Rheumatoid Arthritis (RA) is an autoimmune disease that affects the lining of joints, causing a painful swelling that can eventually result in bone erosion and joint deformity.

Nearly 1.3 million people worldwide are affected by RA, with the highest incidence in women and those over the age of 40. The cost of medical care, pharmaceuticals, disability, and lost wages resulting from RA contributes to the nearly $303 billion spent on this disease.  

Fortunately, it is possible to restore balance and facilitate healing in RA patients through functional medicine principles.

Natural treatments for RA include:

• Identifying specific triggers through functional lab testing.
• Focusing on a whole food diet while eliminating certain foods that contribute to inflammation.
• Healing the gut lining with appropriate supplements.
• Modifying lifestyle choices to facilitate the body's healing.  

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What is Rheumatoid Arthritis

The immune system plays a primary role in developing autoimmune diseases like RA. The immune system is constantly at work assessing, surveilling, and repairing the environment and appropriately responding in the presence of a perceived threat. A threat can be anything from food, virus or bacteria, pesticides, artificial coloring, or a new medication. In autoimmunity, the threat becomes the body's own tissue or organ.  

The immune system is quite complex. There are two components of the immune system, the innate and adaptive. The innate immune system is one that a person is born with and is the body's first line of defense. The adaptive immune system develops in response to the environment, producing T-cells and B-cells. Through the action of the adaptive immune system, a stronger immune response is created, along with antibodies to protect against future threats of the same kind.  

When a threat is present, the innate immune system responds first and, if unable to rid of the threat, will signal the adaptive immune system to take over. There are many immune cells involved in these cascades. Most notably, T-cells and macrophages will secrete chemicals called cytokines in response to a threat. These cells are either pro-inflammatory or anti-inflammatory. A specific type of white blood cell, called T-Regulatory cells, helps keep T-lymphocytes from getting out of control and attacking self-tissues.    

A proper immune response is well-balanced and is able to appropriately remove the threat while B-cells create antibodies against future exposure. The immune system becomes overwhelmed when there is ongoing exposure to a threat, and an imbalance occurs between the amount of pro-inflammatory versus anti-inflammatory cytokines. Chronic autoimmune activation has been linked to dysregulation of T- and B-cells.

Rheumatoid Arthritis is an inflammatory arthritis that affects synovial joints. In a healthy joint, the bone is protected by an articular capsule, including an inner layer of connective tissue called the synovial membrane. This membrane secretes synovial fluid, which acts as a protective cushion and provides lubrication and nutrients for the joint. When there is inflammation within this synovial space, the membrane becomes painful and swollen. In RA, pro-inflammatory cytokines and other inflammatory mediators circulate within the bloodstream. They can get trapped in the synovial joint spaces, resulting in the onset of joint pain and inflammation. Moreover, as a result of this overwrought and imbalanced immune system, there is a loss of tolerance to the synovial membrane cells, resulting in degradation of the associated cartilage, bone, and tendons within the joint (3,4,5,6).

The 4 Stages of Rheumatoid Arthritis

The stages of RA are referred to as:

• Stage I: When genetic predisposition and exposure to environmental risk factors will begin to trigger an immune response.
• Stage II: When autoantibodies of RA, like rheumatoid factor and anti-cyclic citrullinated peptide, are present in blood testing
• Stage III: When symptoms like joint pain or stiffness are present, but there is no other clinical evidence of arthritis  
• Stage IV: When there is clinical evidence of arthritis in 1 or 2 joints, it is considered early undifferentiated arthritis. If these symptoms are intermittent, it is called palindromic rheumatism.
• Stage V: When the individual meets diagnostic criteria, Established RA

Rheumatoid Arthritis Signs & Symptoms

Rheumatoid Arthritis is one of several inflammatory joint diseases. Therefore understanding signs and symptoms can help discern one disease state from another. A person with an autoimmune disease, like RA, can be asymptomatic for many years before developing symptoms.

Common Signs and Symptoms of RA Include:

• Tender, Warm, Painful Joints in the small joints (hand, wrist, feet) or at least two or more large joints (knee, shoulder, hip)
• Bilateral Joint Involvement (i.e., both hands or feet)
• Stiffness in joints, usually worse in AM and lasting at least 30 minutes
• Rheumatoid nodules on joints
• Symptoms that are present for at least six weeks  
• Elevations in autoimmune inflammatory and immunologic markers
• Evidence of erosions or effusions on Xray, MRI, or Ultrasound
• Presence of white blood cells on a culture of synovial fluid

Because the immune system is involved, many will experience constitutional symptoms, perhaps even before the onset of joint manifestations. These include:

• Weight Loss
• Fever
• Fatigue
• Weakness

As RA progresses and inflammation becomes chronic, there is an increased risk of developing extra-articular symptoms. These symptoms vary widely and contribute to the increased morbidity and mortality of RA. (1,2,3)

Rheumatoid Arthritis Possible Causes

The cause of Rheumatoid Arthritis is multifactorial, primarily involving the triad of autoimmunity: genetics, environment, and enhanced intestinal permeability. These factors, along with an imbalanced immune system, contribute to the development of RA. Let's explore these causes a bit further.

Genetics

Having a genetic predisposition increases the risk of RA by 60%. Many genes have been identified as risk factors for RA with the human leukocyte antigen (HLA) class, especially the HLA-DRB1 gene (3,7).  

Females

Women are at a statistically higher risk of developing an autoimmune disease. Specific to RA, they have a 3x higher likelihood compared to men. This is thought to be due to the relationship between sex hormones and immune system regulation.  

Age

Rheumatoid arthritis most commonly occurs between the ages of 35 and 50; however, recent studies indicate that more than 50% of those diagnosed are over 65. Interestingly, studies have shown that those with RA have immune systems that have prematurely aged by 20 years and can predict certain disease outcomes depending on the age of disease onset (3,12,13,14).  

Environment

Epigenetics is the ability to change genetic expression through a person's lifestyle choices. Many studies point to the environment having a more significant impact than genetic predisposition when examining causes of RA. Even early in life, certain environmental choices have been associated with increased risk of RA, including smoking, high birth weight, breastfeeding mothers, obesity, decaffeinated coffee intake, and socioeconomic status (1,8,9,10,11).

Sugar Consumption

It has been shown that increased sugar consumption may increase inflammatory stress. In a large study performed in the United States, women who consumed more than one serving of sugar-sweetened soda per day had an increased risk of developing seropositive RA.

Enhanced Intestinal Permeability  

Enhanced intestinal permeability (EIP), also referred to as "leaky gut," has been associated with the development of autoimmune diseases. The intestinal lining consists of tight junctions that act as protective barriers, only allowing specific and essential molecules to permeate. When these junctions are more significant, it allows larger molecules to pass through and into the bloodstream, where they are immediately seen as a threat, and the immune system responds. Many factors have been shown to contribute to EIP, like vitamin D deficiency, zonulin, food sensitivities, mycotoxins, chemicals in food, medications (i.e., NSAIDs, oral contraceptives, antibiotics), and chronic stress (16,17,18,19).  

Imbalance Immune System

An imbalanced immune system speaks to one that is aggressively activated against something it perceives as a threat (including itself) or under reactive, unable to respond appropriately. As is the case with environmental exposures, the causes of this can be multifactorial and include:

• Genetic predisposition
• Foods containing chemicals, fillers, artificial colors, and flavorings are genetically modified.
• Chemicals in personal hygiene and household products.
• Chronic stress. This can be intrinsic (i.e., insulin resistance, oxidative damage) or extrinsic (from busy life, strained relationships, a negative environment).
• Toxicity from mold, heavy metals, poor air quality, poor water quality
• Food sensitivities. Especially gluten, the protein found in wheat.
• Impaired digestion and decreased absorption of essential nutrients needed for immune system regulation, like Vitamins A, D, zinc, and B-Vitamins.

Functional Medicine Labs to Test for Rheumatoid Arthritis

Traditional Lab Work

Traditional lab work in RA includes Rheumatoid Factor (RF), antibodies to cyclic citrullinated peptides (anti-CCP), and erythrocyte sedimentation rate (ESR).  

Both RF and anti-CPP are elevated in approximately 60-80% of people with RA. However, some may be seronegative and still have symptoms consistent with RA. These antibodies have been associated with a higher risk of bone erosion.  

The ESR is a helpful but nonspecific marker of inflammation that can help guide the practitioner to the severity of the disease.  

A complete blood count with differential (CBC w/ Diff)) will help identify any presence of anemia and infection (3).

Gut Inflammation

In order to successfully manage the dysregulated immune system that is happening in RA, we have to examine the status of the microbiome and explore other causes of inflammation.  

• Food sensitivity testing, like the KBMO, will help to identify foods that are triggering IgG and IgA immune system activation, including gluten, contributing to inflammation, EIP, and impaired nutrient absorption. Note: if a patient has taken steroids or immunosuppressants within the six weeks before testing, it is recommended to delay testing. These medications, by design, have suppressed the immune system, and the test results will not be reliable.

• A GI Map is a comprehensive stool test that will identify the presence of pathogens and inflammatory markers in the stool. This test also speaks to the overall digestive health, including the amount of short-chain fatty acids (SCFA), which, when ample, ensures there are proper levels of T-regulatory cells needed for a balanced immune system. An add-on zonulin marker would help identify "leaky gut."

Methylation Panel

Methylation is a biochemical process that primarily helps to ensure optimal genetic activation. This panel explores the methylation pathway and will identify where there are blocks that may place a patient at higher risk for developing diseases. An essential part of healing will be to understand methylation patterns and work to ensure detoxification pathways are supported.  

Hormone Balance

A Dutch Complete provides insights into hormone and adrenal health, which have critical roles in immune health, as they can modulate and affect the function of the cells used in both the innate and adaptive immune systems (20). Other significant findings include melatonin levels, whose role is integral in calming the immune system, and organic acids related to methylation and glutathione synthesis, necessary for proper detoxification, as noted above.  

Micronutrient Testing

A key component of autoimmune disease is caused by Enhanced Intestinal Permeability (EIP). When a patient has EIP, they are more likely to be deficient in essential nutrients and minerals that the immune system requires to function optimally. The presence of pathogen overgrowth will also contribute to malabsorption and maldigestion. Spectracell provides cellular nutritional markers that can be valuable in developing a treatment plan to best support a patient's unique biochemistry.  

Other Lab Tests to Check

Although it's not always necessary, some practitioners may choose to obtain imaging of the individual's affected joints to help guide them on diagnosis and treatment plans. This can include x-rays, MRIs, or ultrasounds. In some cases, aspiration of the joint will be necessary to culture the synovial fluid and rule out other possible causes of inflammatory arthritis.  

Conventional Treatment for Rheumatoid Arthritis

There are several drugs used in the management of RA that, in one way or another, suppress the actions of the immune system so that the inflammation can be calmed. Conventional, biologic, and target synthetic disease-modifying antirheumatic drugs (DMARDs) are commonly used, with Methotrexate being the preferred monotherapy.

Glucocorticoids and non-steroidal anti-inflammatory (NSAIDs) are often used in the short term for quick symptom relief while waiting for the DMARDS to take full effect (2).

The goal of pharmacologic management in RA is to reduce inflammation, prevent joint damage, and prevent long-term sequelae of the autoimmune dynamic. While any of these therapeutics can be life-saving, it does not treat the root cause of immune system dysfunction that is driving the RA process. Exploring these root causes while implementing natural remedies for RA will likely lead to more symptom resolution and sustainable results.

Natural Treatments for Rheumatoid Arthritis

Herbs for Rheumatoid Arthritis

Herbs have been widely known to have medicinal properties and have been used to treat certain diseases for centuries. The anti-inflammatory, antioxidant, and immunoregulatory properties of these herbs make them great treatment options. Boswellia, curcumin, green tea, borage oil, and rosemary have all been shown to improve inflammation and pain symptoms in individuals with RA. Many of these can be taken via a supplement. However, they can also be incorporated into meals and beverages.

Supplements for Rheumatoid Arthritis

In addition to using herbs to treat RA, supplements also provide a significant benefit in supporting immune health, reducing oxidative damage, improving digestion, healing EIP, and diversifying the microbiome.

People with RA often have deficiencies in essential nutrients needed to keep their cells healthy and to have a robust, effective immune system. Probiotics and prebiotics effectively calm the immune system and restore a diverse microbiome. The results of the GI Map can help to tailor which probiotics are best.

Digestive enzymes are helpful due to insufficient secretion of enzymes from the pancreas and gallbladder, which further contributes to impaired fat absorption and microbial imbalance. Supplements such as Vitamin D, L-glutamine, zinc, and fish oil effectively heal the gut lining and improve permeability.

Supplements needed for immune health include Vitamins D, A, and C, along with essential minerals like magnesium, zinc, and selenium. In adults over 40 who are supplementing with Vitamin D, it is also important to take ample Vitamin K2. This will help bring calcium into the bones rather than the bloodstream, where it can circulate and create calcifications in blood vessels, organs, and joints! Fish oil is also recommended due to its anti-inflammatory properties. Flavonoids found in many fruits and vegetables, like Quercetin, have shown to be beneficial.

Lifestyle Changes

• Stop smoking. Smoking is a high environmental risk factor known to cause RA.
• Diet: Focusing on whole foods, like fruits, vegetables, healthy fats, and lean protein, is a foundational approach to all healthy lifestyles. In RA, specifically, it is recommended to eliminate gluten and dairy due to the inflammation and enhanced intestinal permeability associated with these.
• Depending on the results of the KBMO, a broader elimination diet may be necessary.
• Avoid chemicals, food additives, and processed sweeteners. The immune system is already dysregulated and may view these as threats.
• Ensure proper hydration with clean, filtered water and avoid drinks high in sugar and caffeine, as this can disrupt the microbiome.  

Summary

Rheumatoid Arthritis occurs when there is an imbalance in the immune system due to genetics, environmental factors, and the presence of enhanced intestinal permeability. The synovial joints become the battleground for this immune system activation, resulting in enough pain and disability that it can interfere with one's quality of life.

A functional medicine approach to RA explores the root cause of the immune system dysfunction and works to support the individual in reversing this dynamic.

By committing to lifestyle changes that encourage the body to thrive, those with RA can have hope for symptom relief and recovery.