chapter 48 - Rheumatoid Arthritis from Rakel: Integrative Medicine on MD Consult

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Rakel: Integrative Medicine, 2nd ed.
Copyright © 2007 Saunders, An Imprint of Elsevier

chapter 48 – Rheumatoid Arthritis

Daniel Muller, MD, PhD Pathophysiology 531 Integrative Therapy 532 Exercise 532 Physical and Occupational Therapy 532 Mind-Body Therapy 532 Nutrition 532 Elimination of Tobacco Use 532 Supplements 532 Botanicals 533 Pharmaceuticals 533 Acupuncture 536 Low-Level Laser Therapy 536 Surgery 536 Therapies to Consider 536 Prevention Prescription 536 Therapeutic Review 537
Pathophysiology

Rheumatoid arthritis (RA) is likely caused by a pathologic immune response in a genetically predisposed person to an environmental insult, likely a viral or bacterial infection. [1] Epidemiologic studies show that genes encoding the class II major histocompatibility antigens are linked to clinical features of RA. The HLADR4 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 disease by presenting an “arthritogenic” viral or bacterial antigen to T cells. However, no organism has been definitively linked to the etiology of RA. Antibiotic therapy with minocycline is helpful in mild disease. However, minocycline may act through direct immunomodulatory or anti-inflammatory effects rather than acting 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, since inhibitors of these molecules decrease disease activity. [2] [3] [4] [5] Similarly, the importance of the roles of cell surface molecules on B and T cells can be shown when used as targets for immunomodulatory therapy. [2] [3] [4] [6] [7] Nonsteroidal anti-inflammatory drugs (NSAIDs) act to inhibit the enzymes that produce inflammatory prostaglandins, particularly thromboxanes and leukotrienes. The newer NSAIDs preferentially inhibit the cyclo-oxygenase (COX)-2 enzyme that produces certain of these inflammatory molecules. Unfortunately, these COX-2 inhibitors may have increased thrombotic and, hence, cardiovascular risks, and may not have any increased gastroprotection. [8] [9] Celecoxib (Celebrex) is still on the market, albeit with increased warnings; other COX-2 inhibitors have been withdrawn from the market. Omega-3 fatty acids and certain botanicals such as ginger and turmeric also may act through decreasing the production or activity of inflammatory prostaglandins. [10] [11] [12] [13] [14] The neural, endocrine, and immune systems all share communication molecules that interact extensively. Molecules from the hypothalamic-pituitary-adrenal axis, particularly cortisol and corticotropin-releasing

http://0-www.mdconsult.com.millenium.itesm.mx/das/book/body/149218586-2/0/149... 11/07/2009

The AntiInflammatory Diet). ambulatory aids.itesm. Joint protection from deformities can be aided by education and use of splints. However. such as walnuts. reduction in intake is worthwhile (see Chapter 88 . Nutrition Food Triggers Fasting clearly decreases symptoms in RA. or hempseed. orthotics. In turn. [27] A small percentage of people with RA appear to have a food intolerance that exacerbates their disease. however. symptoms rapidly recur with the resumption of food intake.com. but weight training and walking work better to decrease bone loss (osteoporosis). wheat. Stretching muscles can help decrease flexion contractures. or nuts. and from nuts. relieving symptoms by 25% or more (see Chapter 98 . [15] Corticosteroid drugs have powerful disease-suppressing activity. leading to muscle disuse and atrophy. psychological factors and depression accounted for at least 20% of disability in patients with RA. Massage and local heat and cold applications can decrease inflammation. greater than the 14% attributable to articular signs and symptoms.Rheumatoid Arthritis from Rakel: Integrative Medicine on MD Consult Page 2 of 11 factor. helplessness had a direct effect on disease activity. can provide modest improvement in the control of RA. 1-800488-4940). such as salmon. The Arthritis Foundation has information on programs (1-800-283-7800). a much larger number believe that certain foods exacerbate symptoms. [26] There are no published studies investigating the role of meditation in RA. and relax muscles. [10] [11] [27] The role of saturated fatty acids (trans fats) in increasing symptoms is unproved. [25] A recent study of meditation in psoriasis. an autoimmune inflammatory skin disease. leading to increased joint stability. A form of Tai Chi called the range of motion (ROM) dance is particularly suited to persons with disabilities (www. Simply writing in a journal about positive and negative emotions for 15 minutes a day can be powerful medicine. [23] Integrative Therapy Exercise Joint pain can inhibit activity. However. Goals are to improve range of motion and strengthen muscles.mdconsult.. The offending foods are usually dairy products.millenium.. Mind-Body Therapy Self-help courses given through the Arthritis Foundation provide information about diseases and medication and can help in developing coping skills. and from the sympathetic-adrenal-medullary system are linked to disease activity in RA. [21] In one study. Aerobic exercise improves mood.chapter 48 . http://0-www.mx/das/book/body/149218586-2/0/149. however.romdance. in view of their association with cardiovascular disease. Other environmental factors such as nutrition. Light weight training can maintain or even increase muscle strength around joints. 11/07/2009 . [24] Meditation has been shown to be helpful for chronic pain. but this effect cannot be shown in blinded trials of food exposure. muscle atrophy can lead to decreased stability of joints.com . Asian exercise disciplines such as Tai Chi and Yoga can also be beneficial. flaxseed. Water exercise can be helpful because it is less stressful on joints. and helps control weight gain. Physical and Occupational Therapy Physical therapy and occupational therapy programs can be invaluable in the treatment of RA. and tobacco also may contribute to the increased risk of RA. Journaling). increase circulation. [22] In another study. An elimination diet for 2 weeks with the reintroduction of the suspected food can be done with or without the supervision of a physician or a nutritionist (see Chapter 86 . Adverse Food Reactions and the Elimination Diet). citrus. Omega-3 and Omega-9 Fatty Acids Increased intake of omega-3 fatty acids from cold-water fish. with equally powerful adverse side effects such as osteoporosis. and other devices. coffee. decreases fatigue. Recommending Meditation). a study examining this question is underway (see Chapter 100 . [18] [19] [20] Stress and psychological factors have been linked to the etiology of RA and to disease exacerbations. [16] [17] Prolactin and the estrogenic and androgenic sex hormones have been postulated to play roles as well. showed decreased time to clearing the skin disease.

RA patients should be counseled to avoid tobacco. Other risks include bleeding. the equivalent of 6 to 11 gm of borage oil daily. [14] Dosage As powdered root. therefore. [18] [20] Intake should be decreased to below this level. One study has shown an association between smoking and increased risk of RA. also has been shown to be helpful. [13] Dosage As the dried root.chapter 48 .. [29] Botanicals Ginger Ginger (Zingiber officinale) may have efficacy in RA by inhibiting inflammatory prostaglandins. [12] Vitamin E should be taken at 800 IU daily as mixed tocopherols. 1. Recommended intake of calcium to prevent osteoporosis is 1500 mg daily. It is probably prudent to add magnesium at 400 to 750 mg daily and a vitamin D supplement at 800 IU per day. and vitamin C at 250 mg twice per day.mdconsult. hypertension or hypotension. Omega-9 fatty acids in olive oil may confer anti-RA activity.8 gm/day. 1 gm two or three times per day to start. [19] Supplements Essential Fatty Acids Omega-3 fatty acids can be increased by dietary means or through supplementation. vitamin E has some analgesic effects. 0. Antioxidants Antioxidant vitamins may be helpful in RA. increase up to 4 gm daily. Elimination of Tobacco Use Smoking causes oxidant stress on connective tissue. not to exceed 400 μg daily.. [11] Effects may not be felt for 6 weeks or more. Approximate doses for supplementation are eicosapentaenoic acid 30 mg/kg/day and docosahexaenoic acid 50 mg/kg/day.com. and hypoglycemia. As a tea.Rheumatoid Arthritis from Rakel: Integrative Medicine on MD Consult Page 3 of 11 Cooked vegetables and olive oil have been found to be independently protective for the development of RA. Turmeric Turmeric (curcumin) in an open trial has been shown to be similar to NSAIDs in efficacy. 1 gm of dried root steeped in 150 mL of boiling water for 5 to 10 minutes and strained. intake should be at least 100 μg daily. [10] [27] Gamma-linolenic acid (GLA). for the possible benefit from its antioxidant polyphenols. 11/07/2009 . Additionally. Selenium can be found in many foods. use 1 cup up to four times daily. including nuts. or the patient can switch to green tea.itesm.millenium. [28] Coffee A high intake of coffee (four or more cups a day) has been linked to increased risk of RA. It can also be taken in 500-mg capsules for a dose of 1 gm two or three times a day.mx/das/book/body/149218586-2/0/149. as evident from the increased wrinkles seen in longterm smokers.5 to 1 gm two or three times daily Precautions http://0-www. Precautions The stimulation of increased bile flow can cause pain in the presence of cholelithiasis. and continued improvement may occur after many months.4 to 2. as they seem to be in osteoarthritis.

Antibiotics Antibiotics. In some patients. For disease flares in isolated joints.. photosensitivity rash. [8] Two other COX-2 inhibitors have been withdrawn from the market.chapter 48 . This approach can often control disease for 1 to 2 months. a low dose of corticosteroids appears necessary for optional function. poses significant risks for gastrointestinal bleeding.5 to 40 mg can be given to control local disease. acne. With long-term use. adalimumab. [16] [17] A common method of treating a flare is to give a long-acting depot preparation such as triamcinolone acetonide (Kenalog) 80 mg intramuscularly. and impaired fertility Echinacea should be avoided by patients with RA. Both have antiplatelet activity. cushingoid features.Rheumatoid Arthritis from Rakel: Integrative Medicine on MD Consult Page 4 of 11 Risks include bleeding. an intra-articular injection of triamcinolone 2.. [30] Side effects include gastrointestinal intolerance. osteoporosis is a significant risk with doses above 7. leflunomide. The long-term use of NSAIDs. Disease-Modifying Antirheumatic Drugs DMARDs are also referred to as slow-acting antirheumatic drugs (SAARDs) because they usually take 6 weeks to 3 months to show activity. prednisone 5 to 7. These drugs also have the potential for renal toxicity and are no more effective than older NSAIDs. for possible decreased gastrointestinal toxicity has been called into question. Recent data point to the risk of increased thrombosis in patients taking COX-2 inhibitors who have a preexisting increased risk of thrombosis or cardiovascular disease. the use of all U. High and even moderate doses can lead to avascular necrosis of joints such as the hip. often within a few hours at high doses. Other risks include atherosclerosis. The patient should be hospitalized overnight for joint aspiration to obtain culture specimens. gastrointestinal intolerance. because the tetracyclines also show immunomodulatory and anti-inflammatory activities. cyclophosphamide. vaginitis. skin and gingival discoloration. http://0-www. and many of the newer ones are restricted on some formularies. Often a minor disease flare can be treated with a moderately high dose such as 30 to 40 mg of prednisone orally and a rapid taper over the course of 1 to 2 weeks. The salutary effects of these agents may not be due to their antibacterial activity. Food and Drug Administration (FDA)– approved DMARDs is supported by Cochrane reviews including low-dose steroids.S. particularly minocycline (Minocin) in a twice-daily dose of 100 mg. However. once infection is ruled out. There are many NSAIDs.mx/das/book/body/149218586-2/0/149. Celecoxib is used in a dose of 200 mg twice daily. this is a rare occurrence. and infection. 11/07/2009 .mdconsult. 48-1 ).itesm. diabetes mellitus. Pharmaceuticals Nonsteroidal Anti-inflammatory Drugs NSAIDs can be used short term with minor risk of gastrointestinal toxicity. disability and joint replacement may be avoided. Note. luckily.millenium. dizziness.5 mg daily is often used for this purpose. The advantage of using the COX-2 inhibitor. hepatic. followed by administration of intravenous antibiotics until results of culture are known. and. long enough for the slower acting disease-modifying antirheumatic drugs (DMARDs) to start working. azathioprine. celecoxib. The classic NSAIDs are ibuprofen (Motrin) used in a dose of 800 mg three times daily and naproxen (Naprosyn) in a dose of 500 mg twice daily. etanercept. sulfasalazine. With proper care and early diagnosis of avascular necrosis. methotrexate (with folic acid). and kidney injury. [9] Note that celecoxib shares a lack of antiplatelet effects with other newer NSAIDs. lung. since there have been anecdotal reports of increased symptoms in persons with autoimmune disease. rarely. hydroxychloroquine. may be useful in patients with less severe disease. both short. or shoulder. Corticosteroids Corticosteroids can rapidly decrease RA symptoms. knee.and long-term toxic effects are well known. A single joint with severely decreased range of motion and increased pain is presumed to be infected until proven otherwise. and infliximab ( Fig. blood should also be drawn for cultures. particularly in the elderly.5 mg daily of prednisone or equivalent.com.

SQ. Both drugs have little short. intramuscular.and long-term toxicity. then every 2 months if normal. Precautions http://0-www. creatinine) before starting. ▪ HYDROXYCHLOROQUINE AND SULFASALAZINE Hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine-EN) each are used early in disease when a diagnosis may not be clear or there is no characteristic erosive disease. SSZ. Dosage The current accepted dose of hydroxychloroquine is 200 mg twice daily. To reduce gastrointestinal intolerance. 11/07/2009 . fatty acid. nevertheless. IM. magnesium.millenium. add 1 mg of folic acid by mouth daily to decrease side effects. an ophthalmologic examination to test for retinal toxicity is recommended every 6 to 12 months. calcium. then every 2 weeks for 6 weeks. albumin. FA. TB. which carries little risk of toxicity. vits.Rheumatoid Arthritis from Rakel: Integrative Medicine on MD Consult Page 5 of 11 FIGURE 48-1 Treatment algorithm for rheumatoid arthritis (RA) in adults. decrease the dose of MTX to 10 to 15 mg once per week. differential. * When starting methotrexate (MTX). subcutaneous.mdconsult. Ca. aspartate aminotransaminase. Se. platelets. selenium. tuberculosis. sulfasalazine. sulfasalazine is usually used in an enteric-coated form. hydroxychloroquine. Mg.com. warn patient to avoid alcohol. vitamins. and schedule laboratory studies (complete blood count.itesm. HCQ.mx/das/book/body/149218586-2/0/149.. † When adding another diseaseremitting antirheumatic drug (DMARD) to MTX.chapter 48 . dosing is started at 500 mg a day and raised by 1 tablet every few days until a dose of 1 gm twice daily is reached..

Use of these agents carries a risk of life-threatening exacerbations of severe infections. albumin.Rheumatoid Arthritis from Rakel: Integrative Medicine on MD Consult Page 6 of 11 Hydroxychloroquine when used in high doses carries a risk of retinal toxicity due to deposition of the drug into the retina. As many as 30% of patients may show almost complete remission of symptoms with the combination of methotrexate and an anti-TNF agent. adalimumab is given subcutaneously once every 2 weeks. and leukopenia.. anakinra (Kineret). yet few patients achieve remission. and recent malignancy. All patients must be tested for latent tuberculosis using the PPD skin test before beginning therapy. A complete blood count. An additional biologic directed toward another cytokine FL-6 (tocilizumab) is nearing final testing and approval for use in RA. including myself.com. especially sepsis. unwillingness to discontinue alcoholic beverages. its use is associated with gastrointestinal and bone marrow toxicity. recommend starting higher doses such as 10 to 15 mg/week. however. [32] Leflunomide interferes with pyrimidine synthesis. Agents directed toward a cell surface molecule on Bcells (rituximal. Azathioprine (Imuran) is metabolized to 6mercaptopurine and interferes with inosinic acid synthesis. usually methotrexate. the liquid form can be used orally and is sometimes less expensive. Leflunomide (Arava) is a newer drug that is similar in efficacy to methotrexate. and infliximab (Remicade) are TNF inhibitors. tacrolimus (Prograf). Leflunomide has fewer hepatotoxic effects and possibly little bone marrow toxicity but is much more likely to cause diarrhea. Doses of methotrexate for RA are usually between 5 and 25 mg given once a week. and chlorambucil (Leukeran). patients are often taught to self-administer the dose subcutaneously once per week to avoid possible problems with gastrointestinal absorption. To decrease side effects. and headache. [31] Methotrexate is a folate antagonist and has a multitude of immunomodulatory activities. There are many side effects. Other immunosuppressive drugs less commonly used are mycophenolate mofetil (CellCept). The dose is usually given orally in tablet form. A baseline hepatitis screen and chest radiography are recommended.chapter 48 . monitoring can be done every 4 to 8 weeks. cyclosporine (Neoral). to reduce the development of autoantibodies. and creatinine levels are done initially and then every 2 weeks for 6 weeks after methotrexate therapy is begun. I always prescribe folic acid 1 to 2 mg to be taken each day. hepatotoxicity. whereas infliximab is usually given intravenously once every 2 months. [6] and a costimulatory molecule on T cells (abatacept). Other Immunosuppressive Drugs Many other immunosuppressive drugs are used in RA. and determination of aspartate transaminase. These drugs also may exacerbate demyelinating disorders. Contraindications to use of methotrexate include preexisting hepatic. A common practice is to start with 7. Patients should temporarily discontinue the anti-TNF therapy during presumed infections and restart the therapy when the infection has resolved. ▪ METHOTREXATE Of all of the so-called DMARDs. Tuberculosis skin testing is reserved for patients with strong risk factors or abnormal appearance on chest radiograph. [7] have been recently approved for use in RA. with little toxicity. There are no data on long-term safety and efficacy. nausea. although many practitioners.millenium.mdconsult. methotrexate (Rheumatrex) has been shown to be tolerated for longer periods of treatment than any other drug. These drugs are most often used with another DMARD. http://0-www. they should be avoided in patients with suspected or proven multiple sclerosis or optic neuritis. Recombinant Biologics Recent advances in the therapy of RA targets cytokines and cell surface molecules used to communicate between cells of the immune system. Methotrexate is the standard by which all other drugs are judged.mx/das/book/body/149218586-2/0/149. is approved for the treatment of RA. however. Ritoxin). platelet count. A decision to start methotrexate therapy or to raise or decrease the dose should be placed in the hands of a practitioner with extensive experience. bone marrow suppression. therefore. the most prominent being hepatitis. and less than a majority achieve a 50% improvement on composite scores. Short-term safety is very high. but its exact mechanism of action in RA is unknown.. or pulmonary disease. Cyclophosphamide (Cytoxan) is often used to treat rheumatoid vasculitis. [2] [3] [4] Etanercept (Enbrel). renal. Sulfasalazine can uncommonly cause rash. whereas methotrexate interferes with purine synthesis. adalimumab (Humira). Thereafter. mouth sores.5 mg orally once per week. pneumonitis. It is often is substituted for methotrexate. An IL-1 receptor antagonist. It is given subcutaneously daily and also increases the risk of serious infection. [33] [34] [35] Etanercept is given subcutaneously once or twice per week. With use of higher doses of 20 mg and more. 11/07/2009 .itesm.

[37] Surgery Loss of joint function and intractable pain may be indications for surgical intervention. I recommend mindfulness meditation. Make sure to balance your protein intake. or spiritual therapies in the management of RA.chapter 48 . They may then choose to visit a practitioner of a selected modality for a trial of the techniques. A recent Cochrane review suggests that LLLT could be considered for short-term relief of pain and morning stiffness for RA patients. Combine aerobics. read funny books. the following can be recommended: ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ Laugh as much as possible. and not thermal effects. 11/07/2009 . Ask what gives you the energy to get up in the morning. get up every morning and force yourself to laugh. dance. Eat well. Do art. If the economic burden is not too great. Cervical spine disease can lead to spinal instability and risk of neurologic injury. in any but the mildest cases of RA. Meditate. Make a list of 25 things for which you are grateful.mdconsult. Therapies to Consider There have not been adequate studies on the role of traditional Chinese medicine or Ayurvedic. Investigate your personality. [38] Try new things that you are afraid to do. the rates of extraarticular manifestations of RA. Watch funny movies.itesm. Eliminate coffee. homeopathy. on cells. Joint replacement can help restore function and increase independent activity. However.Rheumatoid Arthritis from Rakel: Integrative Medicine on MD Consult Acupuncture Page 7 of 11 A single small controlled trial of acupuncture in RA showed decreased knee pain for an average of 1 to 3 months. and make sure you have an adequate vitamin intake. Replacement of one joint can result in increased stress on other joints during recovery and rehabilitation.com. Make high-sugar desserts a small. play an instrument. If you feel stuck. particularly since it has few side effects. You'll find it is awkward at first. and alcohol. seem to be decreasing. THERAPEUTIC REVIEW Evidence is accumulating that current allopathic treatments are successful in slowing joint destruction and in decreasing the mortality associated with RA. Find “positive” support groups. Find meaning in life.mx/das/book/body/149218586-2/0/149.. PREVENTION PRESCRIPTION There are no proven methods of preventing RA. strength training. hence. Note that long-term corticosteroid use can cause fragility of vessels and connective tissue. Patients should learn about several different modalities and then record their feelings about these modalities in a journal. beat a drum. Exercise. further exploration of that therapeutic modality may be in order. Synovectomy can be helpful when systemic therapy and intra-articular corticosteroids are ineffective. find a good psychotherapist. but it works anyway! Journal about stressful events. Try a vegetarian diet. Patients with RA have an increased risk of surgical and postoperative complications. Therefore. Hang out with “positive people. [36] Low-Level Laser Therapy Low-level laser therapy (LLLT) uses a single wavelength laser source that likely has photochemical effects. [31] [33] [34] [35] [39] In addition. write poetry or prose. Make it a time to play! Love people. such as Felty's syndrome and rheumatoid vasculitis.millenium. Be creative.. rare treat. and stretching. smoking. increasing the risks of surgery. an integrated approach should include the http://0-www.” make sure they outweigh the “negative” people in your life.

wheat. Physical therapy can be used initially for instruction. tobacco. Journaling). or nuts.itesm. The Anti-Inflammatory Diet). mind.chapter 48 . Recommended intake of calcium is 1. magnesium 400-750 mg daily and a vitamin D supplement of 800 IU/day are also recommended. turmeric 0.Rheumatoid Arthritis from Rakel: Integrative Medicine on MD Consult so-called DMARDs. 11/07/2009 .. Most patients are given methotrexate therapy unless there are contraindications or side effects. ▪ 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. Most patients with RA are receiving combinations of drugs.5-1 gm bid-tid can be tried. and vitamin C in a dose of 250 mg bid.5 gm daily. and alcohol should be eliminated. ▪ Pharmaceuticals • • • NSAIDs are used as little as possible owing to gastrointestinal toxicity. If no effect is seen after 6-8 weeks.mdconsult. ▪ Botanicals • • Start with ginger at 1 gm bid to a maximum of 4 gm daily.4-2. usually starting with methotrexate. Celecoxib dose is 200 mg bid.com. Journaling should be encouraged (see Chapter 98 . Selenium intake as nuts or supplements should be at least 100 μg daily.mx/das/book/body/149218586-2/0/149. Olive oil should be increased in the diet as well.8 gm/day. Adverse Food Reactions and the Elimination Diet). The classic NSAIDs are ibuprofen 800 mg tid and naproxen 500 mg bid. An antiinflammatory diet is also recommended (see Chapter 88 .. • Vitamin E should be taken in a dose of 800 IU daily as mixed tocopherols. a trial of an elimination diet for 2 weeks with the reintroduction of the suspected food can be undertaken. Also recommended are relaxation exercises and the development of methods to cope with stress. With suspected intolerance to dairy products. Tai Chi in the form of the range-of-motion dance can be helpful. • ▪ Removal of Exacerbating Factors • Use of coffee. ▪ Supplements • Omega-3 fatty acids are recommended. along with GLA 1. http://0-www. and spirit. not to exceed 400 μg daily. citrus. ▪ Exercise • Page 8 of 11 Muscle strengthening and stretching can be invaluable for maintaining function. ▪ Mind-Body Techniques • Meditation is highly recommended for RA patients willing to devote the daily time to looking more closely at the connection among body. (see Chapter 86 . The COX-2 inhibitors decrease but do not eliminate the risk of gastrointestinal bleeding. doses for supplementation are eicosapentaenoic acid 30 mg/kg/day and docosahexaenoic acid 50 mg/kg/day.millenium. Tai Chi and Yoga also may include a meditative component to the training. the equivalent of 6-11 gm of borage oil daily.

Olsen N. Methotrexate and leflunomide can be used together with only a modest increase in risk of side effects. turmeric. or infliximab is added if methotrexate is only partially effective. Singh R. ▪ Surgery • Loss of joint function and intractable pain may be indications for surgical intervention. Other commonly used supplements or botanicals such as ginkgo may add further risk. Leflunomide or azathioprine is often substituted for methotrexate if there are intolerable side effects with methotrexate. the interactions of supplements and botanicals on allopathic pharmaceuticals are not fully understood. 2.. Synovectomy can be helpful when systemic therapy and intra-articular corticosteroids are ineffective.mx/das/book/body/149218586-2/0/149. 8. et al: Efficacy of B-cell-targeted therapy with rituximab in patients with rheumatoid arthritis. Kimmel S. The addition of any new treatment should prompt increased laboratory monitoring for patients receiving immunosuppressive pharmaceuticals. All health care professionals involved in the patient's care must be aware of all therapies being used. 350:2167-2179. N Engl J Med 2004. Panayi G: Cytokine pathways and inflammation in rheumatoid arthritis. Szczepanski L. Genovese M. 16:659-682. 344:907-916. a TNF inhibitor such as etanercept. N Engl J Med 2001. Choy E. Particular care must be used in patients taking other antiplatelet agents or warfarin sodium (Coumadin). Rheum Dis Clin North Am 2004.mdconsult. 6. Robinson DB. 11/07/2009 . some of which are only now being defined. 3. 30:405-415. et al: Patients exposed to rofecoxib and celecoxib have different odds of http://0-www. Muller D: The molecular biology of autoimmunity. N Engl J Med 2004. The DMARDs and the recombinant biologics have many varied side effects. Stein CM: New drugs for rheumatoid arthritis. El-Gabalawy HS: Emerging biologic therapies in rheumatoid arthritis: Cell targets and cytokines. et al: Abatacept for rheumatoid arthritis refractory to tumor necrosis factor alpha inhibition. Joint replacement can help restore function and increase independent activity. 7.millenium. Corticosteroids in moderately high doses with a rapid taper are often used for exacerbations. Immunol Allergy Clin North Am 1996. In addition. 17:274-279.itesm..com. 353:1114-1123. Schiff M. 5. ▪ Low-Level Laser Therapy • LLLT can be tried with little risk of side effects. Choy E: Clinical experience with inhibition of interleukin-6. Becker J. Caution: Studies have not been done on the possible additive effects of ginger. This modality may be less effective in patients taking corticosteroids. and an NSAID for increased risk of hemorrhage. Curr Opin Rheumatol 2005. adalimumab.Rheumatoid Arthritis from Rakel: Integrative Medicine on MD Consult Page 9 of 11 • • • • A common combination is methotrexate and hydroxychloroquine. The newest biologics are on the verge of FDA approval. Edwards J. vitamin E. N Engl J Med 2005. 350:2572-2581. ▪ Acupuncture • Acupuncture can be tried for any patient with RA. Commonly. Reilly M. Berlin J. REFERENCES 1. 4. Szechinski J.chapter 48 . The immunosuppressive pharmaceuticals should be used only with input from a subspecialist rheumatologist.

5:196-201. Hurewitz A. Heliovaara M. Arthritis Rheum 1999. Arthritis Rheum 2002. Rheum Dis Clin North Am 2000. 60:625-632. van Reesema D. 27. et al: Heavy cigarette smoking is strongly associated with rheumatoid arthritis (RA). Chang E: Gastrointestinal bleeding rates among managed care patients newly started on COX-2 inhibitors or nonselective NSAIDs. Results of a placebo-controlled double-blind trial. Herman J. J Behav Med 1985. Indian J Med Res 1980. 142:157-164. and disease activity in rheumatoid arthritis. Kabat-Zinn J. rheumatoid factor. 71:632-634. Mikuls T.. 26.com. Page 10 of 11 9. Arthritis Care Res 1998. Kabat-Zinn J. Jacobs J. Stone AA. Arthritis Rheum 2001. 333:142-146. Deodhar SD. particularly in patients without a family history of RA. Sirivastava KC.itesm. 11. Smyth J. 15. Schauenstein K: Diet and rheumatoid arthritis: A review. Mustafa T: Ginger (Zingiber officinale) and rheumatic disorders. and side effects. 17. Mangge H. 24. Linos A. Ann Intern Med 2005. 29:25-28. Cutolo M: Involvement of the hypothalamic-pituitary-adrenal/gonadal axis and the peripheral nervous system in rheumatoid arthritis. Henderson CJ. Kirwan JR and the Arthritis and Rheumatism Council Low-Dose Glucocorticoid Study Group : The effect of glucocorticoids on joint destruction in rheumatoid arthritis.mdconsult. Guo R. Escalante A. 42:1712-1721. 11:135-145. Rheum Dis Clin North Am 1999. Med Hypotheses 1989. 23. et al: Dietary factors in relation to rheumatoid arthritis: A role for http://0-www. 60:223-227. 12.. Kaklamani VG. Cypren L. Stockl K. 8:163-190. Knekt P.Rheumatoid Arthritis from Rakel: Integrative Medicine on MD Consult nonfatal myocardial infarction.mx/das/book/body/149218586-2/0/149. Straub R. 11/07/2009 . 14. Huyser B. 59:631-635. tea. N Engl J Med 1995. Chrubasik S: Phyto-anti-inflammatories: A systemic review of randomized. 18. 26:13-27. Ann Rheum Dis 1997. Kaklamani E. Shepstone L.chapter 48 . 25:937-968. nutritional supplements. Burney R: The clinical use of mindfulness meditation for the self-regulation of chronic pain. et al: Putative analgesic activity of repeated doses of vitamin E in the treatment of rheumatoid arthritis. Psychosom Med 1998. Ann Intern Med 2002. Wheeler W. et al: Psychological factors. 22. 136:1-12. et al: Coffee consumption. 13. Lipworth L. 28. 21. 28:201-209. 16. Smarr K. Scand J Rheumatol 1999. Panush RS: Diets. Bijlsma J: Low-dose prednisone therapy for patients with early active rheumatoid arthritis: Clinical efficacy. Sethi R. 20. double-blind trials. Del Rincon I: How much disability in rheumatoid arthritis is explained by rheumatoid arthritis?. Ernst E. and the risk of rheumatoid arthritis. Light T. and nutritional therapies in rheumatic diseases. J Manage Care Pharm 2005. 25.millenium. 56:649-655. Aho K. JAMA 1999. et al: Coffee. 44:493-507. Angelone E. 46:83-91. 10. Parker J. Arthritis Care Res 1992. Cerhan J. disease-modifying properties. 11:550-558. Moots R. Parker J: Stress and rheumatoid arthritis: An integrated review. Edmonds SE. placebo-controlled. 19. Kaell A: Effects of writing about stressful experiences on symptom reduction in patients with asthma or rheumatoid arthritis. and caffeine consumption and risk of rheumatoid arthritis: Results from the Iowa Women's Health Study. 281:1304-1309. et al: Influence of a mindfulness meditation-based stress reduction intervention on rates of skin clearing in patients with moderate to severe psoriasis undergoing phototherapy (UVB) and photochemotherapy. Criswell L. Hutchinson D. immunologic activation. van Everdingen A. Srimal RC: Preliminary studies on antirheumatic activity of curcumin (deferaloyl methane). Winyard PG. Ann Rheum Dis 2001. Ann Rheum Dis 2000.

Curtis J. 3: 38.www.Rheumatoid Arthritis from Rakel: Integrative Medicine on MD Consult olive oil and cooked vegetables?. Arthritis Rheum 2004. II. Hernandez-Cruz B. 30. 50:72-77. Navarro-Sarabia F. 33. Cochrane Musculoskeletal Group Cochrane Database Syst Rev 2005. Wells G. J Rheumatol 1974. CA. 31. Am J Clin Nutr 1999.mdconsult.html http://0-www. Rheum Dis Clin North Am 1995. Temperament Character Intelligence. Ariza-Ariza R.millenium. et al: Etanercept for the treatment of rheumatoid arthritis. Baragar FD: Preliminary clinical study of acupuncture in rheumatoid arthritis. Welch V. Copyright © 2009 Elsevier Inc. Breedveld FC. 32. 11/07/2009 . Schleusser B.com Bookmark URL: /das/book/0/view/1494/95. Cranney A.com. Villanueva I: Adalimumab for treating rheumatoid arthritis.chapter 48 . Merlino L. Cerhan J. Alarcon GS: Minocycline for the treatment of rheumatoid arthritis. Mikuls T. Pincus T: Assessment of long-term outcomes of rheumatoid arthritis.mx/das/book/body/149218586-2/0/149. Cranney A. 3: 35. and III) for treating rheumatoid arthritis. Keirsey D: Please Understand Me: II. Rheum Dis Clin North Am 1998. 70:1077-1082. Blumenauer B. Man SC. Judd M.itesm. Brosseau L. Blumenauer B. 24:489-499. Cochrane Musculoskeletal Group Cochrane Database Syst Rev 2005. Prometheus Nemesis.mdconsult. Cochrane Musculoskeletal Group Cochrane Database Syst Rev 2005. Del Mar. Arthritis Rheum 2000. 59:841-849. 3: 34. Krause D. 3: 36. 1998. et al: Vitamin D intake is inversely associated with rheumatoid arthritis: Results from the Iowa Women's Health Study. Page 11 of 11 29.. Ann Rheum Dis 2000. et al: Low-level laser therapy (classes I. 43:14-21. 39. et al: Infliximab for the treatment of rheumatoid arthritis. Cochrane Musculoskeletal Group Cochrane Database Syst Rev 2005. Rau R: Response to methotrexate treatment is associated with reduced mortality in patients with severe rheumatoid arthritis. Herborn G. . 1:126-129. All rights reserved. Dayer JM: Leflunomide: Mode of action in the treatment of rheumatoid arthritis.. Judd M. 37. 21:619-654.