Rheumatoid Arthritis

Rheumatoid arthritis (RA) is an autoimmune condition that affects 1 person in every 100 or 200. It typically starts affecting people between the ages of 40 and 70, although there are plenty of exceptions to this.

In RA the immune system starts attacking the synovium that surrounds the joints thoughout the body. In some cases the disease progresses to then attack the cartilage and finally the bone local to the joint. Significant destruction of the joint can occur leading from initial stiffness and pain to ultimately an inability to move certain joints.

Most typically the small joints in the hands, feet and upper spine are initially affected with pain, swelling and stiffness. Often opposite sides of the body are equally affected, although not always. Morning stiffness is commonplace and can take up to an hour to relieve.

Determining if you have rheumatoid arthritis is normally via measurement of C-reactive protein - CRP, or erythocyte sedmentation rate - ESR(1). The first, CRP, measures levels of a protein produced by the liver in response to inflammaton in the body. The second, ESR, measures how fast red blood cells fall in a test tube. Faster falling blood cells results from increased levels of the protein fibrinogen (produced as a result of inflammation), which causes coagulation.

Ankylosing spondylitis and psoriatic arthritis are similar arthritic conditions, which share many of the same treatment pathways as rheumatoid arthritis. They are all inflammatory, unlike osteoarthritis, which is due more to wear and tear of joints.

Causes

What causes rheumatoid arthritis is not clear. It is thought that infection could possibly play a role, but there are a number of other factors that also have an association with RA.

  1. Genetic risk - On chromosome 6, your DRB1 gene (MHC class II) has hundreds of possible forms. One particular form "15:01" is strongly associated with the nervous system disorder - Multiple sclerosis while another, "04:04", is assoicated with the adrenal disorder - Addison's disease. With Rheumatoid arthritis there are several forms of DRB1 that are associated with the disease, "04:01" being one. Added to this are other genes that also play a role. Much of the research to do with genetic risk is referred to as the "shared epitope hypothesis". Basically meaning that if your genes create proteins that can be recognized by the immune system, then your risk of RA increases significantly.
  2. Hormones - About 3 times more women than men suffer with rheumatoid arthritis. It is thought that the sex hormone, oestrogen, may make RA more likely. Having said that, it is often the case that pregnancy reduces syptoms. This may be because pregnancy reduces the activity of the immune system.
  3. Smoking - Smoking increases risk of rheumatoid arthritis in some people who have certain genes. For smokers in general, the risk of rheumatoid arthritis is significantly raised by having a lot of salt in the diet(2).
  4. Alcohol - Drinking moderate amounts of alcohol seems to lower the risk of rheumatoid arthritis(3). Once you have RA however it may be prudent to reduce your intake, especially if you are taking the drug methotrexate, which has been associated with liver damage in a small number of people.
  5. Other - Coffee and red meat are other food and drinks that are sometimes mentioned along with rheumatoid arthritis. The truth is however that there is little hard evidence that they are bad for people with RA.

Prognosis

While RA is a progressive autoimmune disease the speed of deterioration varies markedly betwen patients. With the correct medical treatment, lifestyle and diet many people will live long and full lives despite the condition.

The majority of sufferers (c. 75%) will experience quiescent periods, when their symptoms are minimal punctuated by flare ups when they suffer a lot more. Most of the remaining sufferers (c. 20%) will experience more continuous symptoms, although with the correct drugs, lifestyle and diet they can minimise the impact these symptoms have on their life. A small proportion (c. 5%) will suffer severe disability early on due to a more active form of the disease.

The long term risk of a certain type of cancer - lymphoma may be higher for people with rheumatoid arthritis (about twice the risk). To put that in context, it is still only a small risk. Some of this increased risk may be due to the drug methotrexate being used in combination with 6-mercaptopurine, both of which can be used to treat RA. However, lymphoma is normally treatable and on balance treatment with methotrexate is thought to confer more benefits in terms of reducing RA symptoms over a lifetime than costs in terms of lymphoma even for those few who develop the cancer. On a positive note, there appears to be a reduced risk of colon cancer with RA, again likely due to the drug treatments used.

The risk of cardiovascular disease is also increased with RA(4). How much of this is due to the inflammation that you get with RA is unclear. It certainly seems probable that the drugs used to treat RA are partly responsible, and this means that newer drug treatments could promise better outcomes in future(5).

Nutritional and physical therapy

There is good evidence that eating the right diet and being active can help reduce symptoms dramatically. 

Healing the gut

As with all other autoimmune conditions, making sure the gut is not damaged is key. It has been found that virtually everyone with an autoimmune condition has one of the following problems:

  1. Increased gut permeability
  2. Altered gut flora
  3. Gut infections
  4. Reduced stomach acid levels

Restrict gluten

There is some evidence that restricting gluten may benefit people with RA(7). My own take would be that there is a large subset of sufferers who really should eliminate gluten from their diet as it is highly likely to be causing problems, probably by increasing gut permeability. As many as one third of us are reactive in some way to gluten with 1% actually suffering with coeliac disease (overt gluten intolerance). As RA is an autoimmune disease it is very likely that a greater proportion of people with RA are sensitive in some way to gluten.

Consume probiotics and prebiotics

There is evidence that most people with RA have an altered population of bacteria in their guts. Taking regular probiotics such as unflavoured yoghurt can help(8). Also likely to help is consumption of starchy vegetables containing soluble fibres that feed the good bacteria - prebiotics. Examples include: potato, sweet potato, parsnip, swedes, turnips, celeriac, carrot, beetroot and squashes.

Example diet

Increasing amounts of glutathione, vitamin D and long chain fatty acids are key to improving symptoms. At the same time decreasing amounts of processed foods, smoking and excessive drinking will also help.

Oily fish such as salmon, trout, sardines and mackerel contain good amounts of omega 3 oils that have been found beneficial in cases of RA(9).

Exercise

Exercise is a powerful tool for improving health in most cases. Rheumatoid arthritis definitely comes into this category where regular movement of joints can help retain range of movement and ease long term pain. Specifically it has also been found to significantly reduce fatigue and improve sleep(10).

Drug therapy

Conventional medicine uses 2 main classes of drugs: DMARDs (disease modifying anti-rheumatic drugs) and others such as glucocorticoids and NSAIDs. DMARDs affect the course of the disease, whereas glucocorticoids and NSAIDs which are steroids and non-steroidal anti-inflammatories (NSAIDs) just reduce symptoms.

DMARDs - non-biologics

Many people with rheumatoid arthritis take a number of drugs, which is both expensive and increases the risk of side effects. The most common drug used nowadays is the non-biologic DMARD, methotrexate. This interferes with DNA production by mimicking folic acid. This results in:

  1. Reduced levels of inflammatory white blood cells that increase inflammation in RA.
  2. Less immune system activity, leading to increased risk of infection.
  3. Reduced cell proliferation that can damage foetuses in the womb. As such it is contraindicated in pregnant women.

Sometimes supplemental folic acid is taken, which has been show to help reduce the side effects(11). By taking folic acid on days that you don't take methotrexate, it is thought that you can gain more from the methotrexate and folate(12).

DMARDs - biologics

Biological agents are currently more expensive than non-biologics such as methotrexate. They are more specific in how they inhibit the activity of the immune system and are generally introduced when RA is not being controlled successfully with non-biological agents. Most have to be administered by injection.

Commonly used biologics such as Humira and Remicade seem ineffective in up to 1/3rd of patients and can also lose effectiveness over time. New types such as Xeljanz, that target different areas of the immune system, have been developed that may fill some of the gap.

Glucocorticoids and NSAIDs

Often used for short term relief when people are first diagnosed or when they have a flare up. This is because the DMARDs can take a few weeks to take effect. Prednisone is possibly the best known.

DrDobbin says

Most of the drugs used in Rheumatoid arthritis have potentially significant side effects. The reason they are being used is because they provide more in the way of relief than side effects. However, if you can reduce your need for these drugs by changing your lifestyle and diet you stand to live a longer and fuller life.

In particular I would advise:

  1. Cutting out gluten for a periods of 2 months to see if that has any beneficial effect.
  2. Avoiding processed food, cigarettes and excessive alcohol. 
  3. Consuming yoghurt and prebiotic fibres on a regular basis.
  4. Exercising regularly. Light stretching, mobilisation of the joints and some enjoyable endurance activity.

References

1) http://www.arthritisresearchuk.org/arthritis-information/conditions/rheu... testing for RA

2) http://www.ncbi.nlm.nih.gov/pubmed/25209067 smoking, salt and RA risk

3) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2937278/ reduced risk of RA with alcohol intake

4) http://onlinelibrary.wiley.com/doi/10.1002/art.24092/full risk of CVD

5) http://www.ncbi.nlm.nih.gov/pubmed/17324968

6) http://www.ncbi.nlm.nih.gov/pubmed/22553482 the gut flora and RA

7) http://rheumatology.oxfordjournals.org/content/40/10/1175.full gluten bad for RA

8) http://www.ncbi.nlm.nih.gov/pubmed/24355439 probiotics helping reduce symptoms

9) http://www.ncbi.nlm.nih.gov/pubmed/25149823 benefits from oily fish

10) http://www.ncbi.nlm.nih.gov/pubmed/25128510  benefits of exercise

11) http://www.ncbi.nlm.nih.gov/pubmed/23728635  folic acid

12) http://www.arthritisresearchuk.org/arthritis-information/q-and-a/drug-in...