Rheumatoid Arthritis and Alternative Therapies

What is Rheumatoid Arthritis?

Rheumatoid Arthritis (RA) is an autoimmune condition with an unknown etiology that affects the joints. There are several factors that play a role in triggering RA: genetic predisposition-(HLA DR1, HLA DR4), environmental triggers (infection, tobacco use), and hormonal factors.

Rheumatoid arthritis presents with a multiple array of symptoms that can vary from having mild joint pain to having systemic manifestations of the disease. Over time, rheumatoid arthritis can lead to an inflammatory joint effusion (i.e. fluid accumulation within the synovial compartment of a joint), progressive destruction with the deterioration of cartilage, bone, ligaments, and tendons (3).

Some patients can develop a transient presentation of RA known as ‘Palindromic Rheumatism,’ in which a subset of patients may present with transient self-limited episodes of mono-or-polyarthritis that may last days to weeks. In many cases, “50% of patients with palindromic Rheumatism will develop RA and only 15% will remain symptom-free after 5 years (4).”

Common clinical features that you may experience:

Most common symptoms include are insidious fatigue, morning stiffness, joint pain, and swelling involving small distal joints (wrists, fingers, toes) in a symmetrical fashion (4).

You may experience the need to get up 1-2 hours earlier than usual so that you can loosen up your joints. You may find yourself needing a warm shower or a need to soak your hands in warm water to loosen up your stiff hands.

• You may have pain with turning doorknobs, opening jars, etc.
• You may experience pain in the ball of the foot upon waking up,
• You may also experience neck pain and stiffness later in the disease course.
• Some patients may experience constitutional signs and symptoms as well: non-tender nodules that may occur on the elbows, Achilles tendon, fingers, or pleuropulmonary involvement that can lead to shortness of breath or chest pain. Eye involvement will present with pain, redness, and dryness, along with dry mouth. (3).
• One important factor to consider is if your RA is not responding to the treatment your physician prescribed you, and you are noticing significant weight loss or depression, make sure to bring these concerns to your doctor to rule out malignancy or other underlying psychiatric diseases.

Lab tests to obtain:

• Approximately 75%-85% of patients with RA test positive for Rheumatoid Factor (4).”
• It is also important to remember that having a positive Rheumatoid Factor (RF) does not mean that you have RA. Low levels of RF factor can be associated with a number of other chronic infectious and non-infectious conditions such as bacterial endocarditis, hepatitis C with Cryoglobulinemia, aging, and primary biliary cirrhosis (6).
• Another Antibody that can be used to diagnose RA is the Anti-CCP Antibody, which has a sensitivity of 70% and specificity of 95% (6).”
• Increased levels of ANA are found in 30% of Rheumatic Arthritis cases.
• Increased inflammatory markers such as CRP and ESR are also found in RA patients.
• Anemia may also be present in patients with RA.

Imaging:

• X-ray is the initial imaging of choice. In aggressive cases of RA, it can take up to 6-24 months until erosions are radiologically evident.

Treatment:

The goals of the treatment are to decrease or eliminate joint pain and swelling, prevent joint damage, and to maintain a manageable lifestyle.

The current treatment regimen includes NSAIDs, COX-2 inhibitors, DMARDS (such as Methotrexate, Hydroxychloroquine, Leflunomide, etc.), Biologics, and Corticosteroids.

• NSAIDs and COX-2 inhibitors are useful due to their anti-inflammatory and analgesics effects.
• DMARDS-reduces the progression of joint destruction. These classes of drugs are part of nearly every patient’s treatment regimen.
• Biologics- “They are structurally engineered versions of natural molecules such as monoclonal antibodies that target culprits responsible for joint destruction.”
• Corticosteroids are given until DMARDS have full effect or as a long-term therapy option for highly reactive RA (5).

Supplements for alternative RA treatment modalities:

There have been many studies that have established a causal effect of developing RA with having a ‘leaky gut’. Russian biologist and Nobel Prize Laureate Elie Metchnikoff introduced the term “Dysbiosis” which describes the imbalance of the normal flora of the gut.

Taking Probiotics (i.e. living bacteria that is normally found in the human digestive tract) is shown to have healing and anti-inflammatory properties. Researchers at Tabriz University of Medical Science in Iran looked at different probiotic strains and the efficacy of treatments with these strains in RA. “Treatment with Lactobacillus Casei for 8 weeks improved pain scores and decreased inflammatory markers and cytokines levels such as IL-10.” (1).

Another Randomized control study found the link between consumption of Fish Oil and RA. Consuming Fish Oil with a combination of RA medication has shown to improve pain in several participants. In these studies, participants on a Lacto-Vegetarian diet or a Mediterranean diet took Fish Oil supplementation and reported greater improvement in symptoms than the people who only took Fish Oil supplements with a typical Western diet. People who followed a Mediterranean diet plan included: foods rich in Omega-3-fatty acids from fish, nuts and seeds, fruits, legumes, olive oil, unsaturated fat, and antioxidants. They were found to also consume decreased amounts of red meat and subsequently reported reduced pain scores as a result. (1).

Supplements that have been noted to reduce inflammation and support a healthy gut biome include:

• Omega 3 Fish Oil
• Omega 6 Fish Oil
• Vitamin D3
• Multivitamin with Antioxidants
• Curcumin
• Vitamin C

Having a healthy diet plan:

Focus on foods with anti-inflammatory properties such as nuts, seeds, avocados, low mercury fish (sardines, pollack, Wild Alaskan King Salmon), turmeric, ginger, and rosemary.

Avoid foods that promote inflammation. Certain wheat flour products (white bread, cakes, cookies), highly acidic foods (alcohol, coffee, sodas), and grain-fed beef (1).

Mind-Body-Spirit Connection:

Stress Management is another important factor when it comes to the management of chronic autoimmune conditions. Chronic stress allows your body to be in a constantly ‘On’ state, in which your body is flooded with hormones and neurotransmitters that can damage your gut bacteria and the intestinal lining which can predispose to chronic fatigue, swelling, and pain. It is important to ask yourself questions such as ‘has there been a stressful or traumatic experience prior to the onset of symptoms? Have you noticed your health declining after a particular incident’?

Being aware of these missing pieces are an important part of your journey towards recovery. You can take the ACE questionnaire found online to understand the trauma you have been exposed to at some point in your life. Some mindful practices that can be implemented include having a regular bedtime and practicing mindfulness meditation that can help you bring awareness to your everyday movements (1).

A technique that you can apply when you feel stressed is ‘Soft Belly Breathing’ adapted from James Gordon, M.D. You can read these instructions beforehand as you implement this technique into your regular routine (2).

• Sit up in a chair or a bed-make sure you are sitting up as straight as you can, close your eyes.
• Breath deeply, in through your nose and out through your mouth, keep the breathing going
• Now imagine your belly is soft. This will deepen your breath and improve oxygenation as it relaxes your muscles. In your mind, as you breathe in, say the word “soft” and as you breathe out, in your mind, say “belly.” As you breathe in, imagine your belly puffing out and as you breathe out, imagine your belly softening in.
• Practice the “soft belly” breathing for five minutes two to three times a day

Consider having a regular bedtime routine:

• Four hours before bedtime: It is advisable to stop drinking any caffeinated beverages and avoid exercising closer to bedtime.
• One hour before bedtime: Turn off all your electronic devices including T.V., laptop, and phone. Winddown your day with calming activities such as journaling, listening to music, etc.
• At bedtime: Make sure you go to bed at the same time every night, even on weekends. It is also important to have a steady wake-up time in the mornings. Make sure your bedroom is cool, dark and quiet.

Some herbal supplements that can help you fall asleep include:

• Theanine: It is a compound extracted from green tea.
• Herbal blends with valerian and passionflower
• 5-HTTP: it is a precursor for serotonin. It can also alleviate some of the depressive symptoms. If you are taking other medications for depression, make sure to consult with the doctor beforehand. (2).

Other practices that you can adopt into your lifestyle include:

• Yoga: a type of movement meditation that can alleviate stress and tension.
• Tai-Chi: a Chinese Martial Art and a form of meditative exercise that focuses on slow methodical movements and circular stretching and bodily balance.
• Meditation and guided visualization: Apps such as Headspace, Calm, or Stop, Breathe & Think can help beginners implement regular meditation daily. You can also join a Buddhist community for meditation in your area called ‘Sangha’s,’ and start your meditation journey. If you want spiritually-based meditation, you can follow along Siddha Yoga Path (www.siddhayoga.org) or Gangaji (Gangaji.org).

Other Treatment modalities that you can consider include:

• Acupuncture- Make sure they are licensed
• Massage Therapy
• CBT and Somatic Experience Therapy (SE): Forms of Talk Therapy that can restructure your thought process.

List of websites that provides insight regarding managing RA:

• Following website contains literature on RA, RA blogs, information about apps you can use for pain management, information regarding help paying for medicine and treatment: https://www.rheumatoidarthritis.org/resources/
• Information about Arthritis Diet can be found here: https://creakyjoints.org/education/arthritis-diet/

Although battling Rheumatoid Arthritis is tough, considering alternative modes of therapies to supplement your current regimen can alleviate the chronic pain and stress associated with the disease.