naturopathydigest.com -- Navigating the Integrative Highway

My symptoms of RA began five or six years ago. I was a few years into building my solo naturopathic practice, and I believe that stress contributed significantly to my developing RA.

The first rheumatologist I consulted was elderly and conservative, but his resume was impressive, in that he also held a PhD in immunology. I had run the blood tests and self-diagnosed RA, but I wanted to confirm that diagnosis with someone who has seen a lot of it. At that time I was taking high doses of aspirin and EFAs and I wasn't in much pain. To his credit, he did a thorough physical exam that included an EKG and spirometry. Subsequent rheumatologists have done little more than look at my hands. When we sat in his office to discuss my treatment, it was clear he had not listened to any of my concerns or objections. He handed me a bag full of samples and prescriptions for several of the drugs discussed below, none of which I took. I am working with a different rheumatologist now, and she is an improvement in that she listens to my concerns about the drugs and lets me make the decision whether or not to take a particular drug. But she still tries to persuade me with fear, and she gives me little credit for knowing more about health and medicine than the general public.

The drugs used to treat RA are, for the most part, an abomination to our naturopathic principles. Their intent is to be toxic and suppressive. When I first balked at taking methotrexate, a chemotherapy drug, saying I didn't want to suppress my immune system, the first rheumatologist replied in exasperation, "But that's what you want to do!" The average RA patient takes at least three drugs, and most take many more.

The regimen is usually started with high doses of a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen. I chose naproxen because it is the only one in its class that has not proven to be cardiotoxic (The rheumatologist tried to sell me on the notion that it might actually be cardioprotective.) The side-effects from the NSAIDS are two-pronged: there is the well-known risk of gastroenteritis and ulcers; and they increase the risk of myocardial infarction, of which I have a family history.

For more than a year, prior to seeing a rheumatologist, I controlled my pain with aspirin – four 365mg tablets twice a day – and tolerated that well until the inevitable heartburn made me discontinue it. Along with an NSAID, the newly-diagnosed RA patient is often prescribed prednisone and a disease-modifying antirheumatic drug (DMARD), usually methotrexate. Methotrexate is taken once a week, and its purpose is to attack and destroy the rapidly dividing, "overactive" lymphocytes.

A typical scenario is that the patient is ecstatic about the initial pain relief with these three drugs, until that inevitable day when the immune system adapts enough to override some of their efficacy. Then the pain returns, doses go up, and new drugs are added to the regimen (without removing any of the prior drugs.) The newer drugs tend to be "tumor necrosis-factor blockers" or TNF blockers (strong immune-system inhibitors). Predictably, both the DMARDs and the TNF blockers render the patient vulnerable to massive infections and cancer. The newest injectable RA drugs are monoclonal antibodies that also work by inhibiting TNF. Like the others, they come with a steep cost in terms of both side effects and money (a year's supply of some of these drugs can run $27,000.)

The Table below summarizes the allopathic treatment of RA. Never during any of my encounters with rheumatologists were diet, exercise or stress management mentioned.

Drug	When Given	Most Serious Side Effects
Ibuprofen (NSAID)	upon diagnosis	GI irritation, increased risk of MI
Mobic (COX-inhib.)	upon diagnosis	GI irritation, increased risk of MI
Naprosyn (NSAID)	upon diagnosis	GI Irritation, kidney damage
Methotrexate (chemotherapy)	upon diagnosis	GI irritation, infections, liver damage, (chemotherapy) lymphoma, neuropathies
Prednisone (corticosteroid)	upon diagnosis	weight gain, adrenal suppression, (corticosteroid) osteoporosis, COPD
Leflunomide (Arava) (DMARD)	2^nd layer	cancer, frequent infections, fatigue
Hydroxychloroquine (anti-malarial)	2^nd layer	aplastic anemia, lymphadenopathy
TNF inhibitors	2^nd layer	MS, septecemia, lymphoma
(Monoclonal ABs) (Injections)	3^rd layer	overwhelming fatigue, flu-like body aches

Now for the naturopathic side. I tried high doses of the anti-inflammatory herbs (several high-dose "arthritis formulas" from some of the leading makers,) EFAs, elimination diets and anti-inflammatory "medical foods." They all had minimal effect when the RA flared and the pain became severe. I still adhere to a whole-food anti-inflammatory diet and take high doses of EFAs (from fish oil), more for cardiac protection than for actual pain relief. I'm here to tell you that RA pain, at its worst, is as bad as it gets. It severely compromises quality of life. There is also the joint swelling to take into account (I can no longer make a fist with either of my hands) rheumatoid nodules and possible deformities (which I have managed to avoid so far). There is also an increased risk for osteoporosis, lymphoma and heart disease. I currently take a good, high-dose multi – 500 mg calcium, 500 mg magnesium, 2000ius vitamin D3, 3g DHA and EPA, and 600mg silymarin – per day. The Table below summarizes supplements I have found useful for RA:

Supplement	Dose/Day	Mode of Action	Purpose
Omega-3 Fatty Acids	3 g	Anti-inflammatory	Lowers inflammatory cytokines Prevents heart disease and cancer
Vitamin D3	>2,000iu	Immune modulator	Lowers autoimmune reaction
Calcium	400mg	Nutritional	Relaxes muscles/reduces pain
Magnesium	400mg	Nutritional	Prevents bone loss
Curcumin	3 g	Choleretic	Helps with detox
CoQ10	100-200mg	Energy production	Improves energy Prevents MI
Silymarin	600 mg	Liver protection	Counteract toxic effects of drugs
Eleuthrococcus	1-2 tsp	Adaptogen	Helps with energy, adrenals

Rheumatoid arthritis challenges us as naturopathic doctors to practice truly integrative medicine. I doubt that you will see many RA patients who are not taking some of the drugs from Table I. I suffered long and hard before I could put my dogma aside and take some of the drugs that alleviated my symptoms. We can be very useful to the RA patient by prescribing natural medicines to counteract the toxicity – and in some cases increase the efficacy – of the drugs so that lower doses can do the job. The drugs dramatically increase the patient's risk of developing heart disease, cancer and osteoporosis. We have many good treatments to counteract these effects and aid in the prevention of these conditions. As naturopathic doctors, we can also serve the RA patient by counseling them toward a nutrient-dense, anti-inflammatory (low sugar, low saturated fat) diet, weight management to reduce stress on joints, effective methods of stress management and sleep support (a challenge with RA, as it tends to flare in the early morning hours.)

As for me, I am down to low doses of the drugs I have deemed the safest, as well as my aforementioned supplement and lifestyle regimen. I exercise and meditate daily, and eat a good (but not perfect) diet. I plan to embark upon another detox soon. I still have some pain and stiffness, but it's bearable and not compromising my quality of life. My energy and mental outlook are good. I'm optimistic that with the proper holistic support, my dear, confused immune system will eventually regain its balance.

About the Author: Dr. Hamman graduated from Bastyr University in 1999 and is now in private practice in San Francisco.