Treating Autoimmune Conditions When Inflammation is Not Present

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Inflammation is considered a hallmark symptom of most of the more than 80 different types of autoimmune diseases presently being diagnosed. But what happens when inflammation is not present and symptoms persist? How does that change the treatment trajectory?

New research published in Science Translational Medicine involving rheumatoid arthritis (RA) patients helps explain why some patients have pain but their joints are not inflamed. This may help practitioners create treatment plans geared towards patients who are unresponsive to anti-inflammatory medications or an anti-inflammatory treatment protocol. This study looked at the genetic expression of the synovial biopsy samples of patients who had established RA with pain and without inflammation.

"RA pain without inflammation is not fully understood, but we are continuing to learn about the underlying mechanisms for this type of pain and swelling as illustrated by this latest study," explained integrative rheumatologist Anastasia Stocker, ND, LAc. “We know that there is a subset of patients that will continue to have pain despite the use of multiple anti-inflammatory medications.”

In fact, it’s estimated that about 20 percent of RA patients who have swollen, painful joints do not get relief from different rounds of the various anti-inflammatory medications presently available.

"These patients often rotate through multiple NSAIDs, biologic agents, and steroids with minimal relief in their symptoms," said Stocker, who is a physician with Aria Integrative Medicine in Seattle. "This is a challenge as their inflammatory markers can decrease, but they are still having pain and swelling."

According to Stocker, some cases of pain can be traced to non-inflammatory mechanisms such as neuropathic pain or central sensitization.

“Chronic joint damage from previous inflammation can also continue to cause pain even in the absence of ongoing inflammation,” she explained. “Structural changes in the joints such as erosion of cartilage and bone can lead to persistent pain without inflammation.” 

What’s the Answer?

Lack of inflammation can be one cause of treatment-resistant autoimmunity, which is when an integrative approach may be especially helpful.

"For all autoimmune patients—those responding to conventional medications and those who are not—I am always working on foundations of health and trying to identify the patient's unique immune system triggers," said Stocker, who discussed her integrative approach in detail with the Natural Medicine Journal Podcast. “Addressing personal immune system triggers can help reduce pain and disease progression.”

Specific to immune system triggers, she looks at current or history of infection, gut microbiome imbalance, hormone imbalance, dietary triggers, and exposure to environmental toxins. From a lifestyle standpoint, Stocker evaluates diet, hydration, stress, social support, and sleep.

“An integrative approach helps us treat patients with autoimmune conditions holistically even when inflammation is not the driving force behind the condition,” Stocker concluded.