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Rheumatoid Arthritis and Inflammatory Diseases

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In theory, it may seem like management of autoimmune diseases is pretty straightforward. Essentially, the goal is to first diagnose the type of disease in order to evaluate prognosis, then aim to suppress the inflammatory process with methods and medications most appropriate for the disease while keeping the side-effect profile as benign as possible. For patients going through this process, though, it is anything but "straightforward."

In my clinic of integrative medicine in San Jose, Calif., I see numerous autoimmune patients on a daily basis. When I first see these patients in my practice, many of them are frequently frustrated with their own body and with the pain and frustration they have to endure on a daily basis. Usually, they are seeing me for an integrative approach to their disease because they are not tolerating conventional treatments well or they are looking for ways to minimize the typical side effects associated with the disease-modifying anti-rheumatic drugs (DMARDs) or to avoid these drugs altogether. I find these patients to be generally very self-motivated, which makes them ideal patients for the integrative-medicine approach.

In order to best describe a patient's road to healing from a life-altering autoimmune disease, let's take a moment to review one of my patient's case.

A patient of mine is a 35-year-old female who was diagnosed with rheumatoid arthritis (RA) about three years ago, but had been having intermittent joint pains in her hands and knees for several years prior to diagnosis. She also had begun to develop more and more myofascial pain in her upper back in the last one to two years. She is still very active and enjoys working out several times per week, but she has to lessen her weighted workouts due to myofascial pains that occur after her sculpting sessions. At the time of diagnosis, her symptoms were escalating -- chronic, persistent finger swelling with joint swelling, and pain in all of her proximal joints in her hand and her wrist. She was also having excruciating pain in her bilateral shoulders and knees on a daily basis. Her labs at that time were positive for elevated C-reactive protein, ESR, ANA, rheumatoid factor, and anti-CCP. The anti-CCP and rheumatoid factor are antibody markers for rheumatoid arthritis. The ANA lab test is a marker for autoimmune disease and the C-reactive protein as well as ESR are markers for level of inflammation. She was diagnosed with rheumatoid arthritis and was started on prednisone therapy while she concomitantly started methotrexate. Her joint MRIs did not indicate joint erosion at the time of diagnosis, nor did her bone mineral density test show any osteopenia or osteoporosis.

She was very self-motivated and began researching healthy ways to manage rheumatoid arthritis and minimizing side effects of methotrexate. She stopped all alcohol consumption along with acetaminophen usage. She also started taking folic acid and eating a more vegetarian diet. Despite her pain, she still managed to incorporate gentle walking into her daily routine, although she was very frustrated at the fact that she was no longer able to run as she used to do as a daily enjoyment.

Despite these efforts, her symptoms flared once she was tapered off the prednisone therapy. She also had subsequent liver function test elevations with methotrexate therapy. Despite multiple attempts at dosage variations and dosing patterns, she had elevated liver function tests with each trial of methotrexate therapy. She was then switched to Adalimumab (a medication for rheumatoid arthritis), where she was finally able to achieve good control of her symptoms without progression of joint erosion on subsequent joint MRIs. However, her initial trial with twice-per-month Adalimumab therapy was insufficient, thus her final treatment regimen was with weekly therapy of the TNF-alpha inhibitor. She has been on this treatment for about two years and she still occasionally has flares that require additional prednisone therapy and joint injections. In the last year, she had to add plaquenil and sulfasalazine into her regimen to further decrease flares. She came to see me with the initial goal of eliminating flares while only on her baseline three medications. As her symptoms improved, her subsequent goal was to come off Adalimumab due to her concerns about being on a TNF-alpha inhibitor on a long-term basis.

This patient is a good example of the general workup and evaluation and treatment of rheumatoid arthritis. She was first screened for RA along with a bevy of other autoimmune diseases that may present with joint pains as well. She was also screened for hepatitis and other viral and bacterial diseases. She had her joint pains and symptoms for many months with preceding intermittent symptoms dating back several years. She was started on disease-modifying drugs while her workup continued, which included imaging for potential joint erosion, bone density study, and tuberculosis screening and evaluation since she was being started on immunosuppressant therapy. She was progressively tried on several DMARDs in an attempt to control disease symptoms and to prevent disease progression. Within modern conventional rheumatic disease management, physicians are also starting to focus more on lifestyle modifications. However, this focus is usually pushed to the wayside if patients are responding well to medications or if the patients seem reluctant to make these changes.

It is ideal to optimize health outcome via a combination of conventional and alternative methods, which should include lifestyle modifications. By utilizing a variety of alternative therapies, patients can achieve less inflammation as a baseline such that they may be able to minimize conventional therapies -- thus improving disease status while decreasing adverse drug events. However, many patients may need to stay at the higher-dosage conventional medications if the lifestyle changes and supplements are not enough to achieve both laboratory and clinical remission.

A complementary approach to autoimmune disease management can be complicated and extensive, depending on severity of the patient. The general areas of interest I target for treatment are nutrition, mind-body balance, correction of physiological deficiencies, and alternative anti-inflammatory supplements/herbs. By targeting therapies at these factors, we can better achieve basic RA treatment principles of reduction of pain, reduction of joint swelling, prevention of progression of disease and joint erosion, and an increase of overall functionality and well-being.

While more scientific evidence is necessary to solidly confirm efficacy of many complementary and alternative medicine (CAM) therapies for RA, there are CAM modalities with preliminary data suggesting its benefits as adjunctive therapies in RA management. For example, mind-body techniques such as mindfulness-based stress reduction techniques, imagery, biofeedback, and tai chi can be very helpful in reducing stress-associated flares as well as improving pain, anxiety, depression, and functionality status of these patients.[1]

In regards to nutrition, since our intestinal tract is one of the largest immune systems in our body, what we eat has a significant impact on the inflammatory status. Studies indicate that an anti-inflammatory diet that is largely vegan or vegetarian or Mediterranean-based can be helpful in calming inflammation. Stringent plant-based juice fasts for short durations have been seen to be beneficial for acute RA flares as well. Most patients should also be considered for elimination diet trials of foods frequently associated with sensitivity or allergies such as dairy, gluten, soy, or nuts may be adjunctively helpful in eliminating factors that exacerbate inflammation.[2],[3]

Continuing with the idea that our intestinal tract has a significant impact on our overall inflammatory status, special attention should be paid to supplements that help to calm the GI tract as well as help to replenish deficiencies that occur with diminished absorption from natural aging and inflammation. Thus, patients should be checked for cofactor, mineral, and vitamin deficiencies as well as screened for heavy metal toxicity and antibodies that suggest other inflammatory triggers.

A key treatment goal would be toward correction of deficiencies as well as appropriate treatment for toxicities and antibodies detected. Patients should also be placed on a personalized anti-inflammatory regimen such as fish oil, gamma-linolenic acid (GLA) therapy, boswellia, turmeric with black pepper, ginger, green tea, and fresh garlic cloves, just to name a few. Acupuncture as well as supplements to facilitate sleep, insulin sensitivity, adrenal function, thyroid function, and regular GI tract functioning would also be instrumental in the CAM approach to RA management.[4],[5],[6],[7]

If you are interested in these treatment options, I would very strongly recommend seeing an integrative physician or naturopath in conjunction with your rheumatologist and primary care doctor to start the regimen with you and monitor your progress and dosing of the regimen. I would not recommend starting supplements on your own because with the RA medications and the potential for disease progression and severity, taking various supplements on your own without guidance cannot be recommended.

When my patient first approached me about CAM therapies, her initial labs demonstrated many nutritional deficiencies such as hypomagnesemia, hypokalemia, vitamin-D deficiency, B12 deficiency, B6 toxicity from her own OTC multivitamin, subclinical hypothyroidism, and low adrenal reserve. She was placed on multiple supplements to correct these abnormalities while she underwent mind-body therapy, nutritional counseling for anti-inflammatory diet, and acupuncture mostly to correct for a significant deficiency in Jing.

The entire treatment course to get her off her Adalimumab took about 10 months but by the fifth to sixth month of CAM therapy, she was no longer having flares while on her three medications and she was no longer requiring joint injections. She was weaned down to every-other-week therapy then down to once-a-month Adalimumab injections by the eighth month, and was finally able to discontinue use at the 10-month mark. She has been able to stay off the TNF-alpha inhibitor therapy with the initial CAM regimen addressing nutrition, mind-body balance, anti-inflammatory supplements, acupuncture, and correction of physiological abnormalities seen on labs.

She is still needing plaquenil and sulfasalazine to maintain her current status, but when she feels a flare coming on, she mitigates the flare and symptoms via a stringent juice fast or anti-inflammatory diet and transiently increases her anti-inflammatory supplements under my supervision. She has not required prednisone therapy or joint injections since the addition of CAM therapy to her conventional regimen.

While the specifics of this case pertain to that specific patient only, the positive treatment outcome need not be. It is important to educate our patients about the importance of approaching inflammation from many angles such that all the factors contributing to inflammation are addressed. It is with this multi-modal approach that we are best able to quell the tidal waves of inflammation raging within our autoimmune patients.

References:

[1] Astin J. 2004. Mind-body therapies for the management of pain. Clin J Pain. 20(1): 27-32.

[2] Walsh N. 2005. Fasting for rheumatoid arthritis. Internal Medicine News. Nov.

[3] Hafström I, et al. 2001. A vegan diet free of gluten improves the signs and symptoms of rheumatoid arthritis: the effects on arthritis is correlate with a reduction in antibodies to food antigens. Rheumatology. 40:1175-1179.

[4] Bliddal H, Rosetzsky A, Schlichting P, et al. 2000. A randomized, placebo-controlled, cross-over study of ginger extracts and ibuprofen for osteoarthritis. Osteoarth Cartil 8:9-12.

[5] Srivastava KC, Mustafa T.1992. Ginger (Zingiber officinale) in rheumatism and musculoskeletal disorders. Med Hypotheses 342-48.

[6] Ammon HP, Safayhi H, Mack T, Sabieraj J. 1993. Mechanism of anti-inflammatory actions of curcumin and boswellic acids. J Ethnopharmacol, 38(2-3): 113-119.

[7] Deodhar SD, Sethi R, Srimal RC .1980. Preliminary studies on anti-rheumatic activity of curcumin. Ind J Med, 71; 632.

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