Rheumatoid arthritis is a painful, inflammatory auto-immune disease that affects millions of people, the majority of which are women. Researchers still don’t understand the cause but they do know that there is a definite difference between “non-inflammatory” arthritis, or osteoarthritis, and inflammatory arthritis, or RA.
RA is a much more complicated disease, but it usually affects the:
Like psoriasis or lupus, RA is an autoimmune disease. This means the body’s immune system attacks healthy tissue.
Various forms of arthritis are listed as coexisting conditions to mast cell disease, but this post is specifically about RA.
How are these two diseases connected?
…markers of mast cell activation are observed in joint fluid from patients with chronic arthritis and mast cell numbers are often greatly expanded within the inflamed synovium. Equipped with an impressive array of mediators, mast cells can promote synovitis by recruiting inflammatory cells from the blood, inducing synovial fibroblast hyperplasia and mediator production, and fostering angiogenesis. Although much remains to be learned about the role of the mast cell in arthritis, such a role now seems highly likely, offering a potential new target for therapeutic agents in the treatment of RA and other inflammatory diseases of the joints.
MCAS fundamentally is a chronic multisystem disease of general themes of inflammation +/- allergic-type phenomena +/- abnormal growth/development in potentially any tissue. Also, “arthritis,” by definition, is an inflammatory disease (the “itis” on the end of “arthritis” means “inflammation,” and the “arthr” at the beginning of the word means “joints”). There is no non-inflammatory arthritis as distinguished from inflammatory arthritis. All arthritis is inflammatory, by definition. (There do exist non-inflammatory joint diseases, but the general word to refer to those conditions, since they don’t involve inflammation, would be arthropathy, not arthritis.) Therefore, yes, MCAS can be at the root of some cases of arthritis.
This graphic from ScienceDirect shows the complex way in which mast cells can contribute to inflammatory arthritis:
..in RA the de novo synthesis of TNF by mast cell results in IL-1β release by macrophages leading to an increase in inflammatory cell infiltrates including neutrophils in synovial joints. Mast cell-derived tryptase via tryptase–heparin complexes activates synovial fibroblasts to express chemokines that recruit neutrophils to the joint.
The relationship between these two diseases is still being researched and the evidence so far is not conclusive enough to say that mast cell disease causes all cases of rheumatoid arthritis but it certainly can contribute to and exacerbate it.
Just like with other inflammatory diseases, our mast cells can play a huge role in both severity of symptoms and treatment.
How do you treat RA in MCAD patients?
One of the first lines of treatment for RA is pain relievers, like opiods, and anti inflammatories, like NSAIDs, both of which those with MCAD (both mastocytosis and MCAS) don’t typically tolerate well.
So that complicates things.
Steroids are also used in both diseases with varying degrees of success. Steroids are generally well tolerated among mast cell patients but long term use is not recommended.
There are other treatments, called DMARDS, that include drugs like methodextrate, which can be used in mast cell patients who have RA but we should use them with caution, according to experts like Dr. Molderings of Bonn University:
The influence of azathioprine, methotrexate, ciclosporine, hydroxyurea, and tamoxifen on MC activity can vary from no to moderate effect depending on individual disease factors. As in therapy of rheumatoid arthritis, azathioprine and methotrexate can be used in daily doses lower than those used in cancer or immunosuppressive post-transplant therapy.
A common triple therapy for rheumatoid arthritis is methotrexate, sulfasalazine, and hydroxychloroquine. There are reports of some mast cell patients having adverse reactions to sulfasazazine and hydroxychloroquine is on the approved list of therapies for mast cell treatment.
Patients have to be careful in selecting treatment for their RA and use caution when offered alternative or unconventional treatments. Even therapies that have been accepted as conventional may not be as effective compared with newer drugs. A Korean woman learned this when she agreed to have gold injected into her wrists and fingers and ended up with an x-ray that looked like this:
Oral and injectable gold preparations are also sometimes used. After the initial diagnosis of rheumatoid arthritis, the patient had been treated with the combination of methotrexate and leflunomide. When she was referred to our hospital, we changed her treatment regimen to a combination of methotrexate and abatacept, and she underwent surgery for the foot deformities, which led to a substantial reduction in joint pain.
Gold injections are the oldest treatment for rheumatoid arthritis, going back 75 years, and are part of the class of DMARD drugs I mentioned earlier.
Gold injections are made from a compound called sodium aurothiomalate, which contains gold. Sodium aurothiomalate belongs to a class of drugs called disease-modifying antirheumatic drugs, or DMARDs.
The anti-inflammatory properties of gold compounds are unknown. However, there has been enough evidence to confirm that gold can inhibit behavior of substances responsible for production of antibodies and the release of inflammatory cytokines.
Due to the number and severity of side effects that they cause, gold treatments are now rarely used to treat RA and other inflammatory conditions. Doctors are prescribing other DMARDs instead, including methotrexate, which is considered safer.
My husband’s grandmother used to have weekly gold injections for her own arthritis back in the 1980’s and swore by them. Today she probably would be offered an alternative, like methotrexate, instead.
The target is to reduce inflammation as much as possible to control pain and to prevent deterioration of the joints and even other organs, such as the eyes and lungs, which RA can affect.
Treating the underlying mast cell disease may provide some relief and lessen symptoms overall, as with other coexisting conditions.