morning.
The swelling of the joints may or may not be visible at first. In the early stages, swelling may only be apparent to a physician upon palpation of the joints. In RA, swelling results from accumulation of fluid and soft tissue, so it feels soft and spongy. This is an important differentiation between RA and osteoarthritis. In OA, swollen joints feel hard and bony rather than soft, and they are usually not inflamed like in RA. The hands are often affected early in the disease, with pain, swelling, tenderness, and grip weakness. Deformities of the hands may be seen in the chronic phase.
Whole body or large joint involvement
- Fatigue
- Weakness
- Low grade fever
- Loss of appetite
- Joint pain
- Stiffness, muscle aches
- Joint swelling
- Joint stiffness is typically worse in the morning
Hand or smaller joint involvement
- Pain or tenderness
- Swelling
- Weak grip
- Long term disease can lead to deformities in the affected areas
- Joint stiffness is typically worse in the morning
Treatment Options
Conventional
Conventional therapy for RA, in addition to drug treatment, includes rest, physical therapy, and weight reduction. Physical therapy can help through exercises to maintain range of motion. Weight loss relieves the stress that excess pounds can place on joints. Surgery may be advised to repair tendons and replace severely damaged joints. Joint replacement may be recommended.
Drug therapy starts with common pain relievers such as aspirin and other “nonsteroidal anti-inflammatory drugs” (NSAIDs). While they give temporary relief of inflammation, NSAIDS alone will not prevent the joint erosion that occurs in RA. Most rheumatologists like to combine drugs called “DMARDs” (disease modifying antirheumatic drugs) with “SAARD” (slow acting antirheumatic drugs). DMARDs include methotrexate, gold, hydroxychloroquine, sulfasalazine, azathioprine, and penicillamine. Of the DMARDs, methotrexate seems to produce the best long-term results with the least toxic side effects. Gold and hydroxychloroquine are options when methotrexate is either ineffective or ruled out for medical reasons.
“Corticosteroids” are a class of anti-inflammatory medications that can suppress the immune system in autoimmune diseases such as rheumatoid arthritis. Given early, they seem to slow the erosion of joints in RA. (8) Because of they have potentially severe side effects with long-term use; many physicians try to prescribe the lowest possible dose for the shortest possible treatment period.
Nutritional Suplementation
Type II Collagen
Collagen is a rope-shaped, fiber-like protein that gives cartilage its structural strength. Type II collagen extracted from chicken cartilage has been tested with some success as a non-drug therapy for rheumatoid arthritis. So far, the research is encouraging. Preliminary studies showing that type II collagen reduces inflammation in animals with experimentally induced arthritis have been followed by positive human trials. The results suggest type II collagen may be a safe and beneficial option for people with RA. In one study, 274 RA patients took either Type II collagen or a placebo (dummy pill) daily for 24 weeks. An interesting thing about type II collagen therapy is the very low dose. This trial tested four different doses: 20, 100, 500 or 2,500 micrograms (a microgram is extremely tiny—a mere thousandth of a gram). Patients on the lowest dose, 20 mcg, had the most improvement, and no side effects were reported. (9)
In another double-blind study, 60 patients with severe rheumatoid arthritis took small doses of chicken type II collagen mixed with orange juice for three months and had a 30 percent reduction in joint swelling and tenderness. Taken in very small doses like this, type II collagen works like a reverse vaccine. When the type II collagen contacts lymphatic tissue in the gut wall, the immune system gets a biochemical message telling it that type II collagen is an acceptable substance. The immune program which sees type II collagen as foreign invader shuts down, suppressing the autoimmune response to the type II collagen in joints. The immune system then stops attacking the joints. This is called “oral polarization”. There is nothing special about chicken collagen versus other types of animal collagen, except it is inexpensive and known to be safe and free of viruses and other contaminants. (10)
Vitamin E
As one of the primary fat-soluble antioxidant nutrients, vitamin E neutralizes free radicals in fatty environments like cell membranes. Research suggests that vitamin E has anti-inflammatory and pain killing capability. One double blind study compared the effect of high dose vitamin E against the drug diclofenac sodium in hospitalized RA patients. After three weeks of treatment, both vitamin E and diclofenac sodium reduced joint stiffness, improved grip strength, and relieved pain. Improvements were similar with both, in fact, the physicians conducting the study and the patients felt that vitamin E and the drug were equally effective. Since there is a risk of side effects in the long-term treatment of chronic rheumatoid arthritis with anti-inflammatory drugs, the authors suggest that high-dose vitamin E is a possible alternative. (11)
In other studies testing vitamin E as a treatment in RA, the results are much more modest. One double blind study of patients taking anti-RA drugs used a battery of clinical and laboratory tests to see if vitamin E could produce any additional anti-inflammatory or pain-relieving effects. The results were somewhat disappointing: vitamin E produced no clinically measurable changes in inflammation, although it did reduce pain. Still, the researchers concluded that vitamin E’s small but significant pain-relieving effect justifies using the vitamin as a complement to standard anti-inflammatory treatment. (12)
Vitamin C
Only a few studies have been published regarding vitamin C and rheumatoid arthritis. In one study, RA patients showed low levels of vitamin C in their blood and white blood cells. (13) (As part of the immune army, white blood cells use up vitamin C fighting infection.) In an animal study, vitamin C was injected into inflamed paws of rats with arthritis. After 20 days of daily vitamin C injections, inflammation and swelling diminished, the animals displayed greater pain tolerance. Based on these results, vitamin C is a supplemental treatment worth trying in RA.
Selenium
Selenium is an essential trace mineral that plays an important role in shoring up the body’s antioxidant defenses. Clues to its potential role in rheumatoid arthritis can be seen in studies showing that RA suffers have much lower than normal selenium levels. (14) , (15) Selenium has been tested clinically as an RA treatment. In a double-blind trial, patients were given 200 micrograms of selenium daily for three months. Interestingly, even though this dose is four times higher than the RDA for selenium, normal blood levels were not restored at the end of the third month. Yet by the study’s end, individuals receiving selenium had fewer tender or swollen joints, and less morning stiffness. They also needed lower doses of anti-inflammatory medication than people in a control group that did not receive selenium.
Most experts now recommend taking a good variety of antioxidant nutrients rather than high doses of a few.
Methyl Sulfonyl Methane (MSM)
Methyl Sulfonyl Methane (MSM) is a natural source of organic dietary sulfur now widely popular as a supplement. There are anecdotal reports of MSM reducing and even eliminating rheumatoid arthritis pain, although this has not been tested in controlled clinical trials. (16) MSM has been researched for nearly twenty years at a university outpatient clinic, with beneficial results in a wide range of conditions.
Copper
Several older studies reported that some copper compounds could be useful in the treatment of rheumatoid arthritis. Copper has been tried in the form of a copper-aspirin chelate called “copper aspirinate.” (Chelated minerals are a form of mineral supplement that chemically bonds a mineral like copper to another molecule. Mineral chelates are generally believed to absorb better in the gut than mineral salts). Based on results from animal studies and uncontrolled human trials, copper aspirinate may work better as an anti-inflammatory than aspirin alone. (17) , (18)
Copper bracelets are an old folk remedy for arthritis. In a double-blind study comparing copper bracelets against copper-colored aluminum bracelets as a placebo (fake treatment), participants significantly preferred the copper bracelets. On average, the weight of the copper bracelets decreased 13mg in one month. This study suggests that small amounts of copper dissolves in body sweat and is absorbed. (19) In a more recent study, copper levels have been shown to directly correlate with symptom levels in patients with rheumatoid arthritis. (20)
Vitamin B5
Pantothenic acid (vitamin B5) has been tried in the past as a treatment for rheumatoid arthritis, with good results. One study published in a 1963 issue of a leading medical journal found below-normal levels of pantothenic acid in RA patients. The lower the levels, the more severe the disease was. (21) In a double-blind study, 18 rheumatoid arthritis sufferers who had not responded to drugs, were randomly assigned to receive either a placebo or 2 grams of pantothenic acid daily. The participants started with a dose of 500mg per day, gradually increasing to 500mg, four times daily by the 10th day. Within two months, individuals taking pantothenic acid reported significant declines in the duration of morning stiffness, degree of disability, and severity of pain, while the controls failed to make any significant gains. (22)
Zinc
Patients with active rheumatoid arthritis reportedly have blood zinc levels that are significantly lower than healthy people. When given a special liquid zinc solution that is used to test for zinc deficiency, healthy controls nearly doubled their blood zinc levels. In contrast, zinc levels in rheumatoid arthritis patients did not rise significantly. This indicates that patients with rheumatoid arthritis may have trouble absorbing zinc. (23)
Antioxidant Nutrients
Antioxidants such as vitamin A, vitamin C, vitamin E, selenium, and many others help rid the body of excess free radicals. Unstable byproducts of metabolism, free radicals cause no harm as long as they stay safely under control. (Free radicals are extremely short-lived molecules; the body is equipped with enzymes that defuse them as soon as they are formed.) Inflammation creates a lot of free radicals that contribute damage at the inflamed site. Antioxidants help unload the body’s free radical burden. Studies confirm that various antioxidant nutrients help chill inflammation and protect tissues from free radicals released in the inflammatory process. (24)
Omega-3 Fatty Acids
Clinical studies support the use of omega-3 fatty acids “DHA” and “EPA” in the treatment of rheumatoid arthritis. Taken in supplement form, omega-3 fatty acids have consistently reduced joint tenderness and stiffness. In these studies the fatty acid supplements were taken in combination with drug therapy. It generally takes a minimum of 12 weeks for the fatty acids to produce noticeable results. At a dose of 3,000 milligrams per day, omega-3 fatty acids prevent white blood cells from releasing chemicals that contribute to inflammation. There are anecdotal reports of RA sufferers successfully reducing or even discontinuing anti-inflammatory medications when taking omega-3 fatty acid supplements. While this sounds promising, more definitive studies are needed before it is known if omega-3 fatty acids can substitute for drug therapy. Omega-3 fatty acids have virtually no reported serious toxicity in the dose range used in rheumatoid arthritis and are generally very well tolerated. (25) , (26) One important note: people taking fatty acid supplements should also consume from 400 to 800 IU of vitamin E daily.
Gamma Linolenic Acid (GLA)
Ordinarily, the body makes its own GLA from linoleic acid, an omega-6 fatty acid found in vegetable oils. The enzyme-driven mechanism that converts linoleic acid into GLA can be impaired, however, opening the way for potential GLA deficiencies. The body uses GLA as a “precursor,” or building material so to speak, for a type of prostaglandin that controls inflammation. Prostaglandins are hormone-like substances found in various tissues. They are highly specialized; one type of prostaglandin actually causes inflammation, while others inhibit it.
Research reveals that GLA supplements can be beneficial for rheumatoid arthritis (RA). In one double-blind study, 56 patients with active RA were given 2.8 grams of GLA or a placebo daily for six months. This was followed by a second six-month period, during which all of the patients took 2.8 gm of GLA a day. Treatment with GLA for the first six months resulted in statistically significant and clinically relevant reductions in the signs and symptoms of rheumatoid arthritis disease activity. Overall meaningful responses (at least 25 percent improvement in four measures) were also better in the GLA treatment group (14 of 22 patients vs 4 of 19 in the placebo group). During the second six-month period, both groups exhibited improvement in disease activity. Thus, patients taking GLA during the entire study continued to gain progressive improvement during the second six-month period. In this group, 16 of 21 patients showed meaningful improvement after 12 months of therapy. (27)
In another double blind, placebo-controlled trial, patients with rheumatoid arthritis were given either black current seed oil or a placebo. Black current oil contains approximately 20% GLA. Treatment with black current seed oil provided a significant reduction in signs and symptoms of disease activity in patients with RA, whereas patients given a placebo showed no change in disease. Unfortunately, many patients withdrew from this study because the therapeutic dosage of black current seed oil and its placebo had to be administered in 15 large capsules daily. Nonetheless, the study’s authors indicated that black current seed oil is a potentially effective treatment for active rheumatoid arthritis. However, means must be found to reduce the size and number of capsules taken so that larger studies of longer duration in RA patients can be done. (28) People taking additional polyunsaturated fatty acids should also consume from 400 to 800 IU of vitamin E daily.
Herbal Suplementation
Boswellia
Boswellia is a gummy resin extracted from Boswellia serrata, a moderate size tree native to India. To this day, Boswellia holds a prominent position in India’s Ayurvedic medical system as a treatment for arthritis, dysentery, liver diseases, obesity, neurological disorders, ringworm, boils, and other afflictions. (29) Modern research revealing that Boswellia has strong anti-inflammatory properties lends scientific weight to its long traditional use, especially where arthritis is concerned. (30)
Animal studies show that active ingredients in the herb called “Boswellic acids” intervene at several steps in the physiology of inflammation. Boswellia seems to slow down the infiltration of inflammation-aggravating white blood cells into tissues, decrease antibody production, and block “complement” proteins that play a role in keeping tissues inflamed. (31) , (32)
Boswellic acids inhibit enzymes that trigger the release inflammatory chemicals. (33) , (34) NSAIDs (non-steroidal anti-inflammatory drugs) do the same thing. Unlike NSAIDs, which are known to accelerate cartilage destruction over time, Boswellia protect key joint components called “glycosaminoglycans” from degradation. (35)
Cat’s Claw
Cat’s claw is a traditional medicine, used in South America, possibly as far back as the Incan civilization. Cat’s claw reportedly supports the immune system and acts as a free radical scavenger. (36) Cat’s claw contains active ingredients called “glycosides” that have been shown to reduce inflammation and fluid accumulation in tissues. (37) The glycosides are also reported to stimulate immune cells called “phagocytes” that function as “garbage collectors” in the body. (38) Cat’s Claw contains yet another active ingredient called “isopteridine” that may support the immune system. There are hints that Cat’s claw may have anti-viral action as well: the herb’s active ingredients may possibly stop some viruses from reproducing. (39) , (40) One of these isolated ingredients has been used in AIDS patients. (41)
Turmeric
Turmeric is best known as the yellow spice which gives curried dishes their pungent flavor. In Ayurvedic medicine, turmeric root has been used for centuries internally as a tonic for the stomach and liver, as a blood purifier, and externally in the treatment and prevention of skin diseases and in arthritic complaints. (42) Turmeric contains active ingredients called “curcuminoids” that are effective antioxidants and arthritis-relieving inflammation fighters. (43) Known collectively as “curcumin,” these substances have piqued the interest of research scientists looking for natural anti-inflammatory agents. Curcumin is no weakling; its anti-inflammatory punch rivals that of conventional drugs such as indomethacin. (44) An abundance of laboratory evidence shows that curcumin inhibits enzymes which catalyze the production of potent inflammatory substances called “leukotrienes” and “prostaglandins.” Again, they hold their own when stacked up against conventional drugs that block these enzymes, such as aspirin. (45) (Not all prostaglandins cause inflammation; some help to control it.) In a double-blind study of individuals with rheumatoid arthritis, curcumin produced significant improvement in all subjects. (46)
Curcumin reportedly has a similar action to that of aspirin and aspirin-like anti-inflammatory agents. (47) Here, curcumin may have a leg up on aspirin, because aspirin blocks a beneficial prostaglandin called “prostacyclin” along with the inflammatory prostaglandins. Curcumin is less clumsy; it has no inhibiting effect on prostacylcin. (48) Because prostacyclin helps prevent blood clots from forming in veins, curcumin may be preferable for individuals with RA who are prone to venous blood clots.
Evening Primrose
Supplementation with essential fatty acids such as EPO has been reported to prevent zinc deficiency, thereby potentially improving immunity. (49) Fatty acids are essential nutrients that help keep the body in balance. The human body can produce all but two of them: omega-3 and omega-6 fatty acids. Both must be obtained through the diet or by the use of supplements. A balanced intake of these two fatty acids is vital, in fact, over consumption of omega-6 fatty acids may actually contribute to inflammation in the long run, unless balanced by omega-3s. Essential fatty acids are needed for building cell membranes and are precursors for the production of hormones and prostaglandins. Modern diets tend to be lacking in quality sources of fatty acids.
Diet & Lifestyle
Food and/or environmental allergies can be a cause of arthritis-like inflammatory conditions.
Intestinal amoebic infections can cause arthritis-like inflammatory conditions. (50)
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