Articles

Arthritis, Rheumatoid

Introduction

Rheumatoid arthritis (RA) is an autoimmune disease that causes a chronic inflammation in the synovial membranes of multiple joints in the body. It attacks the lining of the joints and often produces severe pain and inflammation, joint disfigurement, and loss of joint movement and function. (1) Extra-articular involvement including rheumatoid nodules, vasculitis, eye inflammation, neurologic dysfunction, cardiopulmonary disease, lymphadenopathy, and splenomegaly are manifestations of the disease. Although the usual disease course is chronic, some patients will spontaneously enter a remission. (2)

The chronic inflammation causes proliferation of the synovial tissue, creating a characteristic of RA known as pannus. It is this process that invades cartilage and eventually the bone surface leading to destruction of the joint. The factors that initiate the inflammatory process are unknown; however, there are several possible causes, including genetics, (3) stress, (4) poor nutrition, (5) and bacterial infection. (6)

Heavy metals such as mercury, cadmium, and lead have been associated with rheumatoid arthritis. One study reported that these toxic metals may interfere with collagen synthesis. (7) Chelation therapy may be helpful for rheumatoid arthritis patients who are found to have an accumulation of heavy metals.

Stress affects the immune system and is linked to disease onset and exacerbation in patients with rheumatoid arthritis. It has also been reported that stressful events often precede the onset of disease flare-ups. (8) In one study, stress management programs produced statistically significant improvements on measures of helplessness, self-efficacy, coping, pain, and health status. These beneficial effects were still detectable at the 15-month follow-up evaluation. This indicates that stress management interventions are capable of producing important clinical benefits for individuals with rheumatoid arthritis. (9)

Statistic

Arthritis Foundation, 2003.

    2.1 million are affected by rheumatoid arthritis, mostly women. 1.5 million women are affected with rheumatoid arthritis. 600,000 men are affected with rheumatoid arthritis. Onset is usually middle-age but can often occur in 20’s and 30’s. Musculoskeletal conditions such as rheumatoid arthritis, cost the US economy 65 billion dollars per year in medical care directly and indirectly, such as lost wages and lost production cost.

American College of Rheumatology, 2003.

    More than 2 million Americans suffer from RA. Most, about 75% or 3 out of 4 patients, are women. The peak onset is between 20 and 45 years of age.

Signs and Symptoms

[span class=alert]The following list does not insure the presence of this health condition. Please see the text and your healthcare professional for more information.[/span]

The symptoms of Rheumatoid Arthritis (RA) usually develop insidiously over the course of several weeks to months, and may include fatigue, weakness, low-grade fever, loss of appetite, and joint pain. Stiffness and myalgia may precede joint swelling. The joints most frequently affected are the small joints of the hands, wrists, and feet. In addition, elbows, shoulders, hips, knees, and ankles may be involved. Patients usually experience joint stiffness that is typically worse in the morning.

The swelling of the joints may be visible, or only apparent on palpation. The swelling feels soft and spongy because of soft tissue proliferation or accumulation of fluid. In contrast, the swelling associated with osteoarthritis is usually bony and infrequently associated with signs of inflammation. Hand involvement is common in RA and is manifested by pain, swelling, tenderness, and grip weakness early in the disease. Deformities of the hands may be seen in the chronic phase of the disease.

Whole body or large joint involvement

    Fatigue Weakness Low grade fever Anorexia Joint pain Stiffness, myalgia Joint swelling Joint stiffness is typically worse in the morning

Hand or smaller joint involvement

    Pain Swelling Tenderness Grip weakness Deformities in chronic phases Joint stiffness is typically worse in the morning

Treatment Options

Conventional

Conventional non-drug therapy usually includes rest, physical therapy (for range of motion exercises), weight loss programs (to help alleviate joint stress), and in some patients, surgery (tenosynovectomy, tendon repair, and joint replacements).

First line pharmacologic therapy is to use aspirin or nonsteroidal anti-inflammatory drugs for pain relief and reduction of inflammation. NSAIDs alone will not prevent joint erosions, and most rheumatologists advocate early combination with DMARDs (disease modifying antirheumatic drugs) also known as SAARDs, or slow acting antirheumatic drugs. DMARDs include methotrexate, gold, hydroxychloroquine, sulfasalazine, azathioprine, and penicillamine. Of the DMARDs, methotrexate appears to have the best long-term outcome. It is less likely to be discontinued due to toxicity or lack of efficacy. Gold or hydroxychloroquine should be considered for patients who have contraindications or are refractory to methotrexate.

Corticosteroids are used for their anti-inflammatory and immunosuppressive properties. Given early in the course of the disease, they appear to reduce the progression of erosive joint changes. (10) Oral glucocorticoids can be used in several ways, but because of adverse effects, should be used in the lowest possible dose for the shortest possible treatment interval.

Nutritional Supplementation


Omega-3, Omega-6

Studies report that patients with rheumatoid arthritis have low concentrations of both linoleic acid (omega-6) and linolenic acid (omega-3). (11) Studies have documented the benefits of omega-3 fatty acids (DHA & EPA) in the treatment of rheumatoid arthritis. Ingestion of dietary supplements of n-3 fatty acids has consistently resulted in reducing both the number of tender joints on physical examination and the amount of morning stiffness in patients with rheumatoid arthritis. In these cases, supplements were consumed daily in addition to background medications. The clinical benefits of the n-3 fatty acids were not apparent until they were consumed for a minimum of 12 weeks. It appears that a minimum daily dose of 3 gm of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) is necessary to derive the expected benefits. These doses of n-3 fatty acids are associated with significant reductions in the release of leukotriene B(4) from stimulated neutrophils and of interleukin 1 (IL-1) from monocytes. Both of these mediators of inflammation are thought to contribute to the inflammatory events that occur in the rheumatoid arthritis disease process.

Several investigators have reported that rheumatoid arthritis patients consuming n-3 dietary supplements were able to lower or discontinue their background doses of nonsteroidal anti-inflammatory drugs or disease-modifying antirheumatic drugs. Because the methods used to determine whether patients taking n-3 supplements can discontinue taking these agents are variable, confirmatory and definitive studies are needed to settle this issue. The n-3 fatty acids have virtually no reported serious toxicity in the dose range used in rheumatoid arthritis and are generally very well tolerated. (12) , (13) People taking additional polyunsaturated fatty acids should also consume from 400 to 800 IU of vitamin E daily.

Gamma linolenic acid (GLA) is the longer chain omega-6 fatty acid (18:3w6) that is derived in the body from linoleic acid. GLA is a much more effective precursor for the anti-inflammatory series 1 prostaglandins (PGE-1) than linoleic acid. Research reveals that GLA can be beneficial in the treatment of rheumatoid arthritis. (14)


Methyl Sulfonyl Methane (MSM)

Methyl Sulfonyl Methane (MSM) has reportedly been successful in the reduction and/or elimination of pain for many patients with rheumatoid arthritis. (15) Clinical trials have not yet been conducted. These reports come from the clinical observations of Dr. Stanley Jacob, who has pioneered research, education, and the use of both MSM and DMSO. Average doses range from 2 to 5 grams daily, but higher doses are also used. MSM is considered safe with no known or reported toxicities.


Copper

Several older studies reported that some copper compounds could be useful in the treatment of rheumatoid arthritis. Copper may provide anti-inflammatory activity when it is chelated with established arthritis medication. For example, copper aspirinate reportedly provides more potent anti-inflammatory activity than aspirin alone. (16) Copper salicylates may be the best copper complex for the treatment of arthritic pain, based on the results of studies with lab animals and uncontrolled human trials. (17)

Copper bracelets are an old folk remedy for arthritis. In a double-blind study using copper bracelets and copper-colored aluminum placebo bracelets, 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. (18) In a more recent study, copper levels have been documented to be directly correlated with disease activity in patients with rheumatoid arthritis. (19)


Vitamin B5

Although current studies have not been conducted, some earlier studies reported that treatment with this vitamin provided benefits to RA patients. One study reported finding that rheumatoid arthritis patients had lower levels of pantothenic acid that normal controls. There was also an inverse relationship between the vitamin levels and the severity of the disease. (20) In a double-blind study, 18 rheumatoid arthritis patients who had not responded to previous drug treatment, were randomly assigned to receive either a placebo or 2 grams of calcium pantothenate orally (starting at 500mg daily, and gradually increasing to 500mg, four times daily by the 10th day). Within two months, the patients taking the calcium pantothenate 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. (21)


Zinc

Patients with active rheumatoid arthritis reportedly have plasma zinc levels that are significantly lower than healthy controls. When given 50mg of elemental zinc in an oral challenge test, the plasma zinc levels in healthy controls nearly doubled, but the plasma levels in rheumatoid arthritis patients did not rise significantly. This indicates that patients with rheumatoid arthritis may have zinc malabsorption problems. (22)


Type II Collagen

Type II collagen, given orally has been shown in preliminary studies to be both safe and beneficial in patients with rheumatoid arthritis. (23) A double blind study of 60 patients with RA were given doses of type II collagen in small doses for a three month duration utilizing a technique called "oral tolerization," which works to induce tolerance to the foreign substance by creating a situation that resembles a reverse vaccine. The study found no side effects and determined that this method of treating RA was safe and relatively inexpensive. (24)


Antioxidant Nutrients

There is an oxidative, free radical component to the inflammatory process in rheumatoid arthritis. Studies document that various antioxidant nutrients can play a role in reducing inflammation and tissue damage caused by the free radicals released in the inflammatory process. (25)

    Vitamin E, which is a naturally occurring lipid-soluble antioxidant, has been suggested to possess both anti-inflammatory and analgesic activity in humans. (26) Vitamin C: Only a few studies have been published regarding vitamin C and rheumatoid arthritis. In one study, both leukocyte and plasma concentrations of ascorbic acid were found to be significantly lower in patients with rheumatoid arthritis. (27) An animal study was designed to determine the influence of vitamin C on locally induced inflammation and arthritis in rat paws. Daily subcutaneous administration of 150 mg/kg of vitamin C over 20 days reduced arthritic swelling, increased pain tolerance, and decreased polymorphonuclear leukocyte infiltration, with no significant change in surface temperature. Vitamin C may provide podiatrists with a supplemental or alternative treatment for patients with rheumatoid arthritis. (28) Selenium: Studies report that patients with rheumatoid arthritis have much lower selenium levels compared to normal controls. (29) , (30) , (31) A study of forty subjects found that intake of vitamin A and beta-carotene measured significantly lower in the subjects with RA. In addition, RA patients had a decreased mean plasma alpha-tocopherol level. (32)

While the antioxidants mentioned are important, it should be stressed that a broad range of antioxidant nutrients should be taken rather than large doses of one or several.

Herbal Supplementation


Boswellia

Boswellia, or Olibanum, is a close relative of the Biblical incense frankincense and has been used historically in the Ayurvedic medical system of India for arthritis, dysentery, liver diseases, obesity, neurological disorders, ringworm, boils, and other afflictions. (33) Boswellia is emerging as a novel dietary supplement agent in the management of symptoms associated with arthritis. (34)

Animal studies performed in India reported individuals ingesting an extract of boswellia had decreased polymorphonuclear leukocyte infiltration and migration, decreased primary antibody synthesis, and the agent caused almost total inhibition of the classical complement pathway. (35) An in vitro study of the isolated chemical constituent b-boswellic acid on the complement system reported a marked inhibitory effect on both the classical and alternate complement systems. (36)

Boswellia’s anti-inflammatory activity seems to be produced by blocking the synthesis of 5-lipoxygenase products, including 5-hydroxyeicosatetraenoic acid (5-HETE) and leukotriene B4 (LTB4). (37) , (38) Also, it is known that NSAIDs can cause a breakdown of glycosaminoglycan synthesis, which can speed up the articular damage in arthritic conditions. (39) Boswellia was reported to significantly reduce the degradation of glycosaminoglycans compared to controls, whereas the NSAID ketoprofen was reported to cause a reduction in total tissue glycosaminoglycan content. (40)


Cat's Claw

Cat’s claw has been used as a traditional medicine, possibly dating back as far as the Incan civilization. Cat’s claw reportedly affects the immune system and acts as a free radical scavenger. (41) Cat’s claw has glycosides that reportedly reduce inflammation and edema. (42) The anti-inflammatory effects of cat’s claw are considered to be due to the sum total of the plant’s constituents, but the sterols have demonstrated anti-inflammatory activity in animal studies. The glycosides are also reported to enhance and stimulate phagocytosis, which if true would be a key part of cat’s claw’s immune function activity. (43) Isopteridine, an alkaloid that has been isolated, is claimed to have immunostimulatory properties. Triterpenoid alkaloids and quinovic acid glycosides have been isolated and studied for antiviral activity, possibly inhibiting replications of some DNA viruses. (44) , (45) One of the isolated alkaloids has been used in some AIDS patients. (46)


Turmeric

In Ayurvedic medicine, turmeric rhizome has been used for centuries internally as a tonic for the stomach and liver and as a blood purifier, and externally in the treatment and prevention of skin diseases and in arthritic complaints. (47) Laboratory and clinical research indicates that turmeric and its phenolics have antioxidant and anti-inflammatory properties. (48) The anti-inflammatory strength of turmeric is comparable to steroidal drugs such as indomethacin. (49) Turmeric has been reported to be antirheumatic, anti-inflammatory, and antioxidant. (50) Curcuminoids reportedly inhibit enzymes which participate in the synthesis of inflammatory substances (leukotrienes and prostaglandins) derived from arachidonic acid, and it is claimed they are comparable in activity to the NSAIDs. (51) In a double-blind study of individuals with rheumatoid arthritis, curcumin produced significant improvement in all subjects. (52) Turmeric is also claimed to inhibit platelet aggregation. (53)

Curcumin reportedly has a similar action to that of aspirin and aspirin-like anti-inflammatory agents. (54) However, an advantage of curcumin over aspirin is claimed, since curcumin, unlike aspirin, is reported to selectively inhibit synthesis of inflammatory prostaglandins but does not affect the synthesis of prostacyclin. (55) Curcumin may be preferable for individuals who are prone to vascular thrombosis and require anti-inflammatory and/or anti-arthritic therapy.


Evening Primrose

Evening primrose oil (EPO) is rich in gamma-linolenic acid which is an omega-6 fatty acid. (56) , (57) Omega-6 fatty acids reportedly reduce the arachidonic acid cascade and decrease inflammation through inhibiting the formation of inflammatory mediators in this process. Supplementation with essential fatty acids such as EPO has been reported to prevent zinc deficiency, thereby potentially improving immunity. (58) Fatty acids are an important part of normal homeostasis. The human body can produce all but two fatty acids - omega-3 and omega-6 fatty acids. Both must be obtained through the diet or by the use of supplements. Obtaining a balance of these two fatty acids is essential. 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.

Homeopathic

Apis mellifica

Typical Dosage: 6X or 6C, 30X or 30CBurning, stinging pains; Sudden swelling; Better from cold applications, worse from heat

Arnica montana

Typical Dosage: 6X or 6C, 30X or 30CPain and inflammation; Joints feel bruised; Pain in back and shoulders, worse with movement

Causticum

Typical Dosage: 6X or 6C, 30X or 30CStiff neck; Dull ache in hands and arms; Drawing pains in hands; Stiffness of legs and feet

Colchicum autumnale

Typical Dosage: 6X or 6C, 30X or 30CRed, painful swelling, especially of smaller joints, fingers, toes, wrists and ankles; Worse from slightest motion

Ledum palustre

Typical Dosage: 6X or 6C, 30X or 30CPainful small joints, especially toes, that pop and crack; Better from cold applications

Rhus toxicodendron

Typical Dosage: 6X or 6C, 30X or 30CJoint stiffness especially in the morning, better by walking and moving around; Pain relieved by heat but aggravated by cold and dampness

Acupuncture & Acupressure

Acupuncture and Moxibustion Therapy
Shi compared the effects of treating rheumatoid arthritis with acupuncture alone and with a combination of acupuncture and moxibustion. The acupuncture-only treatment treated 20 patients at Guan Yuan (RN 4) with acupuncture alone, while the combination treatment treated 30 patients at the same acupoint with both acupunture and moxibustion. The moxibustion treatment was administered twice daily, each session lasting 2 hours. One unit of treatment was five days for both treatments. The results: of the combination treatment group, 10 patients significantly improved, 15 patients improved, 5 patients with no response, with a total effective rate of 83%; of the acupuncture-only group, 5 patients significantly improved, 10 patients improved, and 5 patients with no response, with a total effective rate of 75%. (59)

Wang, et al. compared the effects of treating rheumatoid arthritis with indirect moxibustion and with oral administration of penicillamine. Finding that the two treatments had similar percentages of patients responding in similar fashions (while the indirect moxibustion treatment was effective in 90.48% of the cases treated, and significantly effective in 39.68% of the cases, the corresponding percentages for the penicillamine treatment were 80% and 32%), the authors concluded that the two treatments were similar to each other and both could be regarded as effective treatments. (60)

Xu, et al. used "midnight-noon ebb-flow bee-sting acupoint therapy" to treat 86 cases of rheumatosis and RA. The results: 7 cases (8.14%) fully recovered and 78 cases (90.7%) improved. The total effective rate was 98.84%. The authors believe that this therapy can lower blood sedimentation, render tests of antistreptolysin O and rheumatoid arthritis factors negative, and therefore improve the biochemical environment of the human body. (61)

Liang treated 30 cases of RA patients with acupuncture and moxibustion during the three hottest ten-day periods of the year. All patients received treatment at acupoints Fenchi (GB 20), Taiyang (EX-HN 5), Taixi (KI 3), Fengshi (GB 31), Quchi (LI 11), and Hegu (LI 4). In addition, patients with elbow joint pain also received treatment at Waiguan (SJ 5), Yanggu (SI 5), and Yangchi (SJ 4); patients with knee joint pain were also treated at Xuehai (SP 10), Yanglingquan (SP 9), Lianqiu (ST 34), and Zusanli (ST 36); those with ankle joint pain were treated at Jiexi (ST 41), Qiuxu (GB 40), Kunlun (BL 60), and Shangqiu (SP 5); patients with joint pain in the little fingers were treated with penetration needles from Neiguan (PC 6) to Waiguan (SJ 5), and from Hegu (LI 4) to Houxi (SI 3); and patients with toe joint pain were treated with penetration needles from Sanyinjiao (SP 6) to Xuanzhong (GB 39) or Bafeng (EX-LE 10). After insertion and a needling sensation was achieved, the needle was retained, and a segment of moxa stick was attached to the filiform needle handle and ignited for moxibustion. The results: after receiving the treatment for 1-3 seasons, out of a total of 30 patients, 20 fully recovered, 8 significantly improved, and 2 with no response. The treatment was considered effective in patients without joint deformity. (62)

Li treated 35 cases of RA with thermal needling therapy. RA patients are known to have experienced pathological changes to their blood rheology, and SOD and LPO levels. The author found that the treatment was conducive to remedying those changes. (63)

Traditional Chinese Medicine

Arthritis, Rheumatoid

Extensive information regarding the treatment of this health condition using Traditional Chinese Medicine is available through the link above.

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. (64)

Clinical Lab Assessment

Some of the following laboratory testing can provide information necessary for the diagnosis and treatment of rheumatoid arthritis. In addition, the tests listed may also give insight to functional metabolism and functional nutrient status in the body.

Allergy and Food Sensitivity Response Assessment

Allergies have been indirectly addressed in regard to RA, but may have considerable impact on the inflammatory process of RA. (65) Direct correlation of impaired digestion or food allergic response is still controversial, (66) though some case studies manifest improvements on food elimination diets.

C-reactive protein (CRP Thyroid Profile)

An abnormal serum glycoprotein produced by the liver during acute inflammation, CRP has been used to monitor rheumatoid arthritis and rheumatic fever, to differentiate between Crohn’s disease and ulcerative colitis, and to detect or monitor inflammatory processes. Elevated levels of CRP have been shown to be present in those individuals who have RA. (67) CRP disappears rapidly when inflammation subsides; thus it is a reliable measure of current inflammatory process.

Fatty Acids

Dietary polyunsaturated fatty acids (PUFA) are primarily composed of omega-3 and omega-6 fatty acids. PUFA are vital in the production of eicosanoids – components involved in regulating inflammatory response, blood vessel leakage, lipid accumulation, and immune cell response.

Hormone Assessment

Estrogen and Progesterone: The role of these hormones in arthritis has been investigated (68) , (69) and correlations have been postulated. It is possible that assessment of these hormones may be useful in the monitoring of RA. It should be noted, however, that RA is a disease of multifactorial origin and hormone assessment should only be a part of a complex evaluation and intervention program. Testosterone: This androgen functions primarily as a reproductive hormone; however evidence suggests it plays a significant role in inflammation through its influence on maintaining a positive balance of sodium, potassium, calcium, and phosphorus.

Rheumatoid factor (RF)

RF is an immunoglobulin that appears in the serum and synovial fluid of RA patients a few months after onset of the disease and may remain for years after beginning therapy. This antibody appears in chronic infections, connective tissue defects, and autoimmune disorders. Found in many diseases, RF is nonetheless useful in a diagnosis of RA, since about two-thirds of RA cases will have positive RF results greater than 1:40 and, combined with a symptomatic clinical presentation, offers confirmation. Analgesics and anti-inflammatory medications do not affect RF levels.

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