Rheumatology; Advances in the Management of Rheumatoid Arthritis

Our understanding of the pathology and management of rheumatoid arthritis (RA) has evolved significantly over last two decades. Since the 2000’s it was known that irreversible joint damage occurred early in the disease and hence early use of disease-modifying anti-rheumatic drugs (DMARDs) was recommended. Despite the available knowledge managing patients of rheumatoid arthritis was always a challenge. The textbook criteria for diagnosing the disease hardly seemed helpful in identifying early disease. The use of sequential monotherapy resulted in relatively poor remission rates.

The evaluation of patients was mainly focused on musculoskeletal manifestations and other systemic complications which were often missed. This was despite the fact that association of atherosclerosis and rheumatoid arthritis was well known. The last decade has seen radical change in every domain of management of RA. This article aims to provide an overview of key advances that have taken place over the last decade, focusing on:

Advances in early diagnosis of RA Because of the need to make an early diagnosis of RA and lack of specific diagnostic tests, it became necessary to identify better diagnostic methods.

Anti-CCP antibody (second generation)

Assays that detect anti-citrullinated peptide antibodies (ACPA) have become popular in recent years for diagnosing early rheumatoid arthritis because they are believed to be more specific than rheumatoid factor tests, with similar sensitivity. Though the few RA antibodies were identified in the early 1960s, but complex assay requirements and uncertainty about their in vivo antigenic target delayed their widespread diagnostic use. In the past decade, investigators have made advances in detecting and understanding these antibodies. Citrullination, a posttranslational modification catalyzed by calcium-regulated peptidylarginine deiminases, has been identified as the key process in the formation of proteins reactive against ACPA.

A systematic review of the accuracy of anticitrullinated antibody in the diagnosis of RA concluded that the testing for second generation Anti CCP (Anti CCP2) should be part of work up of patients with early RA. However this relates more to the ability of Anti CCP to predict rapid radiologic disease progression rather than use in diagnosis of the disease.

Anti MCV antibody:

Auto-antibodies against mutated and citrullinated vimentin (MCV) represent a novel diagnostic marker for rheumatoid arthritis (RA). Anti-MCV anti

Magnetic Resonance Imaging (MRI):

Plain radiographs had limitations for early diagnosis as they only revealed evidence of joint damage. The advent of magnetic resonance imaging (MRI) has, however, made it possible to study very early inflammatory changes of RA such as synovitis, joint effusion and bone marrow oedema. Erosions can be seen on MRI as early as 4 months from onset of symptoms. Bone marrow oedema, the precursor of erosions and joint damage, can

Ultrasound:

Ultrasound seems more practical in use as it too can detect active inflammatory changes such as synovitis and increased synovial blood flow (the latter through Doppler ultrasound). It is more sensitive than clinical examination for detecting synovitis,12 and better than plain radiographs for detecting erosive changes13 . It is cheap and non-invasive with no risk of ionising radiation. The use of diagnostic ultrasound for earlier diagnosis of RA has greatly increased in the last few years, and training courses are now regularly offered for rheumatologists.

Clinical criteria with the availability of new diagnostic methods the need for a new clinical criterion was identified. American College of Rheumatology (ACR) and European League against Rheumatism (EULAR) developed new classification criteria for RA in 2010 aimed at early diagnosis (Table 1)14. These criteria are intended for patients with at least 1 joint with definite clinical synovitis (swelling, not just tenderness), and in whom the synovitis is not explained by another disease such as psoriasis, systemic lupus erythematosus, or gout. Patients are considered to have RA if they have a score of at least 6. These criteria are aimed at picking up early disease but do not intend to replace the clinical diagnoses which seem obvious in established disease.

Evaluation of treatment response

Early and aggressive therapy should be a part of management of all patients of rheumatoid arthritis as per recent guidelines. The concept of tight control has received much attention with the results of TICORA and CAMERA trials. In the Tight Control of Rheumatoid Arthritis (TICORA) study, patients in the “tight control,” or intensive, group had escalation of therapy if the specific cut off score was not achieved. In the routine therapy group clinical decisions were made based on clinician’s judgment every 3 month on follow up and no specific targets were planned. The intensive group had lower disease activity scores and higher disease remission rates than the routine therapy group. In the Computer Assistant Management in Early Rheumatoid Arthritis (CAMERA) trial, clinical decisions were made in accordance with computer decisions in the intensive group. On monthly follow up doses of methotrexate were adjusted to target a predefined quantitative response level. Both trials found reduced disease activity and radiographic progression and clinical remission in patients whose treatment was regularly adjusted than in those treated conventionally. These trials emphasized importance of using clinical assessment scores for appropriate results.

The recent developments in the management strategies for rheumatoid arthritis have made significant contribution to reducing the disease progression and improving outcomes of the patients. Identifying the candidates early in ‘window of opportunity” and aggressive target oriented approach can prove to be a boon to the patients in long run. The addition of biologic agents to the armamentarium of available disease modifying agents early in course of the disease can result in satisfying functional recovery and even remission in patients of RA. With judicious use of medications and careful monitoring quality of life of patients with RA can be surely improved.

I really like when I can use a standard protocol for a disease and receive consistently good results. This is especially true when it is a condition such as rheumatoid arthritis, an autoimmune condition. Specifically, “autoimmune disease” refers to a condition where the body mistakes its own tissues for foreign invaders such as bacteria and viruses and creates antibodies to seek out and destroy those specific tissues. In the case of rheumatoid arthritis, the body attacks its own synovial tissues within the joints.

Besides being an autoimmune disease, rheumatoid arthritis differs from the more common osteoarthritis in terms of cause. Where rheumatoid arthritis is characterized by redness, swelling and eventual crippled joints and may affect all tissues of the body including soft tissues, osteoarthritis is caused by wear and tear of the joints that occurs in most animals as a somewhat normal course of aging.

At the onset RA might first affect the small joints of the fingers and toes with symptoms of warm, redness, stiffness, and swelling in these joints.  Eventually this can spread to larger joints including hips, shoulders and knees with occasional periods of remission. RA can damage the joints within three to six months of onset and individuals with RA may be unable to work after 10 years. Furthermore, it can affect other tissues including the heart, lungs, vascular system, eyes, skin and blood. All of these further complicate diagnosis. Western medicine has no cure for RA.

There is a standard blood test for used to diagnose rheumatoid arthritis. Personally, I don’t refer to the RA factor blood test in my practice to treat a condition such as RA because traditional herbal medicine doesn’t require such a test. Furthermore, sometimes such tests applied to incurable diseases such as RA deepen a commitment in the patient’s mind to having a condition which from the body-mind perspective only makes rallying the complete healing forces of the body more difficult. Additionally, the RA factor test is unreliable; it can test positive in normal people and negative if there are other autoimmune conditions active in your body such as Sjogren’s disease, lupus, and viral hepatitis. Finally, I have treated many people who tested positive for RA successfully, provided the condition is not so advanced as to exhibit severe bone degeneration with twisted, crippled joints. In all cases, significant pain relief can be consistently achieved with the adoption of an anti-inflammatory diet and nature’s wonderful healing herbs.

It is estimated that approximately 41 out of 100,000 are diagnosed with RA per year and 1.3 million American have been diagnosed with it. The risk is somewhat higher for women and begins earlier in life than for men. Heart attack and stroke risk increases as much as 60% one year after diagnosis, people with RA are more liable to infections, and twice as likely to suffer from depression.

Drugs used to relieve symptoms are among the worst in terms of short- and long-term adverse effects. Drugs used in the treatment of RA include:

Nonsteroidal anti-inflammatory drugs (NSAIDs), which are the mildest pharmaceutical treatment option. They range from aspirin to many others including ibuprofen. These help to reduce inflammation but do not halt the progression of the disease. The next in line are corticosteroids, which quickly reduce inflammation and are supposed to be limited to short-term usage.

The next group of drugs is classified as disease-modifying antirheumatic drugs (DMARDs) which work to slow down the progression of RA and biologic DMARDs which are often used in combination to increase the efficacy of DMARDs.

Conventional medicine is beginning to acknowledge that dietary changes, lifestyle changes and herbs can relieve RA symptoms. My own clinical experience concurs with this.

There are few serious diseases that I can say seem to respond to a basic treatment protocol. However, so many patients who have come to me diagnosed with RA and osteoarthritis have responded positively to essentially the same basic protocol, which I share with you below.

Adopt an anti-inflammatory diet which consists of eliminating all refined white sugar, refined flour products, dairy, alcohol, and coffee. For some this may include gluten as well as other possible allergenic foods. Instead one should adopt a fiber-rich diet of organic fruits and vegetables, animal products such as naturally and organically raised animal foods, free-range chicken and eggs.

For many this may mean beginning with a special healing diet of kicharee based on a combination of rice (white or brown), split yellow mungs beans, and spices such as turmeric, cumin coriander and ghee.

Omega-3 fatty acids are well known to reduce inflammation throughout the body and are extremely beneficial for the treatment of RA. Various brands are of good quality including Nordic Naturals, Life Extension, Dr. Mercola’s krill oil, Carlsen’s, and Kirkland’s. I suggest a daily dose of 1000 to 1600 milligrams daily.

Alpha Lipoic Acid (ALA) is a powerful detoxifying antioxidant with special affinity for the liver and kidneys. ALA assists in converting glucose into energy, improves insulin sensitivity which asserts blood sugar control and is even known to reduce neuropathy in diabetics. It also naturally increases glutathione, the most powerful antioxidant that is produced naturally by our body. There are many fine products on the market, including Source Naturals time-released capsules available in 100, 300 and 600 mg doses, NOW Alpha Lipoic Acid, Pure Encapsulations Metabolic Xtra, and Vitacost. Take 200-600 mg daily.

A single daily good quality multivitamin should be taken for a few months to remedy any vitamin deficiencies. I use Source Natural’s Life Force Vitamins, but there are many other good quality multivitamins on the market. I usually like anything that now brand produces. Rainbow Light also has a fine multivitamin.

One should get moderate daily exercise; a vigorous walk or swim is excellent options. Yoga stretches, besides making for more flexibility and limberness, also work on activating the deep hormonal systems of the body – be careful to not overdo yoga when beginning as it can result in sprains and strains which may limit further exercise at least for a while. Remember, a personal exercise routine is not a competition. Any exercise can be overdone. All one needs is about a half hour daily.

If one has access and can afford it, a series of acupuncture treatments can be extremely beneficial, especially if the acupuncturist employs methods other than just needles such as moxibustion  (applying heat close to acupoints and areas on the body), gua sha (a relatively painless rubbing over specific areas), and cupping therapies. I feel confident that this protocol will absolutely relieve or cure most cases of early stage arthritic conditions of all kinds (before deformity has occurred) and relieve inflammation and pain generally in all cases.