An Herbal Approach To Rheumatoid Arthritis

I recently conferred with a patient who had been diagnosed with rheumatoid arthritis (RA), a chronic inflammatory type of arthritis that affects the lining of the joints, causing painful swelling and potential joint destruction and deformity. The standard treatment for the disease is high dosages of pharmaceutical drugs, including anti-inflammatories, steroids, and immune suppressive drugs. The danger is that although these drugs suppress symptoms and may keep the disease somewhat under control, they do not address the underlying causes. And the side effects of these types of drugs can be significant, including serious liver damage, increased risk for infection, and heart disease.

As with most diseases, conventional medicine makes the mistake of solely focusing on the relief of symptoms—no matter what the cost—instead of the individual and the underlying contributing factors to the disease. In certain severe cases, it may be necessary to interrupt the vicious cycle of autoimmunity (where the body attacks itself) with the help of conventional medicine. However, it is vital at the same time to work with natural medicine to address the underlying factors, potentiate the use of conventional drugs (such as steroids), offset short and long-term side effects, and slowly wean people off these drugs by enhancing the innate capacity to heal from within by using botanical, nutritional, dietary and life-style medicine.

With a complex condition such as RA, it’s important to look at the whole picture. In the paradigm of Mederi Medicine, also known as the Eclectic Triphasic Medicine System (ETMS), we employ three diagnostic lenses: 1) the person’s constitution and symptom presentation, 2) blood work and other diagnostic tests, and 3) the known disease patterns and possible genetic type predisposed to RA, such as those with methyl defects.

The basic approach of the ETMS to RA is:

• Nourishment with botanicals and nutrients to supply the building blocks for collagen, joints, ligaments, tendons, and all connective tissue.
• Aid in anabolic-recovery and healing and regeneration, enhancing both strength and lubrication, which assist in mobility and flexibility.
• Mitigate and modulate inflammation and oxidative damage.

I evaluate each patient as an individual, asking questions such as: “What are your symptoms and when did they start? Did anything precede the RA, such as an infection, or an acute stressful event? What does your blood work look like?” Besides inflammatory biomarkers such as SED rate and CRP, as well as CBC, I often advise having hormones checked, such as DHEA sulfate, vitamin D (both 25 OH and 125diOH) and homocysteine. The SED rate, CRP, and WBC (CBC) help in assessing the current level of inflammation while the other tests assess related microenvironment biomarkers that reflect overall health. For example, low levels of vitamin D are associated with an increased risk in RA and autoimmunity.

If a patient is in significant pain, it might be necessary to start with a low dose of steroids (most likely prednisone) and anti-inflammatory drugs, such as Bufferin (aspirin with calcium and magnesium to buffer the effects of aspirin on the stomach) or Celebrex, which is a COX-2 inhibitor. Recently, researchers found that 500 mg 2 times daily of Boswellia serrata extract was more effective than Celebrex at relieving symptoms of pain and discomfort.¹ Boswellia is one of the main herbs in one of the formulations I use for RA. I recommend holding off on immune suppressive drugs, which most likely will be chemotherapy (such as methotrexate), because they cause significant stress to the liver and GI tract as well increase susceptibility to infections.

If possible, I recommend beginning with botanical formulations, but if someone is suffering and needs quick relief, I suggest using the lowest possible dose of prednisone possible to get relief. At the same time, I recommend an ETMS protocol that includes several botanical and nutritional formulations designed to potentiate the anti-inflammatory effects of the drugs, while simultaneously protecting the body from the adverse effects of the drugs. RA is a multifaceted disease, and the program I advise is correspondingly comprehensive.

The primary formulations I recommend for rheumatoid arthritis include the following:

• Formula #1 contains boswellic acid-rich boswellia, feverfew extract, scutellaria baicalensis extract, honokiol-rich magnolia extract and andrographolide-rich andrographis extract.

• Formula #2 contains salmon derived collagen, green lipped mussel extract powder, glucosamine and chrondroitin sulfate, devil’s claw (Harpagophytum procumbens) extract containing 15% harpagoside, white willow (Salix alba) bark extract containing 30% salicin, yucca (Yucca schidigera) root extract, and black pepper (Piper nigrum) extract containing 95% piperine.

Salmon derived collagen provides an array of nutrients, including the amino acids proline and hydroxyproline, which assist in joint and connective tissue health. Salmon derived collagen aids in the production of synovial fluid, which protects the hardness and flexibility of cartilage. Salmon derived collagen is also rich in cartilage proteoglycan, which suppresses inflammation in diseases such as RA. Several recent studies have found that salmon contains small bioactive protein molecules (called bioactive peptides) that may provide special support for joint cartilage, insulin effectiveness, and control of inflammation.^2,3

Green lipped mussel extract is a rich source of nutrients, including a wide range of glycoaminoglycans (including chondroitin sulphate). It has been shown in clinical trials to significantly reduce pain and improve joint mobility, with no side effects.^4,5  It has also been shown to decrease inflammatory biomarkers.^6,7

Devil’s claw is native to the southern part of the African continent and has historically been used as a pain-relieving anti-inflammatory. Pharmacologically, the herb has anti-inflammatory and analgesic properties. Recent research suggests that there may be a down-regulation of COX-2 and iNOS, as well as a similar effect on TNF alpha transcription.^8-11

The use of willow bark dates back thousands of years to the time of Hippocrates, when patients were advised to chew on the bark to reduce fever and inflammation.  The bark of white willow contains salicin, a chemical similar to aspirin (acetylsalicylic acid). In combination with the herb’s powerful anti-inflammatory plant compounds called flavonoids, salicin is thought to be responsible for the pain-relieving and anti-inflammatory effects of the herb. Salicin inhibits the over expression of cyclooxygenase-2 (COX-2) and nuclear factor kappa beta (NF-kB), which are involved in both inflammation and abnormal gene expression. In studies, willow bark extract has been found to be a useful and safe treatment for arthritis-related pain and inflammation.^12,13

• Formula #3 contains curcumin-rich turmeric, OPC-rich grape seed and skin extract, green tea extract, a gingerol-rich ginger extract, amla (Indian gooseberry extract), quercetin, resveratrol and piperine-rich black pepper extract.

• Formula #4 is an inward yin nourishing Kidney Essence (endocrine) tonic formula that contains rhemannia, shatavari (Asparagus racemosus), Dioscorea, black cohosh, hops (Humulus lupulus), Eucommia and licorice. This formula assists in endocrine/hormonal health by enhancing “Essence,” the Endocrine Energy System as a whole. It nourishes, strengthens, and balances essence, thus building the inner energy, which is networked with the immune system and essential to buffering the hyper-immune state of RA. I also sometimes recommend taking a more anabolic restorative Kidney tonic in the morning that contains steroidal-rich adaptogens, including rhaponticum carthamoides, ajuga turkestanica and cissus quadrangularis.

My reason for recommending endocrine tonic formulas is because I believe that it is an essential part of healing to address the underlying cause of disease. This approach facilitates the innate healing response of the body. Research shows that stressful/inflammatory conditions activate the immune system and subsequently the hypothalamic-pituitary-adrenal (HPA) axis through the central and peripheral production of proinflammatory cytokines such as IL-6 and TNF-alpha.¹⁴ Further research points to the complex relationship of the HPA and sympathetic nervous system (SNS), the gonadal hormones (hypothalamic-pituitary-gonadal axis, HPG), and other hormones; estrogens are implicated as enhancers of the immune response and androgens and progesterone as natural suppressors.¹⁵

• Formula #5 is a fatty acid mixture of high-quality EPA/DHA rich fish oil with sea buckthorn oil and pine seed oil or a GLA-rich oil such as borage seed or black currant seed oil. Pine seed oil contains pinolenic acid, a GLA-like compound that also reduces the inflammatory cascade. This combination oil possesses wonderful immune and prostaglandin modulating ability as well as the excellent GI protective effects of sea buckthorn oil.

Fish oil, which is rich in omega-3 fatty acids, can suppress the production of proinflammatory eicosanoids. In September, 2013, a study published online in Annals of the Rheumatic Diseases showed that using fish oil as an adjunctive treatment in patients with early rheumatoid arthritis may benefit patients and allow for less aggressive treatment with disease-modifying antirheumatic drugs, and may also have cardiovascular benefits.¹⁶

• For pain and inflammation control I recommend a formula that contains a 30% salicin-rich willow bark extract, a 50% THP corydalis extract, wild turmeric extract, dong quai extract, boswellia extract and white peony extract. A typical recommendation is 1-2 caps with each meal and 3-4 before bed.

• I also recommend a medicinal smoothie that includes a probiotic powder called Therobiotic (probiotic supplementation has been shown to improve inflammatory status in patients with RA) and a powdered herb blend to protect the GI tract, regulate the immune system, and help to control inflammation. The formula I often use in combination for intestinal health consists of DGL licorice root, marshmallow root, BiAloe 18% Acemannan aloe vera extract, covalent bonded glutamine, propolis and echinacea.

Studies show that probiotics are a useful preventive and therapeutic strategy in autoimmune diseases (AD) such as RA. Three interacting factors including an aberrant intestinal microbiota, a “leaky” intestinal mucosal barrier, and altered intestinal immune responsiveness appear to create a perfect environment for AD development. The regulation of intestinal microflora composition by probiotics offers the possibility to influence the development of mucosal/systemic immunity in a positive way.¹⁷

• Depending on the individual, I may recommend a protective cell detoxification formula rich in isothiocyanates and methlyation donors. Isothiocyanates have been shown to reduce inflammation in patients with RA. For example, ulforaphane, an isothiocyanate derived from cruciferous vegetables such as broccoli, regulates synoviocyte hyperplasia and T cell activation in RA.¹⁸

• I may also create a custom formulation that includes one of my adaptogenic formulations making up 50% of the total formula, combined with specific endocrine enhancing and immune modulating herbs such as cat’s claw, meadowsweet, or bryonia.

• A topical gel or cream for pain and sore joints can be helpful, and unless the individual is experiencing a “flare” of the disease (characterized by heat signs such as fever or significant redness around the inflamed joints), I suggest hot Epsom salt baths before bed.

Of course, I recommend a diet that helps to control inflammation and at the same time builds and strengthens the individual’s constitution. The optimal diet is based on fruits, vegetables, and fish and is free of refined or processed foods. I suggest focusing on specific anti-inflammatory foods such as brightly colored berries, sulfur-rich vegetables (broccoli, cabbage, kale) and cold water fish (salmon, trout).

In my experience, patients who follow this protocol are able to wean themselves completely off of pharmaceutical medications—or at the very least, are able to reduce medications to a minimum. It takes time and persistence, but the results are worthwhile.

References:

1. K. Prabhavathi U, Shobha Jagdish Chandra, et al. Randomized, double blind, placebo controlled, cross over study to evaluate the analgesic activity of Boswellia serrata in healthy volunteers using mechanical pain model, Indian J Pharmacol. 2014 Sep-Oct; 46(5): 475–479.

2. Yoshimura S, Asano K, et al. Attenuation of collagen-induced arthritis in mice by salmon proteoglycan. Biomed Res Int. 2014; 2014:406453. doi: 10.1155/2014/406453. Epub 2014 May 22/

3. Sashinami H1, Asano K, et al. Salmon proteoglycan suppresses progression of mouse experimental autoimmune encephalomyelitis via regulation of Th17 and Foxp3(+) regulatory T cells, Life Sci. 2012 Dec 17;91(25-26):1263-9.

4. Szechinski, J, Zawadzki M, et al. Measurement of pain relief resulting from the administration of Perna canaliculus lipid complex PCSO-524 as compared to fish oil for treating patients who suffer from osteoarthritis of knee and/or hip joints. Rheumatologia Volume 49, Issue 4, Pages 244-252.

5. Brien S, Prescott P, et al. Systematic review of the nutritional supplement Perna Canaliculus (green-lipped mussel) in the treatment of osteoarthritis. QJM. 2008 Mar;101(3):167-79. doi: 10.1093/qjmed/hcm108. Epub 2008 Jan 25. Review.

6. Lee CH1, Butt YK, et al. A lipid extract of Perna canaliculus affects the expression of pro-inflammatory cytokines in a rat adjuvant-induced arthritis model, Eur Ann Allergy Clin Immunol. 2008 Dec;40(4):148-53.

7. Halpern GM. Anti-inflammatory effects of a stabilized lipid extract of Perna canaliculus (Lyprinol). Allerg Immunol (Paris). 2000 Sep;32(7):272-8.

8. Fiebich BL, Heinrich M, et al. Inhibition of TNF-alpha synthesis in LPS-stimulated primary human monocytes by Harpagophytum extract SteiHap 69. Phytomedicine 2001;8:28-30.
9. Loew D, Mollerfeld J, et al. Investigations on the pharmacokinetic properties of Harpagophytum extracts and their effects on eicosanoid biosynthesis in vitro and ex vivo. Clin Pharmacol Ther 2001;69:356-364.
10. Jang MH, Lim S, et al. Harpagophytum procumbens suppresses lipopolysaccharide-stimulated expressions of cyclooxygenase-2 and inducible nitric oxide synthase in fibroblast cell line L929. J Pharmacol Sci 2003;93:367-371.
11. Kundu JK, Mossanda KS, et al. Inhibitory effects of the extracts of Sutherlandia frutescens (L.) R. Br. and Harpagophytum procumbens DC. on phorbol ester-induced COX-2 expression in mouse skin: AP-1 and CREB as potential upstream targets. Cancer Lett 2005;218:21-31.

12. Khayyal MT et al. “Mechanisms involved in the anti-inflammatory effect of a standardized willow bark extract.” Arzneimittelforschung. 55.11 (2005):677-87.

13. Schmid B, Ludtke R, et al. Effectiveness and tolerance of standardized willow bark extract in arthritis patients. Randomized, placebo controlled double-blind study, Z Rheumatol. 2000 Oct;59(5):314-20

14. Cutolo M, Foppiani L, et al. Hypothalamic-pituitary-adrenal axis impairment in the pathogenesis of rheumatoid arthritis and polymyalgia rheumatic. J Endocrinol Invest. 2002;25(10 Suppl):19-23.

15. Cutolo M, Sulli A, et al. Hypothalamic-pituitary-adrenocortical and gonadal functions in rheumatoid arthritis. Ann N Y Acad Sci. 2003 May;992:107-17.

16. Proudman SM, James MJ, et al. Fish oil in recent onset rheumatoid arthritis: a randomised, double blind controlled trial within algorithm-based drug use. Ann Rheum Dis. 2013 Sept 30.

17. Özdemir Ö. Any role for probiotics in the therapy or prevention of autoimmune diseases? Up-to-date review, J Complement Integr Med. 2013 Aug 6;10. pii: /j/jcim.2013.10.issue-1/jcim-2012-0054/jcim-2012-0054.xml. doi: 10.1515/jcim-2012-0054.

18. Kong JS1, Yoo SA, et al. Inhibition of synovial hyperplasia, rheumatoid T cell activation, and experimental arthritis in mice by sulforaphane, a naturally occurring isothiocyanate. Arthritis Rheum. 2010 Jan;62(1):159-70. doi: 10.1002/art.25017