Rheumatoid Arthritis
Rheumatoid Arthritis (RA) is an autoimmune disease that affects approximately 1.3 million Americans. Women are 2-3 times more likely to develop RA than men. It generally starts between the ages of 30 and 60 in women and later in life in men. The lifetime risk of developing RA is 3.6 percent for women and 1.7 percent for men. However, RA can strike at any age — even small children can get it.
What is Rheumatoid Arthritis (RA)?
Image Credit: https://www.practicalpainmanagement.com/patient/conditions/rheumatoid-arthritis/closer-look-rheumatoid-arthritis-symptoms
Rheumatoid arthritis is a chronic inflammatory disorder that can affect more
than just your joints. In some people, the condition can damage a wide variety of body systems, including the skin, eyes, lungs, heart and blood vessels.
Considered to be an autoimmune disorder, rheumatoid arthritis occurs when your immune system mistakenly attacks your own body's tissues.
Unlike the wear-and-tear damage of osteoarthritis, rheumatoid arthritis affects the lining of your joints, causing a painful swelling that can eventually result in bone erosion and joint deformity.
The inflammation associated with rheumatoid arthritis is what can damage other parts of the body as well. While new types of medications have improved treatment options dramatically, severe rheumatoid arthritis
can still cause physical disabilities.
What are the symptoms of Rheumatoid Arthritis?
Signs and symptoms of rheumatoid arthritis may include:
• Tender, warm, swollen joints
• Joint stiffness that is usually worse in the mornings and after inactivity
• Fatigue, fever and loss of appetite
Early rheumatoid arthritis tends to affect your smaller joints first particularly the joints that attach your fingers to your hands and your toes to your feet. As
the disease progresses, symptoms often spread to the wrists, knees, ankles, elbows, hips and shoulders. In most cases, symptoms occur in the same joints on both sides of your body.
About 40% of people who have rheumatoid arthritis also experience signs and symptoms that don't involve the joints. Areas that may be affected include:
• Skin
• Eyes
• Lungs
• Heart
• Kidneys
• Salivary glands
• Nerve tissue
• Bone marrow
• Blood vessels
Rheumatoid arthritis signs and symptoms may vary in severity and may even come and go. Periods of increased disease activity, called flares, alternate with periods of relative remission when the swelling and pain fade or disappear. Over time, rheumatoid arthritis can cause joints to deform and shift out of place.
What causes Rheumatoid Arthritis?
Rheumatoid arthritis is an autoimmune disease. Normally, your immune system helps protect your body from infection and disease. In rheumatoid arthritis, your immune system attacks healthy tissue in your joints. It can also cause medical problems with your heart, lungs, nerves, eyes and skin.
Doctors don't know what starts this process, although a genetic component appears likely. While your genes don't actually cause rheumatoid arthritis, they can make you more likely to react to environmental factors such as infection with certain viruses and bacteria that may trigger the disease.
What are the risk factors for Rheumatoid Arthritis?
Factors that may increase your risk of rheumatoid arthritis include:
• Your sex - Women are more likely than men to develop rheumatoid arthritis.
• Age - Rheumatoid arthritis can occur at any age, but it most commonly begins in middle age.
• Family history - If a member of your family has rheumatoid arthritis, you may have an increased risk of the disease.
• Smoking - Cigarette smoking increases your risk of developing rheumatoid arthritis, particularly if you have a genetic predisposition for
developing the disease. Smoking also appears to be associated with greater disease severity.
• Excess weight - People who are overweight appear to be at a somewhat higher risk of developing rheumatoid arthritis.
What treatments are available for Rheumatoid Arthritis?
Medications
The types of medications recommended by your doctor will depend on the severity of your symptoms and how long you've had rheumatoid arthritis.
• NSAIDs - Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain and reduce inflammation. Over-the-counter NSAIDs include ibuprofen (Advil) and naproxen sodium (Aleve). Stronger NSAIDs are available by prescription. Side effects may include stomach irritation, heart problems and kidney damage.
• Steroids - Corticosteroid medications, such as prednisone, reduce inflammation and pain and slow joint damage. Side effects may include thinning of bones, weight gain and diabetes. Doctors often prescribe a corticosteroid to relieve symptoms quickly, with the goal of gradually tapering off the medication.
• Conventional DMARDs - These drugs can slow the progression of rheumatoid arthritis and save the joints and other tissues from permanent damage. Common DMARDs include methotrexate, leflunomide, hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine). Side effects vary but may include liver damage and severe lung infections.
• Biologic agents - Also known as biologic response modifiers, this newer class of DMARDs includes abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi), infliximab (Remicade), rituximab (Rituxan), sarilumab (Kevzara) and tocilizumab (Actemra). Biologic DMARDs are usually most effective when paired with a conventional DMARD, such as methotrexate. This type of drug also increases the risk of infections.
• Targeted synthetic DMARDs - Baricitinib (Olumiant), tofacitinib (Xeljanz) and upadacitinib (Rinvoq) may be used if conventional DMARDs and biologics haven't been effective. Higher doses of tofacitinib can increase the risk of blood clots in the lungs, serious heart-related events and cancer.
Therapy
Your doctor may refer you to a physical or occupational therapist who can teach you exercises to help keep your joints flexible. The therapist may also suggest new ways to do daily tasks that will be easier on your joints. For example, you may want to pick up an object using your forearms.
Assistive devices can make it easier to avoid stressing your painful joints. For instance, a kitchen knife equipped with a hand grip helps protect your finger and wrist joints. Certain tools, such as buttonhooks, can make it easier to get dressed. Catalogs and medical supply stores are good places to look for ideas.
Surgery
If medications fail to prevent or slow joint damage, you and your doctor may consider surgery to repair damaged joints. Surgery may help restore your ability to use your joint. It can also reduce pain and improve function.
Rheumatoid arthritis surgery may involve one or more of the following procedures:
• Synovectomy - Surgery to remove the inflamed lining of the joint (synovium) can help reduce pain and improve the joint's flexibility.
• Tendon repair - Inflammation and joint damage may cause tendons around your joint to loosen or rupture. Your surgeon may be able to repair the tendons around your joint.
• Joint fusion - Surgically fusing a joint may be recommended to stabilize or realign a joint and for pain relief when a joint replacement isn't an option.
• Total joint replacement - During joint replacement surgery, your surgeon removes the damaged parts of your joint and inserts a prosthesis made of metal and plastic.
Surgery carries a risk of bleeding, infection and pain. Discuss the benefits and risks with your doctor.
Lifestyle and Home Remedies
You can take steps to care for your body if you have rheumatoid arthritis. These self-care measures, when used along with your rheumatoid arthritis medications, can help you manage your signs and symptoms:
• Exercise regularly - Gentle exercise can help strengthen the muscles around your joints, and it can help reduce fatigue you might feel. Check with your doctor before you start exercising. If you're just getting started, begin by taking a walk. Avoid exercising tender, injured or severely inflamed joints.
• Apply heat or cold - Heat can help ease your pain and relax tense, painful muscles. Cold may dull the sensation of pain. Cold also has a numbing effect and can reduce swelling.
• Relax - Find ways to cope with pain by reducing stress in your life. Techniques such as guided imagery, deep breathing and muscle relaxation can all be used to control pain.
Alternative Medicine
Some common complementary and alternative treatments that have shown promise for rheumatoid arthritis include:
• Fish oil - Some preliminary studies have found that fish oil supplements may reduce rheumatoid arthritis pain and stiffness. Side effects can include nausea, belching and a fishy taste in the mouth. Fish oil can interfere with medications, so check with your doctor first.
• Plant oils - The seeds of evening primrose, borage and black currant contain a type of fatty acid that may help with rheumatoid arthritis pain and morning stiffness. Side effects may include headache, diarrhea and gas. Some plant oils can cause liver damage or interfere with medications, so check with your doctor first.
• Tai chi - This movement therapy involves gentle exercises and stretches combined with deep breathing. Many people use tai chi to relieve stress in their lives. Small studies have found that tai chi may improve mood and quality of life in people with rheumatoid arthritis. When led by a knowledgeable instructor, tai chi is safe. But don't do any moves that cause pain.
What is Low Dose Naltrexone?
LDN is a prescription drug that helps to regulate a dysfunctional immune
system. It reduces pain and fights inflammation. It is not a narcotic or a
controlled substance. It is an opioid receptor antagonist that is taken orally to block opioid receptors. An antagonist is a chemical that acts within the body to reduce the physiological activity of another chemical substance.
Naltrexone was approved by the FDA in 1984 for the treatment of opioid addiction, usually at a dose of 50-100mg a day. It blocks the receptors that opioids like oxycodone bind to negating the euphoric effect. However, at much lower doses, naltrexone has been used for autoimmune disorders like
Hashimoto’s disease as well as chronic pain.
For more information on how LDN works, please click here.
Image Credit: https://pubchem.ncbi.nlm.nih.gov/compound/Naltrexone
How does LDN provide relief?
Before we discuss how LDN works, we need to go over the role of endorphins in the body. Endorphins are opiate-like molecules in the body. They are produced in most cells in the body and are important regulators of cell growth and the immune system. The particular endorphin that has been found to influence cell growth is called Opioid Growth Factor (OGF). For an endorphin such as OGF to exert its beneficial effects, it must interact with the body’s cells. It does this by binding to a receptor on the surface of the cells.
Naltrexone is an orally administered drug that binds to opioid receptors. In doing so, it displaces the endorphins which were previously bound to the receptors. Specifically, by binding to the OGF receptors, it displaces the body’s naturally produced OGF. As a consequence of this displacement, the affected cells become deficient in OGF and three things happen:
1) Receptor production is increased, in order to try to capture more OGF.
2) Receptor sensitivity is increased, also to try to capture more OGF.
3) Production of OGF is increased, in order to compensate for the perceived shortage of OGF.
Since LDN blocks the OGF receptors only for a few hours before it is naturally excreted, what results is a rebound effect; in which both the production and utilization of OGF is greatly increased. Once the LDN has been metabolized, the elevated endorphins produced as a result of the rebound effect can now interact with the more-sensitive and more-plentiful receptors and assist in regulating cell growth and immunity. The elevated level of endorphins can result in an enhanced feeling of well-being as well as a reduction in pain and inflammation. The duration of the rebound effect varies from person to person but generally lasts about one day. This effect can only be utilized by taking a low dose of naltrexone and not a high dose or extended-release naltrexone.
What does the research show?
Research has been done over the years evaluating how LDN and its use in Rheumatoid Arthritis patients. Some of the studies that have been published are smaller studies but show promise for the treatment of chronic pain using LDN. Studies include:
• PLOS One - showed that patients taking LDN decreases use of other medications including NSAIDs, opioids, and DMARDs.
• American Journal of Hospice and Palliative Medicine - showed anti-inflammatory effects and increased endogenous opioid production of LDN leading to pain relief.
For a list of more studies, please click here.
What dosage forms are available?
LDN is available by prescription only from compounding pharmacies. It is available as an immediate-release oral capsule or a liquid. LDN is typically prescribed at doses from 0.001mg-16mg with the most common dose of 4.5 mg.
Ask your doctor or one of our compounding pharmacists if LDN is right for you.
Sources:
https://www.healthline.com/health/rheumatoid-arthritis/facts-statistics-infographic#Symptoms-and-risk-factors
https://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/symptoms-causes/syc-20353648
https://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/diagnosis-treatment/drc-20353653
https://pubmed.ncbi.nlm.nih.gov/30917675/
https://pubmed.ncbi.nlm.nih.gov/30763385/