Rheumatoid Arthritis

Question 1

Rheumatoid Arthritis

Answer 1

A chronic inflammatory autoimmune disease characterised by synovial joint inflammation , potentially affecting all organs except the brain.

Question 2

RA: Signs and symptoms

Answer 2

• Symmetrical polyarthritis affecting small distal joints of the hands / feet. Can affect more proximal joints.
• Hand deformities (e.g., swan neck).
• Subcutaneous nodules.
• Complications: C1/2 vertebral subluxation, pleurisy, pulmonary fibrosis, kidney disease, Sjögren’s syndrome, carpal tunnel syndrome.

Question 3

RA: Pathophysiology

Answer 3

• Citrullination occurs. APCs recognise citrulline containing regions of several proteins as foreign.
• APCs present the antigens, triggering T-cell differentiation. Autoantibodies created
• T-cells -> produce inflammatory cytokines
• The inflammatory cytokines → cartilage degradation and → increasing osteoclasts and bone destruction (RANKL)

Question 4

RA: RANKL

Answer 4

Receptor activator of nuclear factor kappa Β ligand (a transmembrane protein) regulates osteoclast activity

Question 5

RA: Causes and risk factors

Answer 5

• Genetics
  -HLA- DRB1: 30%
  –PTPN22 SNP - non HLA
• Smoking
• Periodontitis induces citrullination.
• Silica dust
• Intestinal dysbiosis - reduced Bacteroides and Bifidobacterium, increased Prevotella copri

Question 6

RA: Blood tests

Answer 6

• Raised inflammatory markers ESR / CRP
• Rheumatoid factor (RF) in 70% of cases
• Anti-citrullinated protein antibodies (ACPAs)

Question 7

RA: Natural approach

Answer 7

• CNM Naturopathic Diet - inflammation (e.g., no refined sugar, trans fats, dairy, limited red meat; high omega 3, etc.).
• Abundant antioxidants (rainbow diet)
• Autoimmune protocol (AIP)
• Gluten

Address the cause:
* Oral microbiome
* Stop smoking
* Gut barrier
* EBV

Question 8

RA: Supplements

Answer 8

Vitamin D
Omega-3
GLA
Resveratrol
Alpha Lipoic Acid
EGCG
Quercetin
Zinc

Question 9

RA: Vitamin D

Answer 9

Inhibits Th17
Promotes Treg differentiation
Lowers RANKL

Question 10

RA: Omega-3

Answer 10

Dose: 1g EPA

Reduces Th17 and Il-17
Inhibits PGE-2, NFkB, TNF-a and Il-6

Question 11

RA: GLA

Answer 11

Dose: 1-2g daily

Reduces pain and stiffness
PGE-1 pathway
Inhibits 5-Lox and NFkB

Question 12

RA: Resveratrol

Answer 12

Dose: 200mg/day

Reduces Th17
Downregulates NFkB and COX-2

Question 13

RA: Alpha lipoic acid

Answer 13

Dose: up to 1200mg/day

Antioxidant
Anti-inflammatory -> NFkB

Question 14

RA: EGCG

Answer 14

2-3 cups green tea a day

Anti-inflammatory
Inhibits NFkB

Question 15

RA: Quercetin

Answer 15

Dose: 1.5 - 3g/day

Anti-inflamm
Inhibits NFkB and CoX-2

Question 16

RA: Zinc

Answer 16

Dose: 15-30mg

• Deficiency / insufficiency -> predispose to inflammation. Delta 6 desaturase activity decreases.
• Low levels are associated with increased: NF kb activation, CRP, IL 1β, and TNF α.

Question 17

RA: Other

Answer 17

Probiotics
Anti-inflamm herbs: Turmeric, Devil’s claw, boswelia, ginger
Tissue salts