A Functional Approach to GI Symptoms Driven by Rheumatoid Arthritis

Using GI-MAP for a Rheumatoid Arthritis Sufferer Experiencing GI Symptoms

Karen is a 63-year-old female who was diagnosed with rheumatoid arthritis (RA) four years before coming to my clinic. After her initial diagnosis, she was able to maintain stability with her disease. However, after becoming the primary caretaker for her ailing parents, the joint pain in her hands and feet flared significantly. Simultaneously, she began experiencing significant gastrointestinal symptoms, including constipation, gas, bloating, and belching.

To treat the new joint pain, her rheumatologist started her on methotrexate therapy along with a course of oral steroids. After a 21-day course, Karen could not successfully taper off the medication. Her rheumatologist then prescribed another 30-day round of methotrexate and steroids. During the second round of treatment, Karen's gastrointestinal symptoms worsened, and she came to see me. Karen had already run a test for SIBO (small intestinal bacterial overgrowth), which had been ruled out. As I usually do with my complicated patients, I immediately ordered a GI-MAP for her.

The RA-Gut Connection in Literature

RA is a chronic autoimmune disease that presents with polyarticular inflammation and destruction mainly of the synovial joints, as well as of other organ systems.¹

Recent data has linked the health of the microbiome to the progression of RA disease, so assessing the comprehensive picture of gut microbiome health is particularly valuable for workup and treatment. In 2016, Chen et al., published human data that showed lower gut microbial diversity and species richness among RA patients compared to healthy controls.² In 2021, a small human study of 32 patients was released that showed that modulating diversity within the microbiome helped RA patients achieve clinical improvements over time.³

GI-MAP Results Back Up Literature Related to the Gut and RA

The results of Karen's GI-MAP showed an evident lack of diversity in keystone species of the microbiome. She had low Enterococcus, Escherichia, and Clostridia species. She also had no detectable level of Akkermansia muciniphila or Faecalibacterium prausnitzii. Additionally, the GI-MAP showed that Karen had low levels of the Bacteroides and Firmicutes phyla.

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Based on the literature linking microbial diversity to RA and Karen's GI-MAP test results, I focused on balancing Karen's microbiome via diet, lifestyle, and supplement interventions. I asked her to increase her intake of fermented foods with as many varieties as possible. Notably, Hannah et al., published in 2021 that after a 17-week clinical trial of introducing fermented foods into the diet, patients were able to enhance the diversity of gut microbes, as evidenced by molecular testing.⁴ We also started the patient on a rotation of mixed probiotics to further support her lower diversity.

Karen tolerated the treatment plan quite well and was thrilled to successfully taper down off the second round of steroids without any issues. She was also able to maintain her stable dose of methotrexate. Best of all, Karen's digestive symptoms improved on the protocol, and she reported far less gas, bloating, or constipation.

GI-MAP and Functional Medicine Inspire a New, Rewarding Lifestyle

My goal as a practitioner is to get to the root cause of a patient's complaints and help them feel better. But I'm most excited when functional medicine inspires patients to change their lifestyles. Karen enjoyed the fermented foods she ate to heal her gut so much that she formed a new relationship with food. Her commitment to adding diversity to her diet soared. She became so excited that she learned about home fermentation and began fermenting and eating her home-grown vegetables. This lifestyle change allows her to treat her garden and her meals as medicine.

Author: Ilana Gurevich, ND, NSOM, FABNG

Dr. Gurevich is a naturopathic medical physician and an acupuncturist who uses individualized natural therapies to address the underlying cause of disease. She encourages her patients to take an active role in their own health care. Dr. Gurevich relies on a variety of natural modalities including Chinese and Western herbal medicine, acupuncture, nutritional supplements, homeopathy, hydrotherapy, and dietary education.

REFERENCES

1. Smolen JS, Aletaha D, Barton A, Burmester GR, Emery P, Firestein GS, et al. Rheumatoid arthritis. Nature Reviews Disease Primers. Nat Publishing Group. 2018;4:1–23.
2. Chen J, Wright K, Davis JM, Jeraldo P, Marietta EV, Murray J, et al. An expansion of rare lineage intestinal microbes characterizes rheumatoid arthritis. Genome Med. 2016;8:43.
3. Gupta, V.K., Cunningham, K.Y., Hur, B. et al. Gut microbial determinants of clinically important improvement in patients with rheumatoid arthritis. Genome Med 13, 149 (2021). https://doi.org/10.1186/s13073-021-00957-0
4. Wastyk HC, Fragiadakis GK, Perelman D, Dahan D, Merrill BD, Yu FB, Topf M, Gonzalez CG, Van Treuren W, Han S, Robinson JL, Elias JE, Sonnenburg ED, Gardner CD, Sonnenburg JL. Gut-microbiota-targeted diets modulate human immune status. Cell. 2021 Aug 5;184(16):4137-4153.e14
5. Mandel DR, Eichas K, Holmes J. Bacillus coagulans: a viable adjunct therapy for relieving symptoms of rheumatoid arthritis according to a randomized, controlled trial. BMC Complement Altern Med. 2010;10:1.
6. Vaghef-Mehrabany E, Alipour B, Homayouni-Rad A, Sharif S-K, Asghari-Jafarabadi M, Zavvari S. Probiotic supplementation improves inflammatory status in patients with rheumatoid arthritis. Nutrition. 2014;30:430–5.