Categories: Diseases & Treatment Plans

Rheumatoid Arthritis (RA)

Rheumatoid Arthritis (RA)

Info
DescriptionAn autoimmune condition affecting the joints causing pain, stiffness, inflammation and deformity
Signs & Symptoms
  • Joint pain and swelling
  • Pain typically worse in morning
  • Stiffness
  • Inflammation
  • Warmth felt at joints
  • Tenderness
  • Limited ROM
  • Fatigue
  • Rheumatoid nodules
Joints commonly affected:
  • Fingers (90% – early)
  • Toes (90% early)
  • Wrist (80% – early)
  • Ankles (80%)
  • Knees (80%)
  • Shoulder (60%)
  • Hip (50%)
  • Elbow (50%)
  • Cervical spine (40%)
  • Sternoclavicular (30%)
  • Jaw (30%)
Causes & Contributors
  • SIBO/dysbiosis/microbial infection
    • Higher rates of Clostridium perfringens
    • parovirus B19
    • Rubella
    • Epstein-Barr
    • Hepatitis B, Hepatitis C
    • Cytomegalovirus
    • Mycoplasma fermentans or mitogen
    • Proteus mirabilis
      • Cross reacts with XI collagen
  • Periodontal bacterial infection
    • Porphyromonas gingivalis
  • Increased intestinal permeability (Leaky gut)
  • Cigarette smoking
  • Dietary allergies
    • Lectins
  • Genetics
    • HLA DRB1/DR4
  • Vaccination
    • may be a trigger in some people
  • Imbalanced hormones
Pathophysiology/Aetiology
  • The synovium of the joints are transformed (through autoimmunity) into an invasive structure know as the pannus. The synovium thickens and there is oedema
  • Hormonal component as observed in the following:
    • Pregnancy can lead to remission
    • History of child bearing can protect against RA
    • HRT may reduce risk of women who carry the HLA-DRB1 gene
  • RA is associated with antibodies to Proteus mirabilis, a common bacteria often involved in UTIs
  • Changes in small intestine microflora may be implicated in disease
Commonly Affected
  • More common in women than men. Ratio 1:3
  • >65 years old
  • Most common autoimmune disease in Australia
Complications
  • Progression of disease
  • Erosion of cartilage and bone
  • Deformity
  • CVD increase
Treatment
Best Therapeutic Treatment
  • Autoimmune condition, consider the following:
    • Past or present infections
    • GI function (Permeability, Flora)
    • Improve detoxification pathways
    • Immune modulation
    • Weed and Seed
      • Remove
      • Replace
      • Repair
      • Repopulate
  • Reduce inflammation and pain
  • Discuss natural anti-inflammatories VS NSAIDs
Pathology Testing
  • CDSA
  • SIBO breath test
  • Intestinal Permeability
Diet
Eat These:
  • Fresh fruit and vegetables
  • Seafood (especially fatty fish)
Avoid These:
  • Sugar
  • Gluten
  • Red meat
  • Refined carbohydrates
  • Processed foods
  • Chemical, additives, preservatives
  • Trans fats
  • Processed meats
  • Caffeine
  • Alcohol
  • Lectins
  • Nightshades
Nutritional
  • Omega 3
    • Anti-inflammatory
  • Probiotics
    • Broad range
    • L. Rhamnosus GG
  • Vitamin D (if required)
    • Immune modulation
Herbal
Example Herbal Formula (Antiviral, autoimmune and anti-inflammatory)
  • Echinacea – 1:2 30ml
    • Immune modulation
  • St Johns Wort – 1:2 20ml
    • Antiviral against enveloped viruses
  • Bupleurum – 1:2 20ml
    • Improves autoimmunity
  • Cats claw – 1:2 25ml
    • Immune enhancing, anti-inflammatory
  • Ginger – 1:2 10ml
Lifestyle
  • Exercise (If possible)
    • Walking outside
    • Yoga
  • Meditation
    • helps with stress and pain
    • Once a day
  • Sunlight exposure
    • To increase vitamin D
Combined Products
  • Anti-inflammatory (Combination tablet/capsule)
    • Tumeric
    • Boswellia
    • Ginger
Consider:
  • Orthoplex Intestaclear
    • Eliminate pathogenic microorganisms
  • Orthoplex Immunobiotic
    • Repair intestinal hyperpermeability
Herbal
  • Boswellia (Boswellia serrata)
    • Anti-inflammatory
  • Tumeric (Curcuma longa)
    • Antioxidant, Anti-inflammatory
  • Echinacea
    • Immunomodulator
    • Lacks evidence to show that it wont increase immune function, leading to possible worsening
  • Devils claw (Harpagophytum procumbens)
    • Anti-inflammatory, Antioxidant
  • Bupleurum
    • Improves autoimmunity
Immunosuppresants
  • Hemidesimus indicus
    • Immunosuppressant
    • Combines well with echinacea for the autoimmune aspect of RA
  • Tylophora
    • Immunosuppressant
  • Phellodendron amurense
    • Immunosuppressant
  • Rehmannia glutinosa
    • Immunosuppressant
    • Little good quality evidence
Nutritional
  • Omega 3
    • Inhibit inflammatory pathways
  • Glucosamine and chondroitin
    • Prevent cartilage erosion
  • Selenium
    • deficiency common in RA
    • has been suggested as being a cause of RF negative RA
  • Vitamin A
    • cartilage growth
    • Regulate immune function
    • deficiency common in RA
  • Vitamin C
    • Antioxidant, anti-inflammatory
    • Collagen production, cartilage
    • Immune function
  • Vitamin D
    • Immune regulation
  • Zinc
    • deficiency leaves joints susceptible to damage from oxidation
    • Commonly deficient in RA, likely due to inflammation
    • Immune function
  • Probiotics
Dietary
  • Avoid food allergies (both IgE and IgG)
Eat These:
  • Fresh fruit and vegetables
  • Seafood (especially fatty fish)
Avoid These:
  • Sugar
  • Gluten
  • Red meat
  • Refined carbohydrates
  • Processed foods
  • Chemical, additives, preservatives
  • Trans fats
  • Processed meats
  • Caffeine
  • Alcohol
*Give food swap ideas if necessary
Lifestyle
  • Exercise
    • where possible
  • Meditation
    • helps with stress and pain
    • Once a day
Pharmaceutical
  • NSAIDS
  • Methotrexate
  • Sulfasalazine
  • Predisolone
Combination Products
  • Orthoplex Intestaclear
    • Eliminate pathogenic microorganisms
  • Orthoplex Immunobiotic
  • Enterocare
More
Differential Diagnosis
  • Ankylosing spondylitis
  • Enteric infections
  • Psoriatic arthritis
  • Reiter’s arthritis
  • Whipple’s disease
  • IBD
Diagnostic Criteria
  • Symptoms for more than 6 weeks
Suffering 4 of the following 7:
  • Morning stiffness
  • Arthritis of three or more joint areas
  • Arthritis of hand joints
  • Symmetric arthirits
  • Rheumatoid nodules
  • Positive for RF
  • Radiographic changes
Markers Often Raised:
  • + RF
  • + Anti-CCP
  • + ANA
Testing/Examinations
  • Clinical examination
    • check for inflammation
    • nodules
    • redness, tenderness
    • ROM
  • Rheumatoid factor
    • Positive in 80% of patients
    • More likely to have joint erosion and deformity and worse prognosis
  • Anti-CCP
    • Positive in 60-70% of patients
    • Predicts progression of RA
    • More likely to have joint erosion and deformity and worse prognosis
  • CRP and ESR
    • Elevated indicates inflammation
  • Antinuclear anitbodies (ANA)
    • Typically elevated
  • Antibodies to extractable nuclear antigens (ENA)
    • to eliminate other MSK conditions
  • IgG food intolerance test
  • CMV, EBV, HIV
    • Assess for viral cause
  • Mycoplasma, Chlamydia, Borellia
  • Iron
    • Usually low in RA patients
  • CDSA
    • identifying pathogenic bacteria, parasites and GIT function given the link between the GIT and RA
    • SIBO breath test
Additional Notes
  • RA seems to have declined after the 1960s, particularly in women. One theory suggests the increased use in OCPs from 1960-2000. Although new data suggests it is on the rise again.
Bodkhe, R., Balakrishnan, B., & Taneja, V. (2019). The role of microbiome in rheumatoid arthritis treatment. Therapeutic advances in musculoskeletal disease, 11, 1759720X19844632. https://doi.org/10.1177/1759720X19844632
Bone, K. (2007). The Ultimate Herbal Compendium. Phytotherapy Press
Braun, L., & Cohen, M. (2015). Herbs and Natural Supplements, Volume 2. Elsevier Health Sciences.
Bullock, J., Rizvi, S., Saleh, A. M., Ahmed, S. S., Do, D. P., Ansari, R. A., & Ahmed, J. (2018). Rheumatoid Arthritis: A Brief Overview of the Treatment. Medical principles and practice : international journal of the Kuwait University, Health Science Centre, 27(6), 501–507. https://doi.org/10.1159/000493390
Gioia, C., Lucchino, B., Tarsitano, M. G., Iannuccelli, C., & Di Franco, M. (2020). Dietary Habits and Nutrition in Rheumatoid Arthritis: Can Diet Influence Disease Development and Clinical Manifestations?. Nutrients, 12(5), 1456. https://doi.org/10.3390/nu12051456
Guerreiro, C. S., Calado, Â., Sousa, J., & Fonseca, J. E. (2018). Diet, Microbiota, and Gut Permeability-The Unknown Triad in Rheumatoid Arthritis. Frontiers in medicine, 5, 349. https://doi.org/10.3389/fmed.2018.00349
Guo, Q., Wang, Y., Xu, D., Nossent, J., Pavlos, N. J., & Xu, J. (2018). Rheumatoid arthritis: pathological mechanisms and modern pharmacologic therapies. Bone research, 6, 15. https://doi.org/10.1038/s41413-018-0016-9
Haroyan, A., Mukuchyan, V., Mkrtchyan, N., Minasyan, N., Gasparyan, S., Sargsyan, A., Narimanyan, M., & Hovhannisyan, A. (2018). Efficacy and safety of curcumin and its combination with boswellic acid in osteoarthritis: a comparative, randomized, double-blind, placebo-controlled study. BMC complementary and alternative medicine, 18(1), 7. https://doi.org/10.1186/s12906-017-2062-z
Hechtman, L. (2018). Clinical Naturopathic Medicine. Elsevier Health Sciences.
Khanna, S., Jaiswal, K. S., & Gupta, B. (2017). Managing Rheumatoid Arthritis with Dietary Interventions. Frontiers in nutrition, 4, 52. https://doi.org/10.3389/fnut.2017.00052
Li, S., Yu, Y., Yue, Y., Zhang, Z., & Su, K. (2013). Microbial Infection and Rheumatoid Arthritis. Journal of clinical & cellular immunology, 4(6), 174. https://doi.org/10.4172/2155-9899.1000174
Mu, Q., Kirby, J., Reilly, C. M., & Luo, X. M. (2017). Leaky Gut As a Danger Signal for Autoimmune Diseases. Frontiers in immunology, 8, 598. https://doi.org/10.3389/fimmu.2017.00598
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