Rheumatoid+Arthritis

//Western Diagnosis//
Nonspecific, symmetrical inflammation of joints resulting in progressive destruction of articular and periarticular structures

Etiology
- Unknown -Women 2-3x more than men -25-50 years old -75% improve in 1st year - 10% eventually disabled

Pathology:
1. Synovial membrane folds and thickens: synovial cells increase in size and number 2. Lymphocytes and plasma cells infiltrate: produce, among other things, RF and other immunoglobins 3. Fibrin deposition, fibrosis, necrosis

Signs & Symptoms
1. Often sudden onset: simultaneous inflammation in multiple SYMMETRICAL joints 2. Insidious onset: progressive joint involvement 3. Tenderness 4. Synovial Thickening 5. SYMMETRIC involvement of hand joints: PIP, M-P 6. Feet, wrists, elbows, ankles 7. Any joint possible 8. Stiffness lasts longer than 30 minutes after inactivity 9. Early afternoon fatigue 10. Deformities develop rapidly -Flexion contractures -Ulnar deviation of fngers -Boutonniere's deformity: flexed PIP, extended DIP -Swan lake deformity: extended PIP, flexed DIP 11. Rheumatoid nodules -characteristic lesion, though not always seen early in disease -Seen in about 30-40% -Subcutaneous -Central necrotic area surrounded by long cells enveloped by lymphocytes and plasma cells 12. Low grade fever

Lab Testing
1. normochromic, normocytic anemia in ~ 80% 2. Hemoglobin over 10gm/dl 3. sed rate is elevated 4. Rheumatoid factor (RF): in 70%, not specific for RA but for autoimmune diseases; confirmation if cinical syndrome also there 5. Synovial fluid abnormal

Imaging
1. Radiology: -Soft tissue swelling -periarticular osteoporosis -joint space narrowing -marginal erosions

Diagnosis
Any 4 of the following 7 criteria. 1-4 must be present for 6 weeks or more: 1. Morning stiffness for an hour or more 2. Arthritis of 3 or more joints 3. Arthritis in hand joints 4. Symmetric arthritis 5. Rheumatoid nodules 6. Serum rheumatoid factor 7. Radiographic changes: hand x-rays must include erosions or bony calcification

Biopsy subcutaneous nodules

Differential Diagnosis
Osteoarthritis Other collagen vascular diseases Rheumatic fever Gonococcal Arthritis Lyme Disease Reiter's Syndrome Psoriatic Arthritis Ankylosing Spondylitis Gout

Treatment
1. **Rest and passive exercise** until inflammation controlled: then active exercise 2. **Nutrition:** possible food allergies, fish and/or plant oils. Elimination diet important. 3. **NSAIDS** -GI irritation, ulcers, bleeding -Headache, confusion, hypertension, edema, nephritis, asthma, urticaria, rhinitis, agranulocytosis -Types: salicylates, indomethacin, ibu, naproxen 4. **Gold compounds** -gold sodium thiomalate, aurothioglucose -parenterally at weekly intervals -eventually every 2-4 weeks -contradicted with hepatic or renal disease or blood dyscaria -UA, Hb, total & differential WBC count, platelet count -Toxicity: pruritis, dermatitis, stomatitis, albuminuria, nephrotic syndrome, agranulocytosis, thrombocytopenic purpura, aplastic anemia, diarrhea, hepatitis, pneumontitis, neuropathy -oral gold (auronofin) - more GI effects 5. **Penicillamine:** if gold doesn't work. Side effects: marrow suppression, proteinuria, MG, nephrosis, connective tissue disease 6. **Hydroxychloroquine:** -dermatitis, myopathy, corneal opacity - all reversible -Irreversible retinal degeneration -ophthalmologic evaluation q6months 7. **Sulfasalazine:** benefits within 3 months -Toxicity: GI, neutropenia, hemolysis, hepa, rash 8. **DMARD's:** works like interferon or blocks tumor necrosis factor 9. **Corticosteroids**: most dramatic short term relief -Benefit diminishes with time -Do not prevent progression of joint destruction 10. **Cytotoxic drugs** - immunosuppressive drugs: methotrexate. Major side effects Eveing primrose oil

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Orthomolecular Treatment
-Omega-6 -Histidine -Phenylalanine (LDPA, DPA) -Betain HCl

Herbal Treatment
Gui Zhi Shao Yao Zhi Mu Tang - recommended by M.B. Lei Gu Teng, "Teng" Herbs, Di Long- recommended by Y.L.

Acupuncture Treatment
Primarily local Ashi points w/ reducing method for 30 minutes followed by cupping over area for 10 minutes

Moxibustion Treatment
2x a day over 8 of the most sensitive local Ashi points for 1 month After a month select 8 different points that are the most sensitive use 1/4-1/3 size of a rice grain length

Article on Herbal Formula procedures: International Journal of Oriental Medicine - V20 N1 1995 Pp.31-37 Start Up - August 2000