Rheumatoid Arthritis, Gout, Pseudogout (CPPD) and Related Health Concerns

Paul L. Reller L.Ac. / Last Updated: August 03, 2017


Rheumatoid Arthritis (RA) is an autoimmune disorder that has defied understanding due to the complexity of the underlying factors that lead to this systemic inflammatory dysfunction. While the disease has been diagnosed at a late stage in the disorder, when episodic joint swelling and pain, usually in the hands, feet or cervical spine occur, and become debilitating, we now know that the disorder progresses slowly over many years, and affects a wide variety of tissues in the body. Early diagnosis and prevention are thus of great importance to the population most affected. The late stage diagnosis of RA occurs mainly with persons between the ages of 40 to 50, with women diagnosed 3 times more than men, but the time to start prevention and early treatment is in your 30's. For those with advanced RA, treatment of the underlying contributors to the disease, as well as treatment of the associated health factors that put you most at risk need to be addressed holistically. While a number of pharmaceutical prescriptions may decrease symptoms and address some cardiovascular risk factors, these drugs do not address the restoration of health. This is where Complementary and Integrative Medicine comes into play. This field of medicine, supported by explosive growth in research, offers improved symptom control, treatment of the problem from the ground up, and healthy prevention of associated systemic problems that could put you at high risk for stroke and heart attack, as well as a variety of common debilitating health problems that you might not be associating with the pathology of rheumatoid arthritis.

Proof of direct medical efficacy of acupuncture, herbal medicine, nutrient medicine, physiotherapies, and healthy treatment regimens such as Tai Chi, has been achieved with very limited resources devoted to standard double-blinded placebo controlled human trials (see the link to the U.S. National Institutes of Health website below). Clinical empirical evidence of effectiveness of this holistic regimen in the treatment of rheumatic diseases has been accumulated for the last 2000 years in China, though, and a wealth of current research provides proof of efficacy related to the myriad health problems now associated with Rheumatoid Arthritis. An integrative holistic treatment protocol for Rheumatoid Arthritis addresses all of these concerns, adjunct treatment to enhance standard pharmaceutical therapy, achieving improved quality of life and avoidance of disease progression, lessening the harsh adverse effects of chronic use of immune suppressants and steroids, and treatment and prevention for comorbid conditions commonly seen with chronic Rheumatoid Arthritis. This is not to say that there is a miracle cure for this very difficult disease with TCM/CIM, or that standard therapy should be abandoned for these other therapies. What we are sure of is that there is a lot of sound research-based evidence to help guide an integration of Complementary Medicine into standard protocol to achieve the best outcome that is possible.

Research in recent years has validated a number of medical herbal and nutrient treatments to integrate into the care of Rheumatoid Arthritis. An array of scientific studies and clinical trials are cited and linked in additional information, and this array of safe and effective therapies in Complementary and Integrative Medicine grows yearly. For instance, alkaloids in the Chinese herbs Stephania Tetrandre and Trypterygium Wilfordii have been shown to significantly suppress the most important pro-inflammatory cytokines that perpetuate Rheumatoid Arthritis, such as interleukin-1 and -6, nuclear factor kappa Beta, and tumor necrosis factor-alpha. Research at Harvard Medical School has produced an advanced bio-identical collagen supplement proven to benefit restoration of the inflamed synovial joint membranes. Optimization of the herbal chemical curcumin has produced a product that can achieve therapeutic blood levels with oral medicine. These and other herbal and nutrient medicines may be prescribed by professional herbalists such as Licensed Acupuncturists, or TCM physicians. Links to research summaries can be seen below.

In recent years, the understanding of the confusing pathophysiology of Rheumatoid Arthritis is progressing rapidly, revealing even more avenues of research into how Complementary and Integrative Medicine can address the many biologic health issues, and the holistic concerns revealed in such study. For example, research in 2014 at the University of Illinois at Chicago (UIC), U.S.A. found that the protein CCL28 is overexpressed in almost all joints affected by Rheumatoid Arthritis, attracting membrane cells that carry its protein receptor, which is then overexpressed as well. Dr. Shiva Shahrara, associate professor of rheumatology at UIC, and lead researcher, noted that this research finally found the lock and key mechanism that plays a key role in the progression of RA, with CCL28 linked to increased angiogenesis, or growth of new blood vessels to accommodate the increased need for oxygen for the cells that migrate to the joints in RA. Dr. Shahrara found that increased levels of CCL28 occurred in patients under conditions of low oxygen, or mild hypoxia. Such research not only reveals the potential for new drugs that block the CCL28 receptors, but for Complementary and Integrative Medicine to prevent or resolve the conditions that lead to overexpression of CCL28. By integrating these approaches, the hope is that a better overall treatment protocol will be developed soon.

There are a wide variety of health problems associated with Rheumatoid Arthritis that are being largely overlooked. Vascular inflammation, or vasculitis, atherosclerosis, or stiffening of the arteries, fibrosis of the lungs, resulting in pneumonia, bronchitis, and increase in the risk of heart attack, amyloidosis, or accumulation of protein fragments in tissue, especially in the kidney and brain, but also contributing to irritable bowel syndromes, lymphatic dysfunction, and cardiovascular disease, are all highly associated with Rheumatoid Arthritis, and point to the array of underlying health problems that make the disease origin so elusive for research. A large study at Aberdeen University Medical School in Scotland, in 2009, found that in RA patients without overt arterial disease, the progression of the disease is highly associated with increased arterial stiffness independent of other cardiovascular risk factors (Journal or Rheumatology; Crilly et al, Dec.2009). While blood pressure and cholesterol medications are often prescribed in the overall treatment of Rheumatoid Arthritis, these medications do not directly treat or reverse stiffening of the arteries, or atherosclerosis. In fact, the medications prescribed may contribute to these various associated pathologies. Statin drugs prescribed for high cholesterol are well known to cause accumulations of protein fragments (as in amyloidosis), which accounts for the high incidence of tissue and joint pain with chronic use, as well as the more rare rhabdomyolysis. Steroid medications are a well known cause of lung fibrosis, as well as atherosclerosis, and increases in cholesterol and triglycerides. Chronic use of NSAIDS, such as Cox-2 inhibitors, comes with considerable risk of cardiovascular disease. Newer immunosuppressant drugs come with even more dramatic risks and negative health consequences, with lymphoproliferative disorders resulting in multiple organ fibrosis and a variety of symptoms for RA patients reversed with withdrawal of immunosuppressant drug (PMID: 24684409). Integration of Complementary Medicine may address these health problems associated with Rheumatoid Arthritis effectively with an individualized step-by-step treatment protocol, resulting in better quality of life in the long run.

Differentiation of Rheumatoid Arthritis from similar diseases, such as gout and pseudogout, or CPPD (calcium pyrophyosphate deposition)

The Centers for Disease Control (CDC) of the United States reports that and estimated 1.5 million adults were diagnosed with Rheumatoid Arthritis in 2007. Since the diagnosis of RA is difficult in the early stages it is believed that a large number of cases that are developing serious and classic symptoms are undiagnosed or diagnosed as another form of arthritis. More than one in five adults in the United States are diagnosed with arthritis, and the CDC estimates that by 2030, an estimated 67 million Americans ages 18 or older are projected to have a doctor-diagnosed arthritis. In 2007, an estimated 294,000 children under the age of 18 had some form of arthritis or rheumatic condition. These alarming figures show that there is a great need in the United States to initiate early treatment and prevention with Complementary and Integrative Medicine. Presently, 7.6% of the U.S. population between the ages of 18-44 report a doctor-diagnosed arthritis, and nearly 30% of persons between the ages of 45 to 64 report a doctor-diagnosed arthritis. A higher prevalence of arthritis diagnosis occurs with overweight and obese patients, women, and patients with depression. A large number of persons with arthritis go undiagnosed, or misdiagnosed, especially in early stages of the disease mechanisms. Presently, about 5% of women over the age of 55 are diagnosed with RA.

Because the general public sees Rheumatoid Arthritis as a disease of the hands only, many patients with common symptoms attribute their health problems to other diseases. The American Academy of Orthopaedic Surgeons states that about 90% of people with RA eventually develop symptoms related to the foot or ankle, usually first manifesting as inflammatory swelling and pain in the toes and forefeet, which often is mistaken for gout. These orthopedic experts state that arthritic symptoms in the feet are sometimes the first manifestation of the systemic disease. Milder stages of the disease may simply cause foot deformities, such as claw or hammer toe, and flat feet. This often leads to low back or knee pain over time. Other symptoms of RA that the association states are common include episodic mild feverishness or flush, easy fatique, and loss of appetite. Television advertisements for pharmaceuticals that treat gout may contribute to the hasty misdiagnosis as the public seeks out these drugs that are advertised rather than waiting until a sound diagnosis is achieved. Diagnosis of RA in early stages may take months, as repeat tests and exams monitor the progression of the disease.

Pseudogout, now called Calcium Pyrophosphate Deposition (CPPD), due to the negative public associations with the term gout, is often mistakenly diagnosed as Rheumatoid Arthritis, as the manifestations are very similar in most cases, with sudden attacks of immune reactivity to calcium crystals when they accumulate in the synovial fluid of the joint. CPPD often first manifests in the joints of the hand and wrist, as well as the knee, and may recur at other joints in the future. A 2014 study in Japan examined over 600 cadavers with an average age of 78, to see what the incidence of CPPD in the knee was, and found that 13 percent showed that CPPD was evident in the knee cartilage, showing that gout and pseudogout often occurs in joint other than the great toe. The presentation of gout and pseudogout is nearly identical. Like gout, these sudden attacks of moderate to severe pain, swelling, redness, and painful tenderness to touch, usually last between 5 and 12 days, but will recur if the underlying causes are not addressed. Gout, which classically affects the big toe, often occurs in other joints as well, including the hands and wrist, so hasty diagnoses of these conditions based purely on presentation and location may result in a misdiagnosis and utilization of the wrong treatment protocol. With Rheumatoid Arthritis this may create a huge problem, as the medications used to treat RA include harsh corticosteroids and immune suppressing drugs. If CPPD occurs and is diagnosed as gout, medications that clear uric acid crystals are used, and these come with adverse effects as well, and will not be helpful. An accurate diagnosis is essential, as well as therapy to address the underlying health problems that have led to each particular disease.

Pseudogout, or CPPD, affects few people before age 60, but it is estimated that 3 percent of people in their 60s, and as many as 50 percent of people as they reach the age of 90, experience CPPD. As the American College of Rheumatology informs on their website, there currently is no treatment in standard medicine that treats the underlying problems in pseudogout, or CPPD, and standard treatment would merely prescribe NSAIDS. Since many patients with CPPD may not tolerate NSAIDS well, with problems of kidney disease or gastrointestinal problems, medical doctors may resort to drugs that treat gout or RA, such as colchicine, corticosteroids injections, and immune suppressing drugs (e.g. Methotrexate), but these medications come with harsh side effects. With CPPD, underlying problems should be ruled out, such as hyperparathyroidism (often accompanying subclinical hypothyroidism), hormone Vitamin D deficiency, hypomagnesemia (magnesium deficiency), hemochromatosis (iron overload toxicity), and Wilson's disease (copper overload toxicity). Most of the time, these problems are not sufficiently investigated, and presently, when the diagnosis of CPPD occurs, 99 percent of the time it is termed idiopathic, meaning no discernible underlying cause. Intelligent patients will insist on a more thorough diagnostic workup, and if there are suspected underlying problems, integrate Complementary Medicine into the protocol, utilizing chelating agents to clear calcium, iron and copper from the tissues, supporting the metabolism with quality magnesium/potassium supplement, and supporting the immune system, as well as relieving focal joint symptoms and poor cartilage health. These cases of gout and pseudogout, as well as RA, often are preceded by unhealthy degeneration and calcification of the cartilage, or bone covering in the joint. Not only herbal and nutrient medicine, but acupuncture and physiotherapy may help restore the health and function of these joint tissues, preventing these rheumatic diseases.

The first step in insuring proper treatment for rheumatic disease is to make sure the diagnosis is correct. The second step is understanding the disease course in order to take the right steps to reverse the pathology. With gout and pseudogout, the initial episodes of symptoms usually last less than 2 weeks, while with Rheumatoid Arthritis, the first stage of the disease usually involves repeated episodes, often aggravated by stress. The American College of Rheumatology emphasizes that there are 3 categories of disease duration in Rheumatoid Arthritis. Early disease often lasts less than 6 months, while stages of intermediate duration last 6-24 months, and stages of long duration last longer than 24 months. Remission of the disease is often seen. The intelligent pro-active patient will do everything sensible to insure that the disease is limited to the early stage and goes into remission, and then will follow a course of preventative maintenance to insure that remission is prolonged. This is where Complementary and Integrative Medicine plays its biggest role. Prevention of the onset of RA is also a smart choice, and utilizing acupuncture, herbal medicine, physiotherapy, and nutritional medicine is the only medical treatment that is presently offered to potentially prevent the onset or worsening of the disease with aging.

For patients diagnosed with Rheumatoid Arthritis at intermediate and late stages, Complementary and Integrative Medicine offers much therapy to help reverse autoimmune mechanisms, help control inflammatory dysfunction, help nourish degenerative joint tissues, treat associated disorders, such as cardiovascular disease, osteoporosis, fibrosis of the lung, interstitial pneumonia and bronchitis, anemia, leukopenia, and other tissue inflammations. In addition, the problems of depression and anxiety that often come with RA, and the many side effects of the standard pharmacological treatments may also be treated with Complementary and Integrative Medicine. A knowledgeable Licensed Acupuncturist may offer much in the overall treatment protocol.