Overtime: Rheumatoid Arthritis

• Rheumatoid arthritis (RA) is likely caused by a pathologic immune response in a genetically predisposed person to an environmental insult, probably a viral or bacterial infection. Epidemiologic studies show that genes encoding the class II major histocompatibility antigens are linked to clinical features of RA.

• The HLA-DR4 and DR1 proteins present foreign and self-antigens to T cells. These molecules are presumed to play a direct role in the etiology of this autoimmune dis ease by presenting an "arthritogenic" viral or bacterial anti-gen to T cells. However, no organism has been definitively linked to the etiology of RA.

• Antibiotic therapy with minocycline is helpful in mild disease, although minocycline may act through direct immunomodulatory or anti-inflammatory effects rather than through antibacterial activity. Other genes of the immune, endocrine, and neural systems may contribute to the pathogenesis of RA.

• The precise pathophysiologic cascade is not yet defined. RA is an autoimmune inflammatory disease in which immunosuppressive drugs constitute the mainstay of therapy. Certain cytokines, such as tumor necrosis factor (TNF), interleukin (IL)-1 and IL-6, appear to play important roles because inhibitors of these molecules decrease disease activity.

• Similarly, the importance of the roles of cell surface molecules on B and T cells can be shown when these molecules are used as targets for immunomodulatory therapy.

Important points to consider

• Echinacea should be avoided by patients with rheumatoid arthritis because of anecdotal reports of increased symptoms in persons with autoimmune disease.

• A single joint with severely decreased range of motion and increased pain is presumed to be infected until proven otherwise. The patient should be hospitalized overnight for joint aspiration to obtain culture specimens. Blood should also be drawn for cultures, followed by administration of intravenous antibiotics until results of culture are known.

Prevention Prescription

• No proven methods of preventing rheumatoid arthritis exist.

• However, the following can be recommended: Laugh as much as possible. Watch funny movies, read funny books, get up every morning and force yourself to laugh. You'll find it is awkward at first. but it works anyway!

• Journal about stressful events. Make a list of 25 things for which you are grateful. Be creative. Do art, dance, play an instrument, beat a drum, write poetry or prose.

• Meditate; I recommend mindfulness meditation. Find meaning in life. Ask what gives you the energy to get up in the morning.

• Investigate your personality. Try new things that you are afraid to do.

• If you feel stuck, find a good psychotherapist. Exercise. Combine aerobics, strength training, and a time to play! stretching. Make it Love people. Hang out with "positive people," make sure they outweigh the "negative" people in your life. Find "positive" support groups.

• Eat well. Try a vegetarian diet. Make sure to balance your protein intake, and make sure you have adequate vitamin intake. Eliminate coffee, smoking, and alcohol. Make high-sugar desserts a small, rare treat.

Integrative therapeutics review

• Evidence is accumulating that current allopathic treatments are successful in slowing joint destruction and in decreasing the mortality associated with rheumatoid arthritis (RA). In addition, the rates of extra-articular manifestations of RA, such as Felty syndrome and rheumatoid vasculitis, seem to be decreasing. Therefore, in any but the mildest cases of RA, an integrated approach should include the disease-modifying antirheumatic drugs (DMARDs), usually starting with methotrexate.

Exercise

• Muscle strengthening and stretching can be invaluable for maintaining function. Physical therapy can be used initially for instruction; tai chi in the form of the range-of-motion dance can be helpful.

Mind-Body Techniques

• Meditation is highly recommended for patients with RA who are willing to devote the daily time to looking more closely at the connections among body, mind, and spirit. Also recommended are relaxation exercises and the development of methods to cope with stress. Tai chi and yoga also may include a meditative component to the training Journaling should be encouraged (see Chapter 96, Journaling for Health).

Removal of Exacerbating Factors

• Use of coffee, tobacco, and alcohol should be eliminated.

• If intolerance to dairy products, wheat, citrus, or nuts is suspected, a trial of an elimination diet for 2 weeks with the reintroduction of the suspected food can be undertaken (see Chapter 84. Food Intolerance and Elimination Diet).

Nutrition

• A diet rich in omega-3 fatty acids is achieved by increasing intake of cold-water fish or adding flaxseed meal or flaxseed oil. Olive oil should be increased in the diet as well. An anti-inflammatory diet is also recommended (see Chapter 86, The Anti-inflammatory Diet).

Supplements

• Omega-3 fatty acids are recommended; doses for supplementation are eicosapentaenoic acid, 30 mg/kg/day, and docosahexaenoic acid, 50 mg/kg/day, along with gamma-linolenic acid, 1.4 to 2.8 g/day, the equivalent of 6 to 11 g of borage oil daily.

• Conjugated linoleic acid (borage oil, evening primrose oil) can be tried, at 2.5 g/day.

• Vitamin E should be taken in a dose of 800 units daily as mixed tocopherols, and vitamin C can be taken in a dose of 250 mg twice daily. Selenium intake, as nuts or supplements, should be at least 100 mcg daily, not to exceed 400 mcg daily. Recommended intake of calcium is 1.5g daily, magnesium, 400 to 750 mg daily, and a vitamin D supplement of 2000 units/day are also recommended.

Botanicals

• Start with ginger, at 1 g twice daily to a maximum of 4g daily.

• If no effect is seen after 6 to 8 weeks, turmeric 0.5 to 1 g two to three times daily can be tried.

Pharmaceuticals

• NSAIDs are used as little as possible owing to gastrointestinal toxicity. The classic NSAIDs are ibuprofen, 800 mg three times daily, and naproxen, 500 mg twice daily.

• The COX-2 inhibitors decrease but do not eliminate the risk of gastrointestinal bleeding. The dose of celecoxib is 200 mg twice daily.

• Most patients with RA are receiving combinations of drugs. Most patients are given methotrexate therapy unless they have contraindications or side effects.

• A common combination is methotrexate and hydroxychloroquine. Corticosteroids in moderately high doses with a rapid taper are often used for exacerbations.

• Commonly, a TNF inhibitor such as etanercept, adalimumab, infliximab, certolizumab, or golimumab is added if methotrexate is only partially effective. If one to two TNF inhibitors are unsuccessful, try rituximab, abatacept, or tocilizumab.

• Leflunomide or azathioprine is often substituted for methotrexate if side effects of methotrexate are intolerable.

• Methotrexate and leflunomide can be used together with only a modest increase in risk of side effects. The DMARDs and the recombinant biologics have many varied side effects, some of which are only now being defined. New biologics are being developed, including oral formulations. The immunosuppressive pharmaceuticals should be used only with input from a subspecialist rheumatologist.

Acupuncture

• Acupuncture can be tried for any patient with RA. This modality may be less effective in patients taking corticosteroids.

Low-Level Laser Therapy

• Low-level laser therapy can be tried with little risk of side effects.

Surgery

• Loss of joint function and intractable pain. may be indications for surgical intervention. Synovectomy can be helpful when systemic therapy and intra-articular corticosteroids are ineffective. Joint replacement can help restore function and increase independent activity.

Caution

• Studies have not been done on the possible additive effects of ginger, turmeric, vitamin E, and an NSAID for increased risk of hemorrhage. Other commonly used supplements or botanicals such as ginkgo may add further risk. Particular care must be used in patients taking other antiplatelet agents or warfarin sodium (Coumadin). In addition, the interactions of supplements and botanicals with allopathic pharmaceuticals are not fully understood. All health care professionals involved in the patient's care must be aware of all therapies being used. The addition of any new treatment should prompt increased laboratory monitoring for patients receiving immunosuppressive pharmaceuticals.

Key Web Sources

• www.arthritis.org.

• www.nccam.nih.gov/health/RA

• http://www.taichihealth com/indexrom.html