Tags Posts tagged with "Arthritis"

Arthritis

One simple lifestyle change is to make certain that those susceptible to gout attacks remain hydrated and consume plenty of fluids. Stock photo
Most risk factors are modifiable

By David Dunaief, M.D.

Dr. David Dunaief

Gout is thought of as an inflammatory arthritis. It occurs intermittently, affecting the joints, most commonly the big toe. The symptoms are acute (sudden onset) and include extremely painful, red, swollen and tender joints. In terms of symptoms, if you have ever had kidney stones, gouty arthritis is just as painful.

Uric acid (or urate) levels are directly related to the risk of gout attacks. As uric acid levels increase, there is a greater chance of urate crystal deposits in the joints. Although, and unfortunately, some patients can still experience gout attacks without high levels of uric acid.

This disease affects approximately 8.3 million people in the United States (1). This number has doubled since the 1960s. Men between 30 and 50 years old are at much higher risk for their first attack (2). For women, most gout attacks occur after menopause.

There are a number of potential causes of gout, as well as ways to prevent and treat it. The most common contributors include drugs, such as diuretic use; alcohol intake; uncontrolled hypertension (high blood pressure); obesity; and sweetened beverage and fructose intakes (3). Though heredity plays a role, these risk factors are modifiable.

The best way to prevent and treat gout is by modifying medications and lifestyle. One simple lifestyle change is to make certain, just like with kidney stone prevention, that those susceptible to gout attacks remain hydrated and consume plenty of fluids.

Just like there are medications that may cause gout, there are also medications that can treat and help prevent gout. If you do get a gout attack, NSAIDs such as indomethacin or steroids such as a Medrol pack help treat the symptoms. In terms of prevention, allopurinol helps to reduce the risk of a gout attack.

I thought we might look at gout by using a case study. I had a patient who had started a nutrient-dense, plant-based diet. Within two weeks, she had a gout episode. Initially, it was thought that her change in diet with increased plant purines might have been an exacerbating factor. Purines are substances that raise the level of uric acid. So, it is not surprising that foods with containing purines might substantiate a gout attack. However, not all purines equally raise uric acid levels.

Animal versus plant proteins

In a case-crossover (epidemiologic forward-looking) study, it was shown that purines from animal sources increase our levels of purines far more than those from plant sources (4). The risk of a gout incident was increased approximately 241 percent in the group consuming the highest amount of animal products, whereas the risk of gout was still increased for those consuming plant-rich purine substances, but by substantially less: 39 percent.

The authors believe that decreasing the use of purine-rich foods, especially from animal sources, may decrease the risk of incidences and recurrent episodes of gout. Plant-rich diets are the preferred method of consuming proteins for patients who suffer gout attacks, especially since nuts and beans are excellent sources of protein and many other nutrients.

In another study, meats — including red meat, pork and lamb — increased the risk of gout, as did seafood (5). However, purine-rich plant sources did not increase risk of gout. Low-fat dairy actually decreased the risk of gout by 21 percent. The study was a large observational study involving 49,150 men over a duration of 12 years.

There are several more studies indicating and reaffirming that plant foods do not increase the risk of gout attacks. The Mayo Clinic also suggests that plants do not increase the risk of gout. When considering my patient’s circumstances, it was unlikely that her switch to a nutrient-dense, plant-rich diet had increased her risk of gout.

Diuretics (water pills)

My patient was on a diuretic called hydrochlorothiazide for hypertension (high blood pressure). There are several medications thought to increase the risk of gout, including diuretics and chronic use of low-dose aspirin. In the ARIC study, patients who used diuretics to control blood pressure were at a 48 percent greater risk of developing gout than nonusers (6). In fact, nonusers had a 36 percent decreased risk of developing gout. This study involved 5,789 participants and had a fairly long duration of nine years. The longer the patient is treated with a diuretic, the higher the probability they will experience gout. It is likely that my patient’s diuretic contributed to her gout episode.

Vitamin C

Vitamin C may reduce gout risk. In the Physicians Follow-up Study, a 500-mg daily dose of vitamin C decreased levels of uric acid in the blood (9). However, be careful with vitamin C supplementation because it can increase the risk of kidney stones.

Medical conditions

There are a number of medical conditions that may impact the risk of gout. These include uncontrolled high blood pressure, diabetes and high cholesterol (7). My patient’s high blood pressure was under control, but she also had diabetes and high cholesterol. These disorders may have also contributed.

Obesity

Obesity, like smoking, seems to have its impact on almost every disease. In the CLUE II study, obesity was shown to not only increase the risk of gout but also to accelerate the age of onset (8). Those who were obese experienced gout three years earlier than those who were not. Even more striking is the fact that those who were obese in early adulthood had an 11-year earlier onset of gout. The study’s duration was 18 years. My patient was obese and had just started to lose some weight before the gout occurred.

Prevention

The key to success with gout lies with prevention. Patients who do get gout writhe in pain. Luckily, there are modifications that significantly reduce the risks. They involve very modest changes, such as not using medications called diuretics in patients with a history of gout; losing weight for obese patients; and substituting more plant-rich foods for meats and seafood. Increasing levels of uric acid may be a useful biomarker for indicating an increased risk of gouty arthritis attacks. However, gout attacks do occur without a rise in uric acid levels, so it is not a perfect. Although the cause of gout may be apparent to you, always check with your doctor before changing your medications or making significant lifestyle modifications, as we have learned from this case study of my patient.

References:

(1) Arthritis Rheum. 2011 Oct;63(10):3136-3141. (2) Arthritis Res Ther. 2006;8:Suppl 1:S2. (3) Am Fam Physician. 2014 Dec 15;90(12):831-836. (4) Ann Rheum Dis. online May 30, 2012. (5) NEJM 2004;350:1093-1103. (6) Arthritis Rheum. 2012 Jan;64(1):121-129. (7) www.mayoclinic.com. (8) Arthritis Care Res (Hoboken). 2011 Aug;63(8):1108-1114. (9) J Rheumatol. 2008 Sep;35(9):1853-1858.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

by -
0 1158

By David Dunaief

We know that inflammation is a critical part of many chronic diseases. Rheumatoid arthritis (RA) is no exception. With RA, inflammation is rampant throughout the body and contributes to painful joints, most commonly concentrating bilaterally in the smaller joints of the body, including the metacarpals and proximal interphalangeal joints of the hand, as well as the wrists and elbows. With time, this disease can greatly diminish our ability to function, interfering with our activities of daily living. The most basic of chores, such as opening a jar, can become a major hindrance.

In addition, RA can cause extra-articular, a fancy way of saying outside the joints, manifestations and complications. These can involve the skin, eyes, lungs, heart, kidneys, nervous system and blood vessels. This is where it gets a bit dicier. With increased complications comes an increased risk of premature mortality (1).

Four out of 10 RA patients will experience complications in at least one organ. Those who have more severe disease in their joints are also at greater risk for these extra-articular manifestations. Thus, those who are markedly seropositive for the disease, showing elevated biomarkers like rheumatoid factor (RF), are at greatest risk (2). They have an increased risk of cardiovascular disease events, such as heart attacks and pulmonary disease. Fatigue is also increased, but the cause is not well understood. We will look more closely at these complications.

Are there treatments that may increase or decrease these complications? It is a very good question, because some of the very medications used to treat RA also may increase risk for extra-articular complications, while other drugs may reduce the risks of complications. We will try to sort this out, as well. The drugs used to treat RA are disease-modifying antirheumatic drugs (DMARDs), including methotrexate; TNF inhibitors, such as Enbrel (etanercept); oral corticosteroids; and NSAIDs (non-steroidal anti-inflammatory drugs).

It is also important to note that there are modifiable risk factors. We will focus on two of these, weight and sugar. Let’s look at the evidence.

CARDIOVASCULAR DISEASE BURDEN
We know that cardiovascular disease is very common in this country for the population at large. However, the risk is even higher for RA patients; these patients are at a 50 percent higher risk of cardiovascular mortality than those without RA (3). The hypothesis is that the inflammation is responsible for the RA-cardiovascular disease connection (4). Thus, oxidative stress, cholesterol levels, endothelial dysfunction and high biomarkers for inflammation, such as ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein), play roles in fostering cardiovascular disease in RA patients (5).

THE YING AND YANG OF MEDICATIONS
Although drugs such as DMARDS (including methotrexate and TNF inhibitors, Enbrel, Remicade, Humira), NSAIDs (such as celecoxib) and corticosteroids are all used in the treatment of RA, some of these drugs increase cardiovascular events and others decrease them. In meta-analysis (a group of 28 studies), the results showed that DMARDS reduced the risk of cardiovascular events by up to 30 percent, while NSAIDs and corticosteroids increased the risk (6). The oral steroids had the highest risk of heart complications, approximately a 50 percent rise in risk. This may be one reason rheumatologists encourage their RA patients to discontinue oral steroid treatments as quickly as possible.
In an observational study, the results reaffirm that corticosteroids increased the risk of a heart attack in RA patients, this time by 68 percent (7). The study involved over 8,000 patients with a follow-up of nine years. Interestingly, there was a dose-response curve. In other words, the results also showed that for every 5 mg increase in dosage, there was a corresponding 14 percent increase in heart attack risk.

BAFFLING DISEASE COMPLICATION
Most complications seem to have a logical connection to the original disease. Well, it was a surprise to researchers when the results of the Nurses’ Health Study showed that those with RA were at increased risk of cardiovascular disease and of respiratory disease (8). In fact, the risk of dying from respiratory disease was 106 percent higher in the women with RA compared to those without, and the risk was even higher in women who were seropositive (had elevated levels of rheumatoid factor). The authors surmise that seropositive patients have greater risk of death from respiratory disease because they have increased RA severity compared to seronegative patients. The study followed approximately 120,000 women for a 34-year duration.

WHY AM I SO TIRED?
While we have tactics for treating joint inflammation, we have yet to figure out how to treat the fatigue associated with RA. In a recently published Dutch study, the results showed that while the inflammation improved significantly, fatigue only changed minimally (9). The consequences of fatigue can have a negative impact on both the mental and physical qualities of life. There were 626 patients involved in this study for eight years of follow-up data. This study involved two-thirds women, which is significant; women in this and in previous studies tended to score fatigue as more of a problem.

LIFESTYLES OF THE MORE PAINFUL AND DEBILITATING
We all want a piece of the American dream. To some that means eating like kings of past times. Well, it turns out that body mass index plays a role in the likelihood of developing RA. According to the Nurses’ Health Study, those who are overweight or obese and are ages 55 and younger have an increased risk of RA, 45 percent and 65 percent, respectively (10). There is higher risk with increased weight because fat has pro-inflammatory factors, such as adipokines, that may contribute to the increased risk. Weight did not influence whether they became seropositive or seronegative RA patients.
With a vegetable-rich, plant-based diet you can reduce inflammation and thus reduce the risk of RA by 61 percent (11). In my clinical practice, I have seen numerous patients able to reduce their seropositive loads to normal or near-normal levels by following this type of diet.

SUGAR, SUGAR!
At this point, we know that sugar is bad for us. But just how bad is it? When it comes to RA, results of the Nurses’ Health Study showed that sugary sodas increased the risk of developing seropositive disease by 63 percent (12). In subset data of those over age 55, the risk was even higher, 164 percent. This study involved over 100,000 women followed for 18 years.

THE JUST PLAIN WEIRD – INFECTION FOR THE BETTER
Every so often we come across the surprising and the interesting. I would call it a Ripley’s Believe It or Not moment. In a recent study, those who had urinary tract infections, gastroenteritis or genital infections were less likely to develop RA than those who did not (13). The study did not indicate a time period or potential reasons for this decreased risk. However, I don’t think I want an infection to avoid another disease. When it comes to RA, prevention with diet is your best ally. Barring that, disease-modifying anti-rheumatic medications are important for keeping inflammation and its progression in check. However, oral steroids and NSAIDs should generally be reserved for short-term use. Before considering changing any medications, discuss it with your physician.

REFERENCES
(1) J Rheumatol 2002;29(1):62. (2) uptodate.com. (3) Ann Rheum Dis 2010;69:325–31. (4) Rheumatology 2014;53(12):2143-2154. (5) Arthritis Res Ther 2011;13:R131. (6) Ann Rheum Dis 2015;74(3):480-489. (7) Rheumatology 2013;52:68-75. (8) ACR 2014: Abstract 818. (9) RMD Open 2015.  (10) Ann Rheum Dis. 2014;73(11):1914-1922. (11) Am J Clin Nutr 1999;70(6),1077–1082. (12) Am J Clin Nutr 2014;100(3):959-67. (13) Ann Rheum Dis 2015;74:904-907.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management.  For further information, go to the website www.medicalcompassmd.com and/or consult your personal physician.