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Healing ArthritisTaming the Flame by Treating Oxidative Stress Susan Blum, MD, MPH
Founder and Director, Blum Center for Health
The views and opinions expressed herein are solely those of the presenter and do not necessarily represent those of Genova Diagnostics. Thus, Genova Diagnostics does not accept liability for consequences of any actions taken on the basis of the information provided.
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Michael Chapman, NDMedical Education Specialist - Asheville
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Susan Blum, MD
Board Certified in Preventive Medicine, Certified in Functional Medicine, is Senior Faculty with the Center for
Mind-Body Medicine, and author of The Immune System Recovery Program
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Technical Issues & Clinical Questions
Please type any technical issue or clinical question into either the “Chat” or “Questions” boxes, making sure to send them to “Organizer” at any time during the webinar.
We will be compiling your clinical questions and answering as many as we can the final 15 minutes of the webinar.
DISCLAIMER: Please note that any and all emails provided may be used for follow up correspondence and/or for further communication.
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Healing ArthritisTaming the Flame by Treating Oxidative Stress Susan Blum, MD, MPH
Founder and Director, Blum Center for Health
The views and opinions expressed herein are solely those of the presenter and do not necessarily represent those of Genova Diagnostics. Thus, Genova Diagnostics does not accept liability for consequences of any actions taken on the basis of the information provided.
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• Learn about the role of oxidative stress in triggering inflammatory arthritis
• Understand how to test for oxidative stress and how to interpret results as a way to direct your treatment
• Learn how to find and treat the root causes of oxidative stress which might be food, stress, gut health, toxicity or infections
Objectives for This Presentation
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Types of Arthritis
• Chronic Inflammatory Arthritis Conditions
– Autoimmune• RA, psoriatic arthritis, ankylosing spondylitis
• Rheumatic disease: ANA + : lupus, Sjögren's syndrome
– Osteoarthritis • Often dismissed as “wear and tear” / “aging”
– Gout• Related to obesity, metabolic syndrome and diet
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McCulloch K, et al. Aging Cell. 2017;16(2):210-218.
A
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Healthy Joints
• Synovial Membrane
– Soft tissue between the joint capsule and cavity
– Secretes synovial fluid that lubricates the joint
– Protects joint from damage
• Cartilage
– Called “articular cartilage”
– Lines the surface of the bones to protect them from damage
Healthy Joint: Synovial membrane is making good amounts of fluid and the cartilage is healthy and protective
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Root Causes of Arthritis
• Autoimmune
– Immune “attack” inside the joints
– Triggers: gut, oral microbiome, infections, toxins
– Damage caused by increased oxidative stress in the joints
• Osteoarthritis
– Aging or injury PLUS systemic inflammation
– Triggers: visceral adipose tissue, metabolic syndrome, gut microbiome
– Damage caused by increased oxidative stress in the joints
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Oxidative Stress
• Normal process: low levels of oxidative stress
– Balance between free radicals (also called Reactive Oxygen Species or ROS) from every day biochemistry and immune activity, and the antioxidants we eat in our diet
• Runaway oxidative stress
– Imbalance between too many free radicals and not enough antioxidant activity
• Synovial membranes thickened (hyperplasia)
– Fluid is thinner, less lubricating
• Eventually leads to cartilage, then bone destruction
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• People with RA have higher levels of ROS, both system-wide and in
the joint capsule
• Studies have also found low levels of glutathione, vitamins C, A, E,
and beta carotene
• The higher the pain and disability scores, the lower the antioxidant
levels and the higher the oxidative stress markers
– Looked at ROS, lipid peroxides, protein oxidation (OxLDL) and DNA damage (8-OHDG)
RA and Oxidative Stress
Mateen S, et al. PloS One. 2016;11(4):e0152925.
Quiñonez-Flores CM, et al. Biomed Res Int. 2016;2016:6097417.
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OA and Oxidative Stress
• Inflammatory compounds from body go into the joints
– Chondrocytes produce ROS
– Directly damage cartilage collagen and change synovial fluid by making it thinner and less protective
• Studies showed low levels of vitamin C were associated with a higher risk of knee OA
– Increasing your vitamin C intake may keep radiographic knee OA and pain from getting worse
Loeser RF, et al. Nat Rev Rheumatol. 2016;12(7):412-20.
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Treating Oxidative Stress
• Find and treat the root cause(s)
– Impaired gut health: the gut microbiome
• Key focus in autoimmune arthritis
– Diet: especially low levels of antioxidants
– Stress and trauma
– Environmental exposures
• Heavy metals, pesticides/herbicides, smoking
– Infections
– Obesity: key focus in osteoarthritis
The whole body is effected, not just the joints!
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The Gut-Arthritis Connection
• People with RA, PsA, AS: damaged tight junctions, high zonulin and leaky gut
• Gut lumen antigens (including bacterial cell wall proteins) get into the body and trigger an immune and inflammatory response
Fasano A. Physiol. Rev. 2011;91:151-175.
Fasano A. Clin Rev Allergy Immunol. 2017;42:71-78.
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RA: How Joints Get Inflamed
• Gut microbial dysbiosis and increased intestinal permeability
– Bacterial Cell Wall Components (BCWC) in the bloodstream and joints
– Example: lipopolysacharides (LPS), can be measured
• RA patients immune response against BCWC of:
– Enterobacteria: Klebsiella, Citrobacter, Proteus, Enterobacter, E. coli, Salmonella, Yersinia, Shigella, Serratia
– Intestinal gram-positive bacteria like Bacillus
Sandhya P, et al. Int J Rheum Dis. 2016;19(1): 8-20.
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Factors Influencing the Gut Ecosystem
Childhood
•Breast vs. formula
•C-section
•Excessive hygiene
Lifestyle
•Chronic stress
•Poor sleep
•Physical inactivity
Food
•Processed diet
•Insufficient fiber and phytonutrients
Environment
• Exposure to toxins
• Medication
• Alcohol
• Infections
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• High levels of oxidative stress associated with ALL TYPES of arthritis
• High oxidative stress markers predict relapse in people apparently in remission
• Testing is important to assess current status, follow treatment, predict relapse, and know when to taper off medication
Measuring Oxidative Stress
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Testing for Oxidative Stress
These markers are included in:
and and
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Oxidative Stress Markers in the NutrEval
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Oxidative Stress Analysis 2.0 (Blood)
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• 60 year old female
• Came to see me to help her get off her medication
– Started ISRP 3 months ago, already improved with diet change and gut treatment
• Tapering the Methotrexate (MTX) (now 15 mg/day) and Rituxan Q6 months, x2 so far
Case Study: Rheumatoid Arthritis
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Timeline
1995/1997• IVF for 2 children• She’s in her 40s
1999• Hands swelled, ignored it• Working• 2 toddlers, breast feeding• Marathons
2000• STRESS and FLARE• Dad remarried, cut off• Hands, feet, wrists• Workup: RA with high RF• Needed to quit work• Rx: Plaquenil, macrobiotic diet,
no dairy, green tea• REMISSION
2002
• Symptoms returned,
added MTX + folate
• REMISSION
• RF normal
• Home with kids,
working 1 day/week
2005
• Gut issues: reflux, abdominal pain
• Endo normal
• GB U/S, ok
• Lived with it
2009
• +PPD: INH for 7 months
• Also, Levoquin on-and-off for bronchitis
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Timeline (continued)
2014• STRESS and FLARE• Father and brother died• Crippled, couldn’t pick up cup• Prednisone (first time) + Embrel x 4
months (in addition to Plaquenil and MTX)
2015• Needed prednisone again for
another 4 months• WBC started dropping (still an issue)• Off Plaquenil, added Rituxan• 6 months ago/August 2015: off
prednisone and finally in REMISSION
2016
• 3 months ago had some gut
issues: gas, bloating, GERD, no
joint symptoms
• Still on MTX and Rituxan
• Read Immune System Recovery
Plan– Elimination diet for first time
ever, vegan
– Currently avoiding gluten, dairy,
sugar, wine, night shades
– Eating eggs
• Lost 10 pounds, still some
gurgling and burping
• 2 weeks later: Gut Cleanse
program
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• Stay on current dose of MTX (she had just lowered it)
• Continue Gut Cleanse herbs for another month: GI MicrobX + Oregano
• UltraInflammx 360 plus shake daily
• Heartburn TX from Vital nutrients
• High dose omega oils: start with 1.5 - 2 grams EPA/DHA plus 500 mg GLA
• Inflammatone (DFH): curcumin/boswellia/enzyme blend
• Daily meditation
• Remain on the elimination diet as currently following
• History of periodontal disease: start waterpik treatment with Biocidin added
• Tests: NutrEval, routine blood work + autoimmune/RA testing, stool test later
Medical Visit #1: Plan
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Supplement Program:
Initial Visit
I added:
• Gut Cleanse Packets
• Heartburn TX
• ProEFA liquid
• Inflammatone
• Biocidin to waterpik
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• Feeling well• Lost 15# now since starting program 4 months ago• Gut symptoms now resolved• Still in remission, no joint pain
• Test results:
– NutrEval
• +oxidative stress• high mercury and lead• high needs for many nutrients
Medical Visit #2:
– Routine/Conventional
• CCP>250• RF 215.6• ANA neg• neutropenia
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Initial NutrEval
March 2016
Test Results:
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Initial NutrEval
March 2016
Test Results:
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Test Results:
CBC shows low neutrophils
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• Continue waterpik with Biocidin
• Increase probiotics
• Increase antioxidants: add Vitamin C, Phytoganix powder, NAC
• Look for sources of lead and limit fish
• Exercise: swimming, walking, yoga
• Daily meditation practice
• Continue Leaky Gut diet for arthritis
• Continue rest of supplements: Inflammatone, omega oils, Vitamin D, collagen complex (Osteovantiv)
Treatment Plan
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Supplement Program:
2nd Visit
I added:
• Phytoganix
• Vitamin C
• CoQ10
• NAC
• Probiotic
• B Supreme
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• 95% gluten and dairy free now
• Ate lots of tomatoes over the summer
• Loves Glutagenics and Inflammatone
• Overall feels better and still in remission
• Did another round of Rituxan
• Down to 6 methotrexate, tapering
• Test results:
– GI Effects• 4+ Klebsiella and 1+ Candida
• Very low Lactobacillus and Bifidobacterium in both PCR and cultures
– Routine/Conventional• ESR, CRP, hsCRP, LpPLA2, fibrinogen normal
• Low neutrophils persist
Medical Visit #3: 6 months Later (October 2016)
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GI Effects
October 2016
Test Results:
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GI Effects
Stool Culture
October 2016
Test Results:
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• Test Results
– GI Effects: • 4+ Klebsiella and 1+ Candida
• Very low Lactobacillus and Bifidobacterium in both PCR and cultures
– Routine/Conventional blood work:• ESR, CRP, hsCRP, LpPLA2, fibrinogen normal
• Low neutrophils persist
• Treatment
– GI Microb-X 2 BID, plus oregano 2 BID for 2 months
– Increased probiotics to 100 billion
Treatment Plan
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Supplement Program:
3rd Visit
I added:
• Gut dysbiosis treatment
• She didn’t want Rx for Candidaso we did 2 months of herbs
• Switched to probiotic powder for increased dosing
• Continued everything else
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• SEVERE STRESS - she’s been in a flare
• Many stressful family issues
• Skin cancer on her face
• TERRIBLE FLARE - all her joints hurt within 1 month after this
• Decided to do another Rituxan treatment, which helped
• Started eating bagels - stopped supplements - went off the program
• Kitchen under construction, can’t cook
• 1 month ago, after she did the testing for this visit, started gluten free again
Medical Visit #4: 6 Months Later (April 2017)
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• NutrEval
– All Oxidative stress markers are worse She did this test on 2/21, while in the middle of this flare
– Gut markers are all high
– B’s and minerals have improved
• GI Effects Comprehensive
– No harmful microbes in the cultures
– PCR: high bacteroidetes
– Beta gluc high
• SIBO + 97/0
Test Results
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2nd Follow-up NutrEval
March 2017
Test Results:
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Note:
• Lipid peroxides higher, was 5.6
• 8-OHDG slightly lower, was 20
• Glutathione was 926
• Mercury gone (stopped eating fish)
• Lead much improved
2nd Follow-up NutrEval
March 2017
Test Results:
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Note:
• Detox markers higher
• Suggests increased oxidative stress/need for more antioxidant support
2nd Follow-up NutrEval
March 2017
Test Results:
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2nd Follow-up
GI Effects
March 2017
Test Results:
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SIBO Breath Test
Test Results:
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• High oxidative stress markers tells us that we need to work harder to treat underlying issues
• Stress can worsen SIBO, and periodontal issues, as well as derail the food plan
• She had given up and all the underlying issues got worse again, despite being able to lower her medication
• Also, we were having underlying issues that needed to be addressed– She would talk about her stress like it was happening to a third person and without emotion
– Had a high tolerance for pain and would let things slide and ignore first warning signs
– She did not keep regular appointments and follow ups were too far apart
Assessment
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• RA with high oxidative stress markers and SIBO
• Stress: major trigger
• Continue treating oral microbiome with waterpik
• Candibactin BR: continue treating the gut as source of oxidative stress
• Focus on returning to whole foods, healthy food plan: 100% gluten-free, dairy-free and nightshade-free again
• Focus on antioxidants– Add Vitamin A, Vitamin E, lipoic acid
– Remind her to take the antioxidant powder (Phytoganix); she hasn’t been doing it
– Increase Vitamin C to bowel tolerance
Treatment Plan
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Supplement Program:
4th Visit
I added:
• Gut treatment with CandibactinBR/AR
• Lipoic acid
• Switched back to lower dose probiotic
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• Returned after 6 months
• Her flare had subsided within 1-2 months of starting the last treatment program and she is in remission again
• Came back to check in; she was concerned that her gut was acting up again due to some reflux and bloating
• Has been mostly consistent with supplements, but stopped some of the antioxidants
• She went down to 4 MTX last week
• Rituxan was due last month (she skipped so far), but considering taking it so she can go skiing
• She didn’t do the repeat NutrEval, just brought blood work– RF 117 (214.6)
– CCP still >250
– ESR 15
Medical Visit #5: 6 Months Later (October 2017)
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• Assessment: RA with high CCP, improving RF, high oxidative stress markers, and recently treated for SIBO
• Focus on gums and periodontal: sent to biologic dentist, probiotic toothpaste, evaluate for mouth breathing at night – Re-start waterpik (she hadn’t kept up with this)
• Retest for SIBO: – If positive, we will do Xifaxan
– If not, no more gut cleanse treatment for now
• Retest Oxidative Stress markers and go back on the full doses of antioxidants that were prescribed last visit
Treatment Plan
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Supplement Program:
6th Visit (most recent)
I changed:
• No more gut cleanse for now
• Added Saccharomyces boulardii
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• Oxidative stress markers can be followed and correlate with disease activity
• True remission is not possible while these levels are high
• Clinical symptoms might be gone, but a flare is lurking around the corner with the next stressful or traumatic event
• Look for sources of oxidative stress: gut/oral dysbiosis, toxins, infections
• Work with your patients on awareness of stress and trauma and building skills for resiliency
• Lifestyle, including food, detoxing the environment, sleep, stress, exercise, are all key to good gut health and low levels of oxidative stress
Take Home Pearls
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Additional Questions?
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February 28, 2018
Dietary Approaches to Treating Multiple SclerosisTerry Wahls, MD
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The views and opinions expressed herein are solely those of the presenter and do not necessarily represent those of Genova Diagnostics. Thus, Genova Diagnostics does not accept liability for consequences of any actions taken on the basis of the information provided.
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Healing ArthritisTaming the Flame by Treating Oxidative Stress Susan Blum, MD, MPH
Founder and Director, Blum Center for Health
The views and opinions expressed herein are solely those of the presenter and do not necessarily represent those of Genova Diagnostics. Thus, Genova Diagnostics does not accept liability for consequences of any actions taken on the basis of the information provided.