Authors: Rita Baron-Faust,Jill Buyon
The Autoimmune Connection: Essential Information for Women on Diagnosis, Treatment, and Getting On With Your Life (8 page)
Corticosteroids (glucocorticoids) are synthetic versions of steroid hormones normally produced in small amounts by your adrenal glands. Not to be confused with the anabolic steroids used by bodybuilders, these are drugs that reduce inflammation and suppress immune activity.
Low-dose glucocorticoids (less than 10 milligrams of prednisone a day) can reduce the symptoms of RA very quickly, sometimes within a matter of days. They are also used to dampen disease flares. Recent studies show that low-dose corticosteroids may even slow the rate of bone damage, so they may have disease-modifying potential. They’re often given with DMARDs. The most commonly prescribed corticosteroid for treating RA is prednisone (Deltasone, Orasone), but others may be used as well. These include methylprednisolone (Medrol), prednisolone (Prelone), and dexamethasone (Decadron). They are given as oral medication or as an injection into a joint or even muscle. Corticosteroid injections can relieve pain, especially early in the disease, and can be used for disease flares in one or two joints. The benefits can be dramatic—but temporary.
Because of the side effects of systemic corticosteroids, especially in doses equivalent to more than 10 milligrams a day of prednisone, their use must be closely monitored. Side effects include weight gain (especially around the abdomen), a round face (so-called “moon face”), increased fat on the upper back (“buffalo hump”), increased appetite, acne, increased facial hair, easy bruising, bone thinning (osteoporosis, see
pages 57
to
58
), and bone death. So if you’re taking these drugs you also need to take calcium supplements, vitamin D, and drugs that prevent or slow bone loss (see
page 58
).
Corticosteroids can also cause high blood pressure, cataracts, an increased risk of diabetes and infections, and sleep disturbances.
Prednisone and other glucocorticoids can also cause extreme psychological side effects, including depression, anxiety, hyperactivity, and outbursts of anger. So if you’re on steroid medications, you’ll need to be prepared. Anything you can do to help manage anger and stress—such as yoga, meditation, and regular exercise—will be important while you’re taking steroids. Some women may be helped by psychological counseling to deal with the effects of these drugs as well as their RA. While taking prednisone can cause physical and emotional stress, you should never stop it on your own. Prednisone and other glucocorticoids should be tapered slowly under a doctor’s supervision.
The next generation of TNFα blockers, including drugs considered
biosimilars
(for example biosimilars to infliximab) are currently in clinical trials, as well as blockers of other members of the interleukin “superfamily” of cytokines (like
IL-17
), and new JAK inhibitors (such as
decernotinib
).
Since there are multiple processes in RA, there are multiple targets to aim at, and it’s likely that some of the new agents in development will be used together. Affecting a single element in RA, while it may slow the disease and the destruction it causes, does not eliminate the disease itself.
But what if a dysfunctional immune system could be replaced with a normal one? That’s the idea behind stem cell transplantation. In this still experimental approach, the immune system is destroyed with high doses of chemotherapy drugs and then reconstituted with stem cells, “pluripotent” cells that have the potential to grow into any kind of cell, including white blood cells. These cells
can be harvested from the blood, the placenta or umbilical cord, or an HLA-matched donor. Some therapies inject stem cells into the joint itself in an effort to regrow damaged tissue. Gene therapy, where genes are coaxed into producing antagonists to inflammatory cytokines, is also being tested.
Joint replacement is the most frequently performed surgery for rheumatoid arthritis, and just about any joint can now be replaced with artificial parts made of metal and ceramic. New materials and cements to fix the new joint in place have increased the longevity of artificial joints. However, some artificial joints don’t function as well as normal joints, and even the best materials can become worn and need to be replaced.
Because RA can damage or rupture tendons, the tissues that attach muscle to bone, tendon reconstruction is sometimes required. Done most often on the hands, the surgery attaches an intact tendon to a damaged one, helping to restore some hand function, particularly if done before a tendon is completely ruptured.
Synovectomy
involves the removal of inflamed synovial tissue and is usually done as part of tendon reconstruction. Other procedures include
carpal tunnel release
,
arthroplasty
, and
joint fusion
. Studies are also under way to investigate the possible use of cartilage regeneration in RA.
Exercise is important for maintaining healthy and strong muscles to support the joints, preserve mobility, and maintain flexibility. It can also help you sleep and reduce pain. In addition, exercise has documented effects for boosting mood. Special exercise programs can be designed just for you by a physical therapist. But just as important as keeping active is balancing activity with rest. You may need more rest when your disease is active and fatigue starts to take a toll. Rest helps to reduce active joint inflammation and pain and fight fatigue. It’s usually more helpful to take short rest breaks than to spend long periods of time in bed, since that can promote stiffness. (These strategies are also helpful for dealing with fatigue in other autoimmune diseases.)
Studies suggest that cognitive behavioral therapy (CBT), which helps reframe how you think and react to events, may also help you overcome fatigue.
Splints and assistive devices can help you function better and reduce stress on your joints. Splints are used mostly on wrists, hands, ankles, and feet to support the joint and reduce pain. They are often custom made by a doctor or a physical or occupational therapist. Self-help devices such as zipper pullers or long-handled shoehorns, special toothbrushes, and jar openers can help make everyday activities easier.
You may have read about the use of “complementary” therapies in RA like acupuncture, fish oil, anti-inflammatory herbs, tai chi exercises, and
Ayurvedic
medicine, the 5,000-year-old traditional herbal medicine of India. Many patients turn to such therapies hoping to avoid or lessen the side effects of medications.
The most evidence so far is for fish oil (omega-3 fats) and a handful of herbs used alongside RA drugs.
Fish oil contains the omega-3 polyunsaturated fats (PUFAs)
eicosapentaenoic acid (EPA)
and
docosahexaenoic acid (DHA)
, which have anti-inflammatory properties that have been shown to relieve joint pain, swelling, and morning stiffness in RA. One recent randomized trial showed that fish oil produced additional benefits when used with conventional medications like methotrexate.
25
A 2013 survey of more than a dozen herbs and supplements by the British National Health Service (NHS) scored fish oil the highest for effectiveness and safety.
26
However, because fish oil has some anticoagulant properties, you’ll need to talk to your doctor before taking it.
A number of herbs are touted as having anti-inflammatory properties in RA, including
evening primrose oil
,
borage seed oil
, and the plant extract
Tripterygium wilfordii Hook F (TwHF, thunder god vine)
, approved in China for treating RA. Some small studies in China and the United States have suggested that TwHF may be as effective as methotrexate or other DMARDs as short-term therapy.
27
,
28
However, these studies involved pharmaceutical grade “standardized” extracts of TwHF (20–60 mg), which are not available in the United States, and Chinese researchers caution that the extract can affect fertility and cause gastrointestinal side effects.
Supplements can interact with your medications, so consult your rheumatologist before buying anything at the health food store or talking to a naturopath or herbalist.
Acupuncture,
a popular component of traditional Chinese medicine, involves placing very thin needles at specific spots along the body (
acupoints
) to stimulate the flow of energy (or
qi
) to treat pain and other conditions. Acupoints correspond with key nerve endings, and some RA patients report relief of pain and swelling with acupuncture. However, well-done clinical studies (some using “sham therapy” of needling at acupoints as a control) have had mixed results. If you want to try it, find a certified acupuncturist.
The good news is that research is ongoing in this area, and the “integrative” care of RA is increasing, with a growing number of centers offering complementary therapies alongside conventional treatments.
One of the best sources of information is the National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health (
http://
nccam.nih.gov/
health/
RA/
getthefacts.htm
). For more, see
Appendix A
.
Stress reduction is another important component in managing RA. While stress doesn’t cause the disease, it can certainly make it harder to live with and even increase disease activity. So learning stress management techniques, such as meditation or taking part in psychological support groups, can go a long way toward giving you more control over your life. Don’t smoke to alleviate stress.
Rheumatoid arthritis is almost three times more common in women than in men. Scientists have been exploring the role of estrogen and other steroid hormones in the body to see whether high or low levels of one or another hormone may make a woman more vulnerable to rheumatoid arthritis.
The observation dating back to 1938 that rheumatoid arthritis improves during pregnancy in 70 percent of women led to speculation that higher levels of estrogen (or certain estrogens) may somehow be protective. But studies using estrogen to improve symptoms have not proven benefit. The improvement during pregnancy (and subsequent worsening during the postpartum period) may not be due to estrogen at all, says David Pisetsky, MD, PhD, professor of medicine at Duke University Medical Center and president of the United States Bone and Joint Initiative. “The initial observation that a hormone produced during pregnancy might be protective actually led to the discovery of cortisol, corticosteroids. So we may be dealing with a steroid effect, but probably not from estrogen. And corticosteroids are anti-inflammatories,” comments Dr. Pisetsky.
“There is research to find out which women will get this effect. One very interesting paper suggested that the more genetically different the mother and father, the more steroids, or immunosuppression, the body would produce. And the more similar the mother and the father were genetically, the fewer steroids, or immunosuppression, would be produced,” remarks Dr. Pisetsky.
Human leukocyte antigens (HLAs)
, the molecules that help define what’s self and nonself) shared by a woman and her unborn child may not only alter the activity of the mother’s immune system during pregnancy, but shared HLAs may also increase—or decrease—the risk of developing RA.
Research by J. Lee Nelson, MD, of the immunogenetics program at the Fred Hutchinson Cancer Research Center in Seattle, showed that greater differences in the genetic makeup between the mother and her fetus were associated with a greater chance of disease remission in RA.
29
The exact mechanism for this is unclear, Dr. Nelson says, but is the subject of ongoing investigation.
It has also been suggested that the immune effects of pregnancy may somehow protect against RA itself (or at least delay its onset). Studies show a twofold increased risk of developing RA in women who have never had a child. On the other hand, a recent study by Dr. Nelson and her colleagues suggest that pregnancy
outcomes
, such as having a very low birthweight baby or a preterm birth, may somehow increase the risk of future RA.
30
This may reflect common risk factors for pregnancy complications and for RA, such as preeclampsia and gestational hypertension and preterm delivery, they speculate. Greater fetal microchimerism may also be linked to adverse pregnancy outcomes, thus influencing the subsequent risk of RA. Alternatively, it may reflect common risk factors for RA and for pregnancy complications, such as preterm delivery, they add.
Over the years, it has been suggested that oral contraceptives may be protective, possibly cutting the risk of RA in half when used for as little as six months. Studies show women using birth control pills at RA onset tend to have milder disease, but a number of randomized controlled trials to assess postmenopausal hormone therapy on the severity and progression of RA have had mixed results.
All of the research into sex-related factors in rheumatoid arthritis is speculative, but it could one day lead to specific prevention or treatment strategies for women.
Kathleen’s story continues:
We had always wanted another child. But they told me that I’d have to go off the medications if I were to get pregnant. They told me my symptoms would probably improve while I was pregnant, but that afterward most women with RA not only go back to a fully active state but also usually get worse. So we’re talking about my choice of having another child or being able to walk, and move, and work. And to me the choice was very clear. That was the choice I was presented with—to put off childbearing until I had this disease under control. And by then, I was in my middle forties. We did try again and were not successful. And then I was 45 and I was trying in-vitro, and the drugs almost put me back in an active state. It was a real risk taking them, but we really wanted another child. So that’s part of the cost of this disease.
