The Nutritional Supplement

Chief complaints:

1. Cardiovascular disease risk
2. Depression
3. History of rheumatoid arthritis
4. Recently developed fatigue

At the age of 44, he began experiencing soreness and pain in his hands. He took NSAIDS for about a year with some relief. However, the pain worsened and began to wake him at night. He finally sought evaluation and at the age of 46 was diagnosed with RA.

• Total Cholesterol = 240
• HDL-C = 36
• LDL-C = 154
• TG = 150
• Of note, his blood pressure was not elevated.

Family History:

• His father died from a stroke at the age of 72 and his older brother was also diagnosed with high lipids and HTN.
• Thus, at the time of diagnosis for his RA, he was started on celecoxib (Celebrex) 100mg BID and atorvastatin (Lipitor) 20mg daily by his physician.

The patient reported good tolerance to both medications although, upon later reflection, he describes the following:

• Within several months of starting the medications, he developed constipation.
• He also began to experience depression. He and his doctor ultimately attributed this to his diagnosis and he was prescribed fluoxetine (Prozac) 20mg daily.
• RP was stable for approximately one year (now age 47), but then began to experience increased frequency of symptom flares in his feet and hands.
• He was started on methotrexate 7.5mg weekly and maintained on celecoxib, fluoxetine and atorvastatin.

The patient, now 48 and 2 years presents as follows:

• His RA symptoms do flare, but with the MTX and celebrex, less often and less severely. He is able to continue to work. He has noticed some increasing stiffness in his neck and knees.
• He has experienced myalgia for over a year which he attributes to his RA, but which has limited his ability to exercise.
• He does not feel as depressed, but describes “having down moods” and also some anxiety about his health.
• He has also begun to experience fatigue. He has trouble getting out of bed and has some joint stiffness in the morning. He feels very tired in the afternoon and has recently resumed an afternoon coffee habit that he had given up until a few months ago.

General:

• Fatigued with lowest energy in the morning and afternoon.
• Occasional pain and stiffness in his wrists, feet, knees and neck. Stiffness of neck. Nocturnal muscle cramps in his upper legs, soreness of his legs throughout the day, somewhat subsiding by evening.
• Occasional reflux (aggravated by spicy foods); no bloating or pain; one bowel movement every 2-3 days; difficult to pass.
• No chest pain or palpitations.
• Anxiety regarding his health as well as a growing sense of depression over his health as well.

Family/Social:

• Currently single; divorced x 10 years after a 12 year marriage. No children. Socializes with co-workers.
• Works retail at USPS

Toxic Exposure:

• Cigarette smoking ½ -1 pack/d x 10 years ages 17y-27y; currently does gardening; uses minimal pesticides and always wears gloves

Diet:

• Avoided coffee until recently. Also avoids lactose milk. Eats cereal and fruit most mornings, sandwich and fruit for lunch; cookie or brownie for snack. Dinners vary and include fast food or salads at home or chicken and potatoes. He enjoys a beer in the evenings.

Stress:

• Worried about his own health; feels lonely sometimes. He socializes with co-workers, has a dog, and spends much of his time alone.

Activity:

• Walks daily x 40 min

Objective Findings:

• Vitals: bp= 130/76p=78rr= 12;regt=98.2
• Respiratory: Respiration even and un-laboured; clear/equal sounds throughout B/L
• Cardio: RRR, no extra sounds
• Abdominal: BS x 4; no organomegaly; NTTP
• M/S & Neuro.: Tenderness of metacarpophalangeal joints B/L on palpation; crepitus on motion. Swelling of first metatarsal joints bilaterally, pain on passive movement. +2 DTR throughout. Neg. Rhomberg’s sign
• Skin: No rheumatoid nodules present

Assessment Considerations:

• Statins disrupt cell membrane integrity, hormone, vitamin D, and bile production.
• Statins and methotrexate specifically, and antidepressants putatively, interfere with mitochondrial production.
• NSAIDS promote intestinal permeability by interfering with brush border mitochondrial functioning.
• Lectins from wheat and tomatoes may bind to N-acetyl glucosamine IgG terminus resulting in immune complex deposition in synovial tissue.
• Autoimmunity, according to Alessio Fasano, requires genetic predisposition, environmental trigger, and intestinal permeability.
• Glyphosate (herbicide) chelates minerals, disrupts sulphate metabolism and kills beneficial bacteria.

Management Considerations:

• When in doubt, start with the gut
• Gluten elimination may yield clinical results including decreased pain, improved mood, improved GI functioning within 1-3 months.
• This patient would benefit from health coaching and/or group visits to minimise isolation.
• Ancestral diet is likely to benefit this patient's dysglycaemia.
• Medications used to treat RA likely increase risk of CVD and may promote disease progression.
• Should expect to see a downward trend in autoantibody production with a successful functional/integrative approach.
• Address diet, nutrient depletions, gut health, and inflammation.
• Expect has increased nutrient demands:
• Inflammation is catabolic
• Compromised digestion/absorption
• Standard American diet
• Drug induced nutrient depletions
• Patient is taking methotrexate which depletes folic acid. A folic acid deficiency could contribute to the fatigue and depression the patient is experiencing thus indicating replenishment.

This patient’s major problem is chronic systemic inflammation which is coming from his leaky-gut syndrome (increased intestinal permeability). This must be addressed.