Diagnosing and treating autoimmune diseases can be challenging and often times there are several options for treatment. In order to get to the root of the problem and get the best possible results from treatment, it is helpful to take a step-wise approach.
Often times, tackling everything at once will not bring about the best results.
At Institute for Specialized Medicine, when we are treating autoimmune diseases it’s helpful to separate therapy into two phases.
- Initial Phase
- Maintenance Phase
By using this framework, it provides guidance and structure when going through all of the therapeutic options. This benefits both the physician and the patient with an open line of communication and understanding of the reasoning behind their therapy.
In this phase we are trying to understand the major problem and treat the most emergent symptoms first. Often times, treating these symptoms brings the patient immediate relief from troubling or painful symptoms; as well as tackling issues before they become bigger problems.
The steps are as follows:
1. Bring the major problem down as soon as you can because this could lead to irreversible damage.
2. Create priorities of need based on assessment and symptoms.
What is the first target? What is the second? Often times this is driven by asking the patient to rank their most troubling to least troubling symptoms.
3. Find the driver of the problem.
Is it food, infection, heavy metals? Address the issue as soon as possible. Autoimmune diseases are driven by something—get to the root of the problem to actually affect change.
4. Correct genetic and epigenetic defects.
Not right away, maybe a few months down the road after the patient feels better. Epigenetics are changes in gene expression (active versus inactive genes) that do not involve changes to the underlying DNA sequence.
Epigenetics are influenced by many things: what you eat, where you live, who you interact with, when you sleep, how you exercise, even aging – all of these can eventually cause chemical modifications around the genes that will turn those genes on or off over time.
A few months down the road may not seem like the emergent phase, but when healing from an autoimmune disease can take years, a few months is a short period of time.
5. Correct metabolic and nutritional problems.
Metabolism is the process your body uses to get or make energy from the food you eat. Food is made up of proteins, carbohydrates, and fats. Chemicals in your digestive system break the food parts down into sugars and acids, your body’s fuel. Your body can use this fuel right away, or it can store the energy in your body tissues, such as your liver, muscles, and body fat.
A metabolic disorder occurs when abnormal chemical reactions in your body disrupt this process. When this happens, you might have too much of some substances or too little of other ones that you need to stay healthy.
Most people with inherited metabolic disorders have a defective gene that results in an enzyme deficiency. In most inherited metabolic disorders, a single enzyme is either not produced by the body at all or is produced in a form that doesn’t work.
1. Typically treating autoimmune diseases does not have a one-month solution. Often times it can take a couple of years, so you need to define and discuss duration of therapy.
2. Discuss and outline goals of therapy.
3. Assess a patient’s compliance with medication. If they are not compliant, switch to something like an injectible or infusion; requiring them to come into the office rather than relying on them to do it at home.
4. Educate and discuss the chance of relapsing
5. Monitor side effects.
Here is a case study of the steps in action
- A 54 year old woman with complaints of joint pain and swelling for 6 months
- Diagnosis of presumable Rheumatoid Arthritis (RA)
- Poor response to NSAIDs
- Poor response to MSM, glucosamine, turmeric, and high dose fish oil
Upon initial physical exam:
- Tenderness of wrists, elbows and knees
- Palpable effusion (build up of fluid) in the left elbow and left knee
Musculoskeletal ultrasound findings:
- Left knee with active synovitis (inflammation of the synovial membrane that lines your joints) by power Doppler, synovial hypertrophy, and large effusion
- Left shoulder with active synovitis by power Doppler, synovial hypertrophy, and large effusion
Lab test results:
- Elevated CRP (blood test used to detect inflammation)
- Elevated ESR (a blood test that can reveal inflammatory activity)
- Low positive Rheumatoid Factor (proteins produced by your immune system that can attack healthy tissue in your body.)
- Strongly positive anti-CCP antibodies (markers for RA)
- Negative ANA-11 detects antinuclear antibodies. Antinuclear antibodies often attack your body’s own tissues.
- Negative lyme western blot (test for Lyme disease)
- Negative streptococcal serology (test for streptococcal infections)
Emergent Phase: Step 1 Treat Emergencies
Diagnosed with early RA and put on a tapering dose of the steroid prednisone.
Why start with a steroid? Because it was a medical emergency.
Her wrists were swollen and her risk of having major joint impairment was quite high. The short period of time she was on prednisone, her wrist pain and joint erosion improved.
Emergent Phase: Step 2 Rank Symptoms and Prioritize
She agreed to start taking hydroxycloroquine (Plaquenil) to treat her RA symptoms, but was totally against taking any biologics due to compromising her immune system and increasing the risk of infections.
Emergent Phase: Step 3 Address Root Problem
Arthrocentesis of left elbow joint was done and a synovial fluid analysis, for Lyme disease, from this joint was performed.
The synovial fluid result showed positive IgM lyme western blot, meaning she had Lyme disease. This is directly in contrast to what her blood work showed; demonstrating that when testing for Lyme disease, it is always recommended to test both blood and synovial fluid.
Our joints and synovial spaces represent biological traps for various microbial antigens which stimulate a local intrasynovial immune response. Based on that principle, synovial fluid analysis should produce more positive results than the correspondent serum analysis. Accordingly, based on our own statistics, patients with Lyme disease have more positive bands upon analysis of synovial fluid as compared to the paired serum samples.
The images below are the lab results from this patient’s serum and synovial fluid taken on the same day. You can see there are more positive bands in the synovial fluid results as well as the positive IgM result compared to her serum.
She was diagnosed with borelliosis (Lyme disease)/RA overlap.
Treatment included a hybrid protocol for borelliosis and RA including triple antibiotic therapy and antimicrobial herbs.
Emergent Phase: Step 4 Correct Genetic and Epigenetic Defects
Decrease consumption of iron containing foods. Joint symptoms are common in iron overload which may resemble RA.
Emergent Phase: Step 5 Correct Metabolic and Nutritional Problems
Because gluten is an inflammatory food and can cause increased inflammation in joints, it was recommended that she go on a gluten free diet.
As we entered into the maintenance phase, we evaluated her compliance with the protocol, continually monitored her lab work, and adjusted accordingly.
Subsequent 6 months
During the next 6 months she started experiencing gradual symptom improvement; however, she still dealt with frequent flare ups of elbow, wrist, and knee effusions.
Arthrocentesis was performed on several joints so as not to lose joint function.
Interestingly, her blood work for Lyme disease that was previously negative was now positive both IgM and IgG Lyme western blot. (Previously only her synovial fluid was positive).
Because of this new result, she began a more aggressive protocol and started incorporating both injectible and oral antibiotics.
Upon instating this protocol, she noticed rapid improvement of her symptoms.
1 year later
She continued her previous 6 month protocol for another 6 months.
She is completely pain free.
Her blood work showed a gradual decline in anti-CCP antibodies (an antibody present in most rheumatoid arthritis patients) and rheumatoid factor. This demonstrates that we were on the right track in treating both her RA and Lyme disease because her RA was being driven by an underlying infectious process (Lyme disease).
2 years later
She is still on antibiotics and antimicrobial herbs.
She has no side effects and is completely symptom free.
The plan is to continue on antibiotics for 4 years and switch to an herbal based maintenance protocol.
Treating autoimmune diseases is definitely a practice in patience. There are going to be good and bad days, but with a systematic approach to treatment the good days will begin to outweigh the bad. Starting out with these principles will help outline a plan of therapy, will set proper expectations and, generate the best results.