By Alan Martin, MD
During my career as a rheumatologist, there has been no more significant breakthrough in the treatment of rheumatoid arthritis (RA) than the introduction of biologic agents when Enbrel came on the market in 1998.
The traditional therapies are still used initially for treatment. These are labeled disease-modifying anti rheumatic drugs (DMARD). The most commonly used DMARD medications are methotrexate, hydroxychloroquine, sulfasalazine and leflunamide. These medications may be used alone or in combinations, as long as there are no contraindications. Some RA patients do achieve a significant improvement and can be maintained on these medications alone. Many patients, unfortunately, do not achieve an acceptable improvement, and their disease activity continues.
The biologic agents have revolutionized the treatment of RA in their ability to slow down disease progression, and in some cases, induce remission of disease. These drugs were engineered to specifically inhibit proteins secreted by cells that regulate the immune response and promote inflammation. There are multiple categories of biologics that each block specific aspects of the immune system. Some examples are Enbrel, Humira, Simponi Aria, Remicade, Actemra, Rituxan, Orencia and Xeljanz. Sixty to seventy percent of patients have a measurable improvement, and fifteen to twenty percent may have remission or close to remission of their RA.
Every patient’s disease process and response to medication is unique, and one biologic may help one patient more than another. Therefore, in some patients, multiple trials of different biologic medications may be used in succession. Treatment decisions are based on the balance of improving the disease process weighed against the risks of drug toxicity. Evaluating which medication is right for each patient, the physician takes into account lab studies, x-rays and the patient’s medical history. Conditions in a patient’s previous or current medical history that may affect the decision of using biologics are infectious exposures, current infection risk, nerve disorders, history of heart failure, other chronic diseases and pregnancy.
To assess the effectiveness of these medications, a rheumatologist uses multiple parameters, including number of joints involved, x-ray progression and functional status. Functional status is assessing the patient’s ability to perform daily activities such as walking, dressing and grooming and performing household or work duties. Unfortunately, not all RA patients are candidates for biologic medications. Fortunately, though, most patients will be able to benefit from the use of biologics and see improvement in their activity and pain level.
We have come a long way since simple analgesics such as aspirin were used to treat RA. Those simple analgesics did not address the disease process and provided minimal pain relief. Now we have biologics that can slow down the disease progression and at times put the disease in remission, which leads to a higher quality and more enjoyable life.
By Lindsay Cunningham, D.O., RhMSUS
Rheumatoid Arthritis Awareness Day is February 2, so this blog post addresses the top questions asked in my clinic regarding rheumatoid arthritis (RA):
- What can I do for myself to help my RA?
- Is there something that I should or should not be eating?
- What diet will help with my rheumatoid arthritis symptoms?
These are great questions, and unfortunately, there is not a straightforward answer with regards to diet. Diets impact our health in more ways than we could imagine, making it a very difficult subject to study. Despite the host of limitations, there is still some evidence that certain dietary changes can reduce general inflammation or symptoms from rheumatoid arthritis. One key thing to remember: Changing inflammation in our body or improvement in RA symptoms does not mean that we are changing the inflammatory process in our joints.
There is no evidence to show us that changes in diet will slow progression of rheumatoid arthritis. Dietary and lifestyle changes should only be one aspect of your complete rheumatoid arthritis care and should not be relied on solely for treatment.
There is not one specific diet recommended for rheumatoid arthritis. Symptomatic relief with regards to arthritis and diet varies greatly among individuals. There is evidence that some aspects of our diets can improve certain types of inflammation, and if desired, could be incorporated into your daily life. The changes with the most evidence include the following: high intake of foods rich in monounsaturated fats and fiber and low intake of processed foods and foods with high content of saturated fats.
The fiber intake is best if it comes from the foods we eat, not from supplementation or pills. These foods include vegetables, fruits, beans, nuts, and whole grains. Food sources rich in omega-3 fatty acids include fish, such as salmon, mackerel, oysters, etc. Try cooking with virgin olive oil, instead of vegetable oil. Remember that the focus is on a well-balanced diet that includes foods rich in fruits, veggies, healthy fats, and fiber. Other than cutting out processed foods and “junk food,” there really hasn’t been an established food group to eliminate.
One thing that’s important to notice: These dietary changes tend to be viewed as good suggestions for most health conditions, not just arthritis. Are these improvements related to weight reduction and other lifestyle improvements, or to the foods themselves? Most of the studies can’t really tell us. There’s probably a little truth to both, although the link to weight loss and reduced disease activity has been fairly well established.
Physical activity is highly recommended for those with rheumatoid arthritis. There is no evidence that being physically active does any additional damage to the joints of those with RA; however, evidence has shown that physical activity improves functional capacity. Find physical activities that focus on aerobic capacity and muscle strengthening with low joint impact overall. If you’re having trouble getting started, physical therapy is a great place to get direction.
And finally, the dreaded but most important topic: weight. Being overweight not only increases your risk of developing RA, but it also increases your body’s level of inflammation (fat tissue produces inflammatory chemicals) and has been shown to worsen control of RA.
If you are overweight, the best news to take from prior studies: weight loss has been shown to reduce disease activity! Weight loss appears to be the most important player in non-pharmacologic management of RA. Weight loss and physical activity should be emphasized over specific dietary changes.
Lifestyle, diet, and other non-pharmacologic changes are important to include in your care of rheumatoid arthritis but should not be done as the sole treatment for RA. Weight loss has been shown to have the largest benefit. Individualized improvements of RA symptoms have been noted with dietary changes, especially with incorporation of vegetables, fruits, fiber, and healthy fats. Consult with your rheumatologist regarding the best way to manage your rheumatoid arthritis in entirety, and do not rely on diet or weight loss alone.
Remember that not all diets or lifestyle changes are safe for all people. If you’re considering any changes to diet or physical activity, you should consult with your health care provider first.