Rheumatoid arthritis arises when the immune system mistakenly attacks the lining of the joints, leading to chronic inflammation, pain and stiffness. Over time, the disease can deform the joints and lead to disability. Strength training and light aerobic exercise, like walking, benefits people with rheumatoid arthritis.

Rheumatoid arthritis is an autoimmune disease in which joints, usually including those of the hands and feet, are symmetrically inflamed, resulting in swelling, pain, and often the eventual destruction of the joint's interior. Rheumatoid arthritis is the most common inflammatory joint disease and a major cause of disability, morbidity, and mortality. It occurs worldwide, affecting approximately one per cent of adults. Rheumatoid arthritis may be accompanied by fatigue, anxiety, weight loss, and depression. Rheumatoid arthritis is the most common of the inflammatory arthritides, affecting millions of adults around the world. It represents a significant cause of increased disability, morbidity, and mortality.

Stop smoking
Cat’s claw a small study showed a reduction in pain in rheumatoid arthritis patients give Cat's claw extract.
Curcumin turmeric could be helpful
Green tea extract may be helpful.
Folic acid (see below)
Ginger extracts may help rheumatoid arthritis patients.
Guggul extract may be helpful in rheumatoid arthritis treatment
Omega-3 fatty acids can reduce joint pain associated with rheumatoid arthritis. See Fish oil s for more information.
Glucomannan supplement may be helpful in rheumatoid arthritis.

Cat's claw
Randomized double blind trial of an extract from the pentacyclic alkaloid-chemotype of uncaria tomentosa (Cat's Claw) for the treatment of rheumatoid arthritis.
Mur E. Innsbruck University Hospital, Austria. J Rheumatol. 2002 Apr;29(4):678-81.
To evaluate safety and clinical efficacy of a plant extract from the pentacyclic chemotype of Uncaria tomentosa (cat's claw) in patients with active rheumatoid arthritis (RA). Forty patients undergoing sulfasalazine or hydroxychloroquine treatment were enrolled in a randomized 52 week, 2 phase study. During the first phase (24 weeks, double blind, placebo controlled), patients were treated with UT extract or placebo. In the second phase (28 weeks) all patients received the plant extract. Twenty-four weeks of treatment with the UT extract resulted in a reduction of the number of painful joints compared to placebo (by 53% vs 24%). Patients receiving the UT extract only during the second phase experienced a reduction in the number of painfuland swollen joints and the Ritchie Index compared to the values after 24 weeks of placebo. Only minor side effects were observed. This small preliminary study demonstrates relative safety and modest benefit to the tender joint count of a highly purified extract from the pentacyclic chemotype of UT in patients with active RA taking sulfasalazine or hydroxychloroquine.

Curcumin and rheumatoid arthritis
Curcumin induces apoptosis and inhibits prostaglandin E(2) production in synovial fibroblasts of patients with rheumatoid arthritis.
Int J Mol Med. 2007 Sep;20(3):365-72. Department of Biochemistry, Dongeui University College of Oriental Medicine, Busan 614-052, Korea.
Rheumatoid arthritis (RA) is a chronic inflammatory disease that is characterized by hyperplasia of the synovial fibroblasts, which is partly the result of decreased apoptosis. This study investigated the mechanisms through which curcumin exerts its anti-proliferative action in the synovial fibroblasts obtained from patients with rheumatoid arthritis. Exposure of the synovial fibroblasts to curcumin resulted in growth inhibition and the induction of apoptosis. Treating the cells with curcumin resulted in the down-regulation of anti-apoptotic Bcl-2 and the X-linked inhibitor of the apoptosis protein as well as the up-regulation of pro-apoptotic Bax expression in a concentration-dependent manner. Curcumin -induced apoptosis was also associated with the proteolytic activation of caspase-3 and caspase-9, and the concomitant degradation of poly(ADP-ribose) polymerase protein. Furthermore, curcumin decreased the expression levels of the cyclooxygenase (COX)-2 mRNA and protein without causing significant changes in the COX-1 levels, which was correlated with the inhibition of prostaglandin E(2) synthesis.

Ginger and rheumatoid arthritis
Comparative Effects of Two Gingerol-Containing Zingiber officinale Extracts on Experimental Rheumatoid Arthritis ( perpendicular).
J Nat Prod. 2009 Feb 13. Funk JL, Frye JB, Oyarzo JN, Timmermann BN. Department of Medicine, University of Arizona, Tucson, Arizona 85724, and Department of Medicinal Chemistry, School of Pharmacy, University of Kansas, Lawrence, Kansas 66045.
Ginger supplements are being promoted for arthritis treatment in western societies on the basis of ginger's traditional use as an anti-inflammatory in Chinese and Ayurvedic medicine. The ability of a well-characterized crude ginger extract to inhibit joint swelling in an animal model of rheumatoid arthritis, streptococcal cell wall-induced arthritis, was compared to that of a fraction containing only gingerols and their derivatives. Both extracts were efficacious in preventing joint inflammation. However, the crude dichloromethane extract, which also contained essential oils and more polar compounds, was more efficacious (when normalized to gingerol content) in preventing both joint inflammation and destruction. These data document a very significant joint-protective effect of these ginger samples and suggest that nongingerol components are bioactive and can enhance the antiarthritic effects of the more widely studied gingerols.

Diet for Rheumatoid Arthritis
A regular, healthy diet can reduce symptoms of rheumatoid arthritis. Some people have flare-ups after eating certain foods. A diet rich in fish and vegetables has beneficial effects on reducing inflammation.
   The traditional diets of people in the Mediterranean region tend to be high in fruits, vegetables, fish and olive oil, and comparatively low in red meat. Components of the Mediterranean diet have anti-inflammatory effects. UK researchers split 130 women with rheumatoid arthritis into two groups. One group attended classes on Mediterranean-style eating, which included hands-on cooking instruction. The other group was given written dietary information only. Women who attended the classes bumped up their intake of fruits, vegetables, and beans and monounsaturated fat and over the next few months reported improvements in pain, morning stiffness and overall health. Annals of the Rheumatic Diseases, September 2007.
   A gluten-free vegan diet full of nuts, sunflower seeds, fruit and vegetables reduces the risk of heart attacks and strokes for people with rheumatoid arthritis and also affect the immune system, easing some symptoms associated with the painful joint condition.

Fat and rheumatoid arthritis
An unfavorable ratio of blood fats could herald the development of the inflammatory joint disease rheumatoid arthritis up to 10 years later. Researchers analysed the fat content of 1078 deep frozen blood samples from 79 people who had given blood between 1984 and 1999 and subsequently went on to develop rheumatoid arthritis 10 or more years later. In particular, they looked at levels of total cholesterol, high density lipoprotein ('good' cholesterol), triglycerides, apolipoproteins A and B, and lipoprotein (a). The samples were then compared with those taken from 1071 randomly selected blood donors, matched for age, sex, and storage time. They found that the samples of people who subsequently developed rheumatoid arthritis had a more unfavorable balance of circulating blood fats than the samples of those who did not develop the disease. On average, total cholesterol was 4% higher, while high density lipoprotein levels were 9% lower. Triglycerides were 17% higher and apolipoprotein B was 6% higher. Taken together, these figures also indicate an increased risk of ischemic heart disease, in which the artery walls are thickened and hardened by fat deposits. This might help to explain the link between an increased risk of cardiovascular disease among patients with rheumatoid arthritis, say the authors. And they speculate that a poorer blood fat ratio might make a person more susceptible to inflammation or inflammatory diseases, such as rheumatoid arthritis. Lipids and inflammation: serial measurements of the lipid profile of blood donors who later developed rheumatoid arthritis. British Medical Journal.

Switching from a typical western diet to a traditional Mediterranean (MD) diet reduces pain and inflammation associated with rheumatoid arthritis within 12 weeks, Swedish researchers report in the March issue of the Annals of Rheumatic Diseases. Dr. L. Hagfors, of Umeå University, and associates designed a diet plan characterized by a high consumption of fruit, vegetables, cereals and legumes. This diet also contains less red meat and more fish than usually consumed by westerners. The investigators slightly modified the diet by permitting patients to use canola oil in addition to olive oil and by substituting green or black tea for wine, both of which are high in polyphenols. Twenty-six patients were randomly assigned the new diet, while 25 patients served as controls. Disease duration was at least 2 years and disease activity score 28 (DAS28) ranged between 2.19 and 7.00 of a possible 10. After 3 weeks, results for the two groups did not differ. By the end of the 12-week study period, however, MD diet subjects showed significant improvements in three of four primary efficacy variables. DAS28 dropped on average by 0.56, Health Assessment Questionnaire had declined, and the vitality and mental health dimension of the SF-36 Health Survey had improved. Only the use of nonsteroidal antiinflammatory use was unaffected. Furthermore, the number of swollen and tender joints and pain scores significantly decreased, as did C reactive protein levels and thrombocyte counts. In contrast, the overall findings remained stable during the course of the trial among patients in the control group. "Even a minor effect that is persistent and accumulates over time might become important," Dr. Hagfors' team points out. The group intends to conduct a 1-year follow-up study.

Vitamin B6 and rheumatoid arthritis
Compared with healthy women, those with rheumatoid arthritis are deficient in vitamin B6 and have elevated levels of homocysteine, a type of amino acid that has been linked to heart attacks and strokes. The vitamin B6 deficit appears to be the result of altered metabolism, not reduced dietary intake. As vitamin B6 levels drop and homocysteine levels rise, disability status worsens. It is not clear whether vitamin B supplement use would benefit those with rheumatoid arthritis, and if it does what the appropriate dosage would be. Journal of the American Dietetic Association, March 2008.

Glucomannan and rheumatoid arthritis
Glucomannan in prevention of oxidative stress and inflammation occurring in adjuvant arthritis.
Neuro Endocrinol Lett. 2008 October. Bauerova K, Ponist S, Navarova J, Dubnickova M, Paulovicova E, Pajtinka M, Kogan G, Mihalova D. Bauerova K, Ponist S, Navarova J, Dubnickova M, Paulovicova E, Pajtinka M, Kogan G, Mihalova D. Institute of Experimental Pharmacology, Slovak Academy of Sciences, Bratislava, Slovakia.
The aim of this study was to evaluate the effects of a biological response modifier, glucomannan, isolated from Candida utilis, on the progress of adjuvant arthritis in Lewis rats. Adjuvant arthrithis was induced in Lewis rats by a single intradermal injection of Mycobacterium butyricum. Glucomannan was administered in two different doses of 5 and 7.5 mg/kg b.w. The important characteristics of glucomannan isolated from Candida utilis, such as good water solubility and relatively small molecular weight, along with the observed in vivo anti-inflammatory and antioxidant effects, appear to be promising features for its prospective use as a natural agent in prevention and supplementary therapy of rheumatoid arthritis.

An autoimmune disease
In rheumatoid arthritis, the immune system attacks the tissue that lines and cushions joints (certain immune cells, perhaps mast cells, attack the carbohydrate molecules, known as glycosaminoglycans, in the joints). Eventually, the cartilage, bone, and ligaments of the joint erode, causing scars to form within the joint. The joints deteriorate at a highly variable rate.

Rheumatoid arthritis symptoms
Rheumatoid arthritis can also produce a variety of symptoms throughout the body. The exact cause of rheumatoid arthritis isn't known, but many different factors, including genetic predisposition, may influence the autoimmune reaction. This disease develops in about 1 percent of the population, affecting women two to three times more often than men. Usually, rheumatoid arthritis first appears between 25 and 50 years of age, but it may occur at any age. In some people, the disease resolves spontaneously, and treatment relieves symptoms in three out of four people; however, at least 1 out of 10 people eventually becomes disabled.

In rheumatoid arthritis, the immune system attacks the tissue that lines and cushions joints (certain immune cells, perhaps mast cells, attack the carbohydrate molecules, known as glycosaminoglycans, in the joints). Eventually, the cartilage, bone, and ligaments of the joint erode, causing scars to form within the joint. The joints deteriorate at a highly variable rate.

Treatment of rheumatoid arthritis
Treatment of rheumatoid arthritis ranges from simple, conservative measures such as rest and adequate nutrition to drugs and surgery. Treatment starts with the least aggressive measures, moving to more aggressive ones if needed. A basic principle of treatment is to rest the affected joints, because using them aggravates the inflammation. Regular rest periods often help relieve pain, and sometimes a short period of total bed rest helps relieve a severe flare-up in its most active, painful stage. Splints can be used to immobilize and rest one or several joints, but some systematic movement of the joints is needed to prevent stiffening. The main categories of drugs used to treat rheumatoid arthritis are non-steroidal anti-inflammatory drugs (NSAIDs), slow-acting drugs, corticosteroids, and immunosuppressive drugs. Generally, the stronger the drug, the more severe its potential side effects, so that closer monitoring is needed.
   When it comes to initial drug treatment for rheumatoid arthritis, many sufferers would prefer not to have to take the steroid prednisone. Dislike for prednisone is strong and widespread.

Non-drug treatment of rheumatoid arthritis
Non-pharmacological treatment modalities are often used as an addition to drug therapy in patients with rheumatoid arthritis. The few available randomized controlled trials that have specifically investigated patients with early RA support the effectiveness of dynamic exercise and cognitive behavioral interventions, and to a lesser extent of joint protection programs and foot orthoses.

Medications used in rheumatoid arthritis treatment
Anti-inflammatories are commonly prescribed to reduce inflammation and pain.
Disease modifying anti-rheumatic drugs include medications like methotrexate, gold, hydroxychloroquine, cyclosporine, D-penicillamine, sulfasalazine, leflunomide are used to preserve joints and may protect against heart disease associated with rheumatoid arthritis.
Biologic response modifiers include Adalimumab (Humira), infliximab (Remicade), etanercept (Enbrel), abatacept (Orencia), anakinra (Kineret) and rituximab (Rituxan) slow progression of the disease and joint damage.
Corticosteroids are fast acting anti-inflammatories good for short term use.
Immunosuppressants: third line medications used for severe RA - azathioprine (Imuran), chlorambucil (Leukeran) and cyclophosphamide (Cytoxan).
Hyaluronic acid intra-articular injections: Sodium hyaluronate (Hyalgan and Supartz) and hylan G-F20 (Synvisc) are substances similar to synovial fluid found in joints and can be injected into the joint.

Which drug is best for rheumatoid arthritis?
It may not make a large difference which drug a patient uses to treat rheumatoid arthritis, although mixing different types of drugs in a cocktail approach may work better than using a single drug treatment. A group at the Agency for Healthcare Research and Quality, led by Dr. Katrina Donahue of the University of North Carolina, looked at 11 different drugs used to treat rheumatoid arthritis. Some drugs used to treat it reduce inflammation directly while others tone down immune system response - leaving patients vulnerable to infections and cancer. The therapies included corticosteroids, synthetic disease modifying anti-rheumatic drugs, or DMARDs, such as hydroxychloroquine, leflunomide, methotrexate and sulfasalazine. Biological DMARDs such as abatacept, made by Bristol-Myers Squibb Co. under the brand name Orencia; adalimumab, sold by Abbott Laboratories as Humira; anakinra or Kineret, made by Amgen Inc ; etanercept, sold by Amgen under the brand name Enbrel; infliximab, sold by Johnson & Johnson under the Remicade brand name; and rituximab, marketed by Genentech Inc and Biogen Idec Inc under the Rituxan and MabThera brand names. As of December 2007, it is not clear which treatment method is best and there are different viewpoints among rheumatologists.

Drugs used for rheumatoid arthritis
The main categories of drugs used to treat rheumatoid arthritis are non-steroidal anti-inflammatory drugs (NSAIDs), slow-acting drugs, corticosteroids, and immunosuppressive drugs. Generally, the stronger the drug, the more severe its potential side effects, so that closer monitoring is needed.
   Prior to the availability of abatacept and rituximab, the routine of care for rheumatoid arthritis was to treat patients with methotrexate by itself; if patients had a good clinical response, methotrexate was continued. X-ray findings were followed on an annual basis, and as long as they had no progressive erosive disease, methotrexate was continued. However, if methotrexate had an insufficient clinical response, adding anti-TNF therapy to methotrexate was standard of care.

Effect of folic or folinic acid supplementation on methotrexate-associated safety and efficacy in inflammatory disease: a systematic review.
Br J Dermatol. 2008 Oct 20. Prey S, Paul C. Department of Dermatology, Paul Sabatier University and Purpan Hospital, 31 059 Toulouse cedex 9, France.
Methotrexate is a folic acid antagonist widely used for the treatment of inflammatory disorders for more than 50 years. Methotrexate is a standard systemic therapy for severe psoriasis and rheumatoid arthritis. Folic acid supplementation has been advocated to limit the toxicity of methotrexate on blood cells, gastrointestinal tract and liver. Supplementation with folic acid is an effective measure to reduce hepatic adverse effects associated with methotrexate treatment. There is no difference between folinic acid and folic acid, but the lower cost of the latter promotes its use.

New treatment medication for RA
Biologic treatment options for rheumatoid arthritis, including abatacept and rituximab, have been approved for use in the management of rheumatoid arthritis since 2005. The newer biologic treatment options, abatacept and rituximab have novel mechanisms of action which have helped to make abatacept and rituximab effective options in many patients for whom traditional therapy has failed.

Complications of rheumatoid arthritis treatment - shingles
Patients with rheumatoid arthritis are at increased risk of herpes zoster, or shingles, a painful skin condition caused by a reactivation of the chickenpox virus. Medications used to treat rheumatoid arthritis increases vulnerability to shingles since they interfere with the immune system.

People with rheumatoid arthritis have a much higher risk of suffering heart attacks or strokes. The risk is comparable to that associated with type 2 diabetes, which is already an established cardiovascular risk factor.

Remission less likely in women
Women with rheumatoid arthritis are much less likely than men to experience remission. Swedish researchers tracked nearly 700 adults, average age 58, who had had rheumatoid arthritis for about six months at the start of the study. Two-thirds of the patients were women. At two years, rheumatoid arthritis was in remission in 40 percent of the patients. At five years, 38 percent of the patients were in remission. However, only 20 percent were in remission at both two and five years. At two years, 48 percent of men and 32 percent of women were in remission. At five years, 52 percent of men and 31 percent of women were in remission. At both time points, men were more than twice as likely as women to be in remission, the study said. Initially, the women in the study did not have more severe rheumatoid arthritis than men. However, the disease quickly became more severe and progressed more rapidly in the women than in the men, according to the research team from University Hospital Lund. The discrepancy in female/male remission rates could not be explained by age, drug treatment, or how long a patient had rheumatoid arthritis.
   Rheumatoid arthritis can last for a few weeks to months, or it can last a lifetime.

Rheumatoid arthritis Research Update
Randomized double blind trial of an extract from the pentacyclic alkaloid-chemotype of uncaria tomentosa (Cat's Claw) for the treatment of rheumatoid arthritis.
Mur E. Innsbruck University Hospital, Austria.
J Rheumatol. 2002 Apr;29(4):678-81.
To evaluate safety and clinical efficacy of a plant extract from the pentacyclic chemotype of Uncaria tomentosa (cat's claw) in patients with active rheumatoid arthritis. Forty patients undergoing sulfasalazine or hydroxychloroquine treatment were enrolled in a randomized 52 week, 2 phase study. During the first phase (24 weeks, double blind, placebo controlled), patients were treated with UT extract or placebo. In the second phase (28 weeks) all patients received the plant extract. Twenty-four weeks of treatment with the cat's claw extract resulted in a reduction of the number of painful joints compared to placebo (by 53% vs 24%). Patients receiving the cat's claw extract only during the second phase experienced a reduction in the number of painful and swollen joints compared to after 24 weeks of placebo. Only minor side effects were observed. This small preliminary study demonstrates relative safety and modest benefit to the tender joint count of a highly purified extract from the pentacyclic chemotype of UT in patients with active rheumatoid arthritis taking sulfasalazine or hydroxychloroquine.

Some patients who take the anti-rheumatic drug Arava (leflunomide) develop peripheral neuropathy, a nerve problem that involves numbness, tingling or pain in the hands or feet.

Rheumatoid arthritis questions
Q. Does Tai Chi help reduce symptoms of rheumatoid arthritis?
   A. Tai Chi does not have a significant role to play in the treatment for rheumatoid arthritis.

Q. Does acupuncture help reduce symptoms of rheumatoid arthritis?
   A. In the long run acupuncture does not have a major influence on rheumatoid arthritis symptoms.

Q. Would Wobenzym help rheumatoid arthritis?
   A. We have not seen any such studies.
 

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