Rheumatoid Arthritis

The Merck manual defines rheumatoid arthritis (RA) as “a chronic syndrome characterized by non-specific, usually symmetric inflammation of the peripheral joints, potentially resulting in progressive destruction of articular and periarticular structures; generalized manifestations may also be present” (Berkow 1992; 1305). RA is generally considered to be an autoimmune disease in which the immune system attacks the cartilage and joint linings. The synovial membrane becomes inflamed, proliferates and thickens, forming villi that encroach upon space in the joint. The inflammatory membrane then produces an abnormal granulation tissue, called pannus, which adheres to the surface of the articular cartilage. At the point of contact between the pannus and the hyaline cartilage, proteolytic enzymes are released and begin to digest the articular cartilage and subchondral bone.

Diagnosis of RA

According to the Merck Manual, any four criteria must be present to diagnose rheumatoid arthritis; criteria 1 through 4 must have been present for at least 6 weeks:

1. Morning stiffness for at least one 1 hour
2. Arthritis of at least three joints
3. Arthritis of hand joints
4. Symmetric arthritis
5. Rheumatic nodules
6. Serum rheumatoid factor, by a method positive in more than 5% of normal control subjects
7. Radiographic changes (erosions, decalcification) (Berkow 1992, 1307) Diagnostic factors in laboratory investigations include elevated ESR (Erythrocyte Sedimentation Rate), normocytic anemia, rheumatoid factor (usually IgM subclass, but also IgG and IgA), elevated immunoglobulins, and lowered serum complement. Investigations of the synovial fluid itself should reveal low viscosity, high cell count (mostly neutrophils), low glucose, high protein and positive RF (Rheumatoid Factor) (Berkow 1992, 1307).

Medical Treatment of RA

Complete bed rest is occasionally indicated for short periods during the most active painful stage of the severe disease. In less severe cases regular rest periods are recommended. Nonsteroidal antiinflammatory drugs (NSAIDs) such as acetylsalicylic acid (ASA) and analgesics such as acetaminophen (paracetamol) are the traditional cornerstones of treatment. ASA interferes with the production of prostaglandins through acetylation of the enzyme cyclo-oxgenase, inhibiting the formation of the inflammatory PgE2 series of prostaglandins. ASA also irreversibly binds with thromboxane A2 in platelets, thereby inhibiting platelet aggregation. Acetaminophen has a pharmacological activity comparable to ASA, but has no activity on platelets. Side effects of ASA include nausea, vomiting, gastrointestinal irritation and ulceration, tinnitus, vertigo, leukopenia, thrombocytopenia, anemia, skin eruptions, asthma, and mental confusion. The side effects of acetaminophen include renal tubular necrosis, renal failure, hepatoxicity and asthma (Berkow 1992, 1308-9). Other commonly prescribed NSAIDs include nabumetone, celecoxib and ibuprofen.

Corticosteroids are also employed and will provide dramatic results initially, although they do not prevent destruction of the joint and will eventually become of less benefit with chronic use. Side effects are weight gain, water and sodium retention, high blood pressure, osteoporosis, thinning of the skin, cataracts, acne, muscle weakness, immunosuppression, stomach ulcers and depression (Berkow 1992, 1310-11).

Immunosuppressive drugs such as cyclosporine, azathioprine and methotrexate are used in rheumatoid arthritis unresponsive to NSAIDs, and function mostly by inhibiting and suppressing white blood cells and the immune response. Side effects due to azathioprine include gastrointestinal disturbances, heartburn, immunosuppression, bleeding and bruising, and malignancy. A side effects due to cyclosporine is kidney damage. Methotrexate is also employed to inhibit cell growth and is used as a antineoplastic drug as well. Possible side effects include mucosal ulceration and bone marrow suppression (Berkow 1992, 1311).

Remittive drugs such as gold and penicillamine are used in patients suffering from serious rheumatoid arthritis. It is not entirely clear how they work but may produce clinical remission and a decrease in tissue destruction. Side effects to gold include pruritis, dermatitis, stomatitis, thrombocytopenic purpura and aplastic anemia as well as diarrhea, hepatitis, pneumonitis and neuropathy. Marrow suppression, proteinuria, nephrosis as well as fatalities due to penicillamine have been reported (Berkow 1992, 1309-10).

Exercise to restore muscle mass and preserve normal range of motion is also encouraged, as well as orthopedic shoes for those so affected. Surgery and joint replacement is indicated in severe degeneration and must be undertaken while the disease is active.

Holistic Treatment in Ayurveda

In Ayurveda, the classical text on diagnosis called the Madhava Nidana provides three basic causes of amavata, a condition that has a great deal of overlap with rheumatoid arthritis. These causes include:

  1. Weakness of digestion: The digestive fire is one of the prime motivators of all human function, ensuring the proper absorption and metabolism of nutrition. When digestion is impaired ama accumulates, the doshas become vitiated, and the vitality (ojas) diminishes.
  2. Incompatible foods in the diet: Incompatable foods include foods consumed out of season or without respect to local bioclimactic factors; unfamiliar foods (asatmya, i.e. opposite of the healthy norm [satmya], i.e. non-traditional foods; spoilt and contaminated foods; food additives; refined flour; feed-lot and farmed meat, etc.
  3. Lack of physical activity: Physical exercise (vyama) is considered an important aspect to dinacharya, the daily regimen recommended in Ayurveda. A lack of exercise predisposes one to amavata because the circulation of blood to and the removal of wastes (ama) from the periphery is impaired.

The treatment of inflammatory joint disease in Ayurveda is thus threefold:

  • support and enhance digestion (agni)
  • facilitate the removal of ama from the body
  • repair damaged tissues and restore vitality (ojas)

The initial treatment often begins with enkindling agni, the digestive fire. This can be achieved by a short period of fasting, sudation therapy and the use pungent and bitter herbs. Fasting is particularly appropriate during a time of exacerbation: the food should be light, little and liquid. Weak ginger tea with a little lemon and honey and a simple diet of kichari (mung and rice soup) is best. Dipanapachana botanicals stimulate the appetite (dipana) and ‘eat up’ (pachana) the accumulated ama, include Nimba (Azadiracta indica), Kiratatikta (Swertia chiretta) and Guduchi (Tinospora cordifolia), Guggulu (Commiphora mukul), Lasuna (Allium sativum), Haritaki (Terminalia chebula), Shunthi (Zingiber officinalis) and Yavani (Trachyspermum ammi). Specific formulae include Yogaraja guggulu and Kaisora guggulu.

The elimination of ama in the joints is best facilitated by applying oil to the affected joints, such as castor oil, and dry heat. It is important to note, however, that counterirritant therapies should never be used in during active inflammation: only during periods of remission. Heated brick dust, heated sand, or powdered rock salt may be wrapped inside a linen bag and applied to the affected to enhance blood flow, after the joints have been massaged with sesame oil. Poultices, fomentations and salves prepared from botanicals that have counterirritant properties can also be used such as Jimson weed (Datura stramonium), Ginger root (Zingiber officinalis), Lobelia (Lobelia inflata), Pine resin (Pinus spp.), Juniper berries (Juniperus communis), Cayenne (Capsicum spp.), and Kelp (Fucus spp.) are useful. Traditional Ayurvedic medicated oils (taila) indicated in RA include Mahanarayana taila, Brihatsaindhavadi taila and Kottamchukkadi taila.

In Ayurveda, RA is a vata issue, and thus general measures to reduce vata are indicated, including therapeutic enema (vasti) with formulas such as Brihatsaindhavadi taila. Gentle aperients such as Triphala and bulk laxatives like Psyllium (Plantago psyllium) can improve the tone of the colon as well as cleanse the tissues.

Hatha yoga and regular exercise also becomes important at this time as it increases circulation to and away from the affected areas, although the person would do well to take care and not engage in any strenuous exercise that may damage the joints further. Useful asanas may include tadasana samasthiti, utthita parsvakonasana, ardha chandrasana, baddhakonasana, paripurna navasana, upavista konasana, paschimottanasana, janu sirsasana, adhomukha virasana, marichyasana, utthita marichyasana, setubandha sarvangasana, viparita dandasana, supta padangusthasana, supta baddhakonasana, supta virasana, and shavasana.

Western herbal treatment of RA

Diuretics such as Birch leaf (Betula alba) and Celery seed (Apium graveolens) are useful as the kidneys are the body’s main way of eliminating acids that may build up in the joints. The former also displays some anti-inflammatory activity due to the volatile oils and resins. The latter contains pthalides that are anti-spasmodic, sedative and diuretic.

Alteratives and cholagogues such as Yellowdock (Rumex crispus), Burdock (Arctium lappa), Dandelion root (Taraxacum officinalis), and Barberry (Berberis vulgaris) are all useful for cleansing and facilitating elimination, clearing the body of accumulated toxins.

Circulatory stimulants such as Prickly Ash berry (Zanthoxylum spp). and Ginger root (Zingiber officinalis) increase blood flow to the affected areas, breaking up stagnation in the joints, as well as have diaphoretic actions that promote elimination.

Digestive tonics are indicated usually in the form of a bitter tonic. These herbs function by improving digestion, especially of proteins by increasing HCl acid production, which may protect against undigested proteins that can irritant the gut wall and stimulate immune reactions. An excellent digestive tonic is Devil’s Claw (Harpagophytum procumbens), which contains harpogoside, a iridoid glycoside that as well as having extremely bitter qualities also has significant analgesic effects. H. procumbens also has anti-inflammatory properties attributed to the whole plant.

White Bryony (Bryonia dioica) is a potentially toxic herb that is considered to be a restorative specific to the serous membranes by nourishing and increasing the secretion of synovial fluid. Its dosed at between 2 and 10 drops thrice daily, no more than 15 mL per week in formula. Horsetail (Equisetum arvense) is restorative to connective tissue because of its high content of soluble silica thus aiding in the repair of the articular discs of an arthritic joint and surrounding connective tissue.

Supplementary treatment of an acute situation may call for the use of anti-inflammatories, analgesics, muscle relaxants and sedatives until the situation is more manageable. White Willow bark (Salix alba), Black Cohosh (Actaea racemosa), Kava (Piper methysticum), and Lobelia (Lobelia inflata) are all indicated for the symptomatic relief of pain due to a flare up of rheumatoid arthritis.

Supplementation with anti-oxidants can help with repair of tissues and prevent further damage to tissues and cells by free-radicals generated in a toxin producing diet and a stressful environment. Vitamin C, D, and E, as well as selenium, zinc, super oxide dismutase, N-acetyl cysteine, manganese and bioflavonoids are all useful to modulate the inflammatory response.

Topical applications include poultices, baths, lotions, plasters and salves. Kelp (Fucus spp.), Ginger root (Zingiber officinalis) and Juniper (Juniperus communis) combine nicely as a medicated oil that is rubifacient, counter-irritant and vulnerary. Other useful topical herbs include St. John’s Wort (Hypericum perforatum), Lobelia (Lobelia inflata) and Cayenne (Capsicum spp).

Dietary treatment of RA

Apart from the key recommendations of diet described above, autoimmune diseases such as rheumatoid arthritis are typically associated with the consumption of agricultural staples, and thus, what is called the ‘paleolithic diet’ can be very helpful. This measure eliminates all cereal grains from the diet, including wheat, rye, barley, kamut, spelt, corn and oat, as well as legumes, sweeteners, and all dairy products. Some non-grass cereals such as quinoa and buckwheat may be tolerated, as is often white rice. This issue of diet as well as key supplements are discussed more fully under autoimmune disease, and explored further in the book Food As MedicineUseful measures to restore the musculoskeletal system include the consumption of bone soups, which contain glycosaminoglycans and other nutrients that help to heal the gut and restore the bones and joints.