by Devin J. Starlanyl © 2004 Page 1

Scope and Purpose: Between 1992 through 1999, over 1,000 patients with

release of acetylcholine at dysfunctional motor end plates. (1, 2) Referred pain from

and painful limit to full stretch range of motion. (1) Visual or tactile identification of

Central TrPs are usually in the belly of muscle, where the motor endplates lie.

Attachment TrPs occur in areas of tenderness where the muscle attaches to other

by Devin J. Starlanyl © 2004 Page 2

(1, p 76) Attachment TrPs are caused by the sustained tension of central TrP-involved

greater tenderness in greater than or equal to 11 of 18 tender point sites. (3) FMS

is essentially a centrally generated hypersensitivity to painful stimuli. (4) There is

Lack of restorative sleep is a common symptom. (5) It is vitally important to

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Dry nares with bleeding 22

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Meralgia paresthetica (numbness/

Meralgia paresthetica (numbness/

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by Devin J. Starlanyl © 2004 Page 6

For many years, the emphasis has been on pain caused by myofascial TrPs,

because the pain can be so prominent. But TrPs can also cause muscle weakness

and restricted range of motion. Physical and occupational therapists, as well as

You cannot strengthen a muscle with a trigger point. The muscle is already

unnecessary." (1)

is not progressive. (6) If it is getting significantly worse with time, there is at least

by Devin J. Starlanyl © 2004 Page 7

The central sensitization of FMS can be both initiated and perpetuated by

peripheral pain sensations (7), such as those caused by myofascial TrPs. The

FMS, as well as widespread pain, fatigue, sleep abnormalities and distress. (7)

and interstitial swelling can be an integral part of this process. (8) Central

following peripheral inflammatory stimuli. (8) This may indicate a similar process

fibromyalgia." (9) Initiating factors for FMS might even begin before birth. Some

by Devin J. Starlanyl © 2004 Page 8

and hypothalamus-pituitary-adrenal (HPA) axis regulation after birth. (10) These

dysfunctions. (11) Each patient is a unique individual, with unique needs, and must

fibromyalgia." (12) For example, although many patients were diagnosed with FMS

associated with insulin resistance (13), these patients were not checked for insulin

carbohydrates, and hypoglycemic symptoms. (13) What I had considered the FMS

not yet have the 11 of 18 tender points may benefit from aggressive pain control

to prevent further central sensitization. (14) Some of these patients developed FMS

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In 1992, an article linked chronic rhinitis to FMS. (15) This team studied 47

neurogenic mechanisms can complicate sinusitis. (16) Stimulation of nasal sensory

On March 23, 2004, at the annual meeting of the American Academy of Allergy,

Asthma and Immunology in San Francisco, a paper was presented. A Mayo Clinic

by Devin J. Starlanyl © 2004 Page 10

forms by local fibrosis. (17) Fibrosis or tissue swelling may make it impossible to

(1) The patient may often recognize the TrP pain patterns. As the patient gets

normal muscles." (1 p, 22) Exercise programs must reflect this if TrPs are part of the

allergies." (1 p105) This can be difficult for people who have allergies and have TrPs.

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activity should be restricted in the 2-3 day post-treatment period. (1, p 186) When

dysfunction..." (18) Many patients (male and female) had developed sexual

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called interoception dysfunctions. (19) Myofascial TrPs can cause peripheral

by Devin J. Starlanyl © 2004 Page 13

well. This pilomotor response can be secondary to myofascial TrPs. (1) Several

documented. (20) People with electromagnetic sensibility do not necessarily have

effect on neural tissue "...in conditions where field sensitivity is enhanced." (21)

(ECM) proteins. (22) Many patients described these symptoms as worsening in

parameters. (23) It is clear that we need more research in this field, but for this to

Table of Contents

Introduction
My Experience with Dr. Brown's Protocol
Nutritional Considerations
Antibiotic Therapy With Minocin
Clindamycin
What To Do If Severe Patients Fail To Respond
Anti-Inflammatories
Prednisone
Remission
Preliminary Laboratory Evaluation For Non-Rheumatologists
Fibromyalgia
Signs And Symptoms of Fibromyalgia
Pain Location
Treatment Of Fibromyalgia
Exercise For Rheumatoid Arthritis
The Infectious Cause Of Rheumatoid Arthritis
Culturing Mycoplasmas From Joints Animal Evidence for The Protocol
The Science of Why Minocycline Is Used
Clinical Studies
Criteria For Classification Of Rheumatoid Arthritis
Bibliography

Introduction

Rheumatoid arthritis affects about 1 percent of our population and at least two million Americans have definite or classical rheumatoid arthritis. It is a much more devastating illness than previously appreciated. Most patients with rheumatoid arthritis have a progressive disability. More than 50% of patients who were working at the start of their disease are disabled after five years of rheumatoid arthritis. The annual cost of this disease in the U.S. is estimated to be over $1 billion.

There is also an increased mortality rate. The five-year survival rate of patients with more than thirty joints involved is approximately 50%. This is similar to severe coronary artery disease or stage IV Hodgkin's disease. Thirty years ago, one researcher concluded that there was an average loss of eighteen years of life in patients who developed rheumatoid arthritis before the age of 50.

Most authorities believe that remissions rarely occur. Some experts feel that the term "remission-inducing" should not be used to describe ANY current rheumatoid arthritis treatment. A review of contemporary treatment methods shows that medical science has not been able to significantly improve the long-term outcome of this disease.

My Experience with the Dr. Brown's Protocol

I first became aware of Doctor Brown's protocol in 1989 when I saw him on 20/20 on ABC. This was shortly after the introduction of his first edition of The Road Back.The newest version is The New Arthritis Breakthrough that is written by Henry Scammel. Unfortunately, Dr. Brown died from prostate cancer shortly after the 20/20 program so I never had a chance to meet him. By the year 2000, I will have treated over 1,500 patients with rheumatic illnesses, including SLE, scleroderma, polymyositis and dermatomyositis.

My application of Dr. Brown's protocol has changed significantly since I first started implementing it. Initially, I followed Dr. Brown's work rigidly with very little modification other than shifting the tetracycline choice to Minocin. I believe I was one of the first people who recommended the shift to Minocin, which seems to have been widely adopted at this time.

In the early 90s, I started to integrate the nutritional model into the program and noticed a significant improvement in the treatment response. I cannot emphasize strongly enough the importance of this aspect of the program. It is absolutely an essential component of the revised Dr. Brown protocol. One may achieve remission without it, but the chances are much improved with its implementation. The additional benefit of the dietary changes is that they severely reduce the risk of the two to six month worsening of symptoms that Dr. Brown described in his book.

In the late 80s, the common retort from other physicians was that there was "no scientific proof" that this treatment works. Well, that is certainly not true today. If one peeks ahead at the bibliography, one will find over 200 references in the peer-reviewed medical literature that supports the application of Minocin in the use of rheumatic illnesses. The definitive scientific support for minocycline in the treatment of rheumatoid arthritis came with the MIRA trial in the United States. This was a double blind randomized placebo controlled trial done at six university centers involving 200 patients for nearly one year. The dosage they used (100 mg twice daily) was much higher and likely less effective than what most clinicians currently use. They also did not employ any additional antibiotics or nutritional regimens, yet 55% of the patients improved. This study finally provided the "proof" that many traditional clinicians demanded before seriously considering this treatment as an alternative regimen for rheumatoid arthritis.

Dr. Thomas Brown's effort to treat the chronic mycoplasma infections believed to cause rheumatoid arthritis is the basis for this therapy. Dr. Brown believed that most rheumatic illnesses respond to this treatment. He and others used this therapy for SLE, ankylosing spondylitis, scleroderma, dermatomyositis and polymyositis.

Dr. Osler was also a preeminent figure of his time (1849- 1919). Many regard him as the consummate physician of modern times. An excerpt from a commentary on Dr. William Osler provides a useful perspective on application of alternative medical paradigms:

Osler would be receptive to the cautious exploration of nontraditional methods of treatment, particularly in situations in which our present science has little to offer. From his reading of medical history, he would know that many pharmacologic agents were originally derived from folk medicine. He would also remember that in the 19th century physicians no less intelligent than those in our own day initially ridiculed the unconventional practices of Semmelweis and Lister.

Osler would caution us against the arrogance of believing that only our current medical practices can benefit the patient. He would realize that new scientific insights might emerge from as yet unproved beliefs. Although he would fight vigorously to protect the public against frauds and charlatans, he would encourage critical study of whatever therapeutic approaches were reliably reported to be beneficial to patients.

Nutritional Considerations

Limiting sugar is a critical element of the treatment program. Sugar has multiple significant negative influences on a person's biochemistry. Its major mode of action is through elevation of insulin levels. However, it has a similarly severe impairment of intestinal microflora. Patients who are unable to decrease their sugar intake are far less likely improve.

One of the major benefits of implementing the dietary changes is that one does not seem to develop worsening of symptoms the first three to six months that is described in Dr. Brown's book. Most of my patients tend to not worsen once they start the antibiotics. I believe this is due to the beneficial effects that the diet has on the immune response. I ask all new patients to read my 6-page handout on the dietary changes. Rather than repeat it here, one could obtain the current version on my web site at www.mercola.com under the tab heading on the left side of the page entitled Read This First.

Antibiotic Therapy With Minocin

There are three different tetracyclines available: simple tetracycline, doxycycline, or Minocin (minocycline). Minocin has a distinct and clear advantage over tetracycline and doxycycline in three important areas.

1. Extended spectrum of activity
2. Greater tissue penetrability
3. Higher and more sustained serum levels

Bacterial cell membranes contain a lipid layer. One mechanism of building up a resistance to an antibiotic is to produce a thicker lipid layer. This layer makes it difficult for an antibiotic to penetrate. Minocin's chemical structure makes it the most lipid soluble of all the tetracyclines.

This difference can clearly be demonstrated when one compares the drugs in the treatment of two common clinical conditions. Minocin gives consistently superior clinical results in the treatment of chronic prostatitis. In other studies, Minocin was used to improve between 75-85% of patients whose acne had become resistant to tetracycline. Strep is also believed to be a contributing cause to many patients with rheumatoid arthritis. Minocin has shown significant activity against treatment of this organism.

There are several important factors to consider when using Minocin. Unlike the other tetracyclines, it tends not to cause yeast infections. Some infectious disease experts even believe that it even has a mild anti-yeast activity. Women can be on this medication for several years and not have any vaginal yeast infections. Nevertheless, it would be prudent to have patients on prophylactic oral Lactobacillus acidophilus and bifidus preparations. This will help to replace the normal intestinal flora that is killed with the Minocin.

Another advantage of Minocin is that it tends not to sensitize patients to the sun. This minimizes the risk of sunburn and increased risk of skin cancer. However, one must incorporate several precautions with the use of Minocin. Like other tetracyclines, food impairs its absorption. However, the absorption is much less impaired than with other tetracyclines. This is fortunate because some patients cannot tolerate Minocin on an empty stomach. They must take it with a meal to avoid GI side effects. If they need to take it with a meal, they will still absorb 85% of the medication, whereas tetracycline is only 50% absorbed. In June of 1990, a pelletized version of Minocin became available. This improved absorption when taken with meals. This form is only available in the non-generic Lederle brand and is a more than reasonable justification to not substitute for the generic version. Clinical experience has shown that many patients will relapse when they switch from the brand name to the generic.

Clinically it has been documented that it is important to take Lederle brand Minocin. Most all generic minocycline is clearly not as effective. A large percentage of patients will not respond at all or not do as well with generic non-Lederle minocycline.

Traditionally it was recommended to only receive the brand name Lederle Minocin. However, there is one generic brand that is acceptable and that is the brand made by Lederle. The only difference between Lederle generic Minocin and brand name Minocin is the label and the price.

The problem is finding the Lederle brand generic. Some of my patients have been able to find it at Wal Mart. Since Wal Mart is one of the largest drug chains in the US, this should make the treatment more widely available for a reduced charge.

Many patients are on NSAID's which contribute to microulcerations of the stomach which cause chronic blood loss. It is certainly possible they can develop a peptic ulceration contributing to their blood loss. In either event, patients frequently receive iron supplements to correct their blood counts. IT IS IMPERATIVE THAT MINOCIN NOT BE GIVEN WITH IRON. Over 85% of the dose will bind to the iron and pass through the colon unabsorbed. If iron is taken, it should be at least one hour before the minocin or two hours after. One recent uncommon complication of Minocin is a cell-mediated hypersensitivity pneumonitis.

Most patients can start on Minocin 100 mg. every Monday, Wednesday, and Friday evening. Doxycycline can be substituted for patients who cannot afford the more expensive Minocin. It is important to not give either medication daily, as this does not seem to provide as great a clinical benefit.

Tetracycline type drugs can cause a permanent yellow- grayish brown discoloration of the teeth. This can occur in the last half of pregnancy and in children up to eight years old. One should not routinely use tetracycline in children. If patients have severe disease, one can consider increasing the dose to as high as 200 mg three times a week. Aside from the cost of this approach, several problems result may result from the higher doses. Minocin can cause quite severe nausea and vertigo. Taking the dose at night does tend to decrease this problem considerably.

However, if one takes the dose at bedtime, one must tell the patient to swallow the medication with TWO glasses of water. This is to insure that the capsule doesn't get stuck in the throat. If that occurs, a severe chemical esophagitis can result which can send the patient to the emergency room.

For those physicians who elect to use tetracycline or doxycycline for cost or sensitivity reasons, several methods may help lessen the inevitable secondary yeast overgrowth. Lactobacillus acidophilus will help maintain normal bowel flora and decrease the risk of fungal overgrowth. Aggressive avoidance of all sugars, especially those found in non-diet sodas will also decrease the substrate for the yeast's growth. Macrolide antibiotics like Biaxin or Zithromax may be used if tetracyclines are contraindicated. They would also be used in the three pills a week regimen.

Clindamycin

The other drug used to treat rheumatoid arthritis is clindamycin. Dr. Brown's book discusses the uses of intravenous clindamycin. It is important to use the IV form of treatment if the disease is severe. Nearly all scleroderma patients should take an aggressive stance and use IV treatment. Scleroderma is a particularly dangerous form of rheumatic illness that should receive aggressive intervention.

A major problem with the IV form is the cost. The price ranges from $100 to $300 per dose if administered by a home health care agency. However, if purchased directly from Upjohn, significant savings will be appreciated. A case of two-dozen 900 mg prefilled IV bags can be purchased directly from Upjohn for about $200.

For patients with milder illness, the oral form is preferable. If the patient has a mild rheumatic illness (the minority of cases), it is even possible to exclude this from their regimen. Initial starting doses for an adult would be a 1200 mg dose once a week. Patients do not seem to tolerate this medication as well as Minocin. The major complaint seems to be a bitter metallic type taste, which lasts about 24 hours after the dose. Taking the dose after dinner does seem to help modify this complaint somewhat. If this is a problem, one can lower the dose and gradually increase the dose over a few weeks.

Concern about the development of C. difficile pseudomembranous enterocolitis as a result of the clindamycin is appropriate. This complication is quite rare at this dosage regimen, but it certainly can occur. It is important to warn all patients about the possibility of developing a severe uncontrollable diarrhea. Administration of the acidophilus seems to limit this complication by promoting the growth of the healthy gut flora.

If one encounters a resistant form of rheumatic illness, intravenous administration should be considered. Generally, weekly doses of 900 mg are administered until clinical improvement is observed. This generally occurs within the first ten doses. At that time, the regimen can be decreased to every two weeks with the oral form substituted on the weeks where the IV is not taken.

What To Do If Severe Patients Fail To Respond

The most frequent reason for failure to respond to the protocol is lack of adherence to the dietary guidelines. Most patients will be eating too many grains and sugars, which disturb insulin physiology.It is important that patients adhere as strictly as possible to the guidelines.A small minority, generally under 15%, of patients will fail to respond to the protocol described above despite rigid adherence to the diet.These individuals should already be on the IV Clindamycin.

It appears that the hyaluronic acid, which is a potentiating agent commonly used in the treatment of cancer may be quite useful. It seems that hyaluronic acid has very little to no direct toxicity but works in a highly synergistic fashion when administered directly in the IV bag with the Clindamycin. Hyaluronic acid is also used in orthopedic procedures. The dose is generally from 2 to 10 cc into the IV bag. Hyaluronic acid is not inexpensive as the cost may range up to $10 per cc.One does need to exert some caution with its use as it may precipitate a significant Herxheimer flare reaction.

Patients will frequently have emotional traumas that worsen their illness. Severe emotional traumas can seriously impair the immune response to this treatment. A particularly useful and rapid technique called Neuro Emotional Technique (NET) can be used to resolve this problem. Practitioners using this technique can be found by calling the One Foundation 800-638-1411.

Anti-Inflammatories

The first non-aspirin NSAID, indomethacin was introduced in 1963. Now more than 30 are available. Relafen is one of the better alternatives as it seems to cause less of an intestinal dysbiosis. If cost is a concern, generic ibuprofen can be used. Unfortunately, recent studies suggest this drug is more damaging to the kidneys. One must be especially careful to monitor renal function studies periodically. It is important for the patient to understand and accept the risks associated with these more toxic drugs.

Unfortunately, these drugs are not benign. Every year, they do enough damage to the GI tract to kill 2,000 to 4,000 patients with rheumatoid arthritis alone. That is ten patients EVERY DAY. At any given time patients receiving NSAID therapy have gastric ulcers in the range of 10-20%. Duodenal ulcers are lower at 2- 5%. Patients on NSAIDs are at approximately three times greater relative risk for developing serious gastrointestinal side effects than are non-users.

Approximately 1.2% of patients taking NSAIDs are hospitalized for upper GI problems per year of exposure. One study of patients taking NSAIDs showed that a life-threatening complication was the first sign of ulcer in more than half of the subjects.

Celebrex has received much recent press due to its decreased toxicity to the gut. That is certainly a step in the right direction. Celebrex inhibits a specific type of prostaglandin and is called a COX2 inhibitor. A similar new drug introduced in 1999 is Vioxx. There was a report in early 1999 in the Proceedings of the National Academy of Science, which showed that these drugs might increase the risk of heart attack, stroke and blood clotting disorders. Researchers found that the drugs suppress production of prostacyclin, which is needed to dilate blood vessels and inhibit clotting. Earlier studies had found that mice genetically engineered to be unable to use prostacyclin properly were prone to clotting disorders. Anyone who is at increased risk of cardiovascular disease should steer clear of these two new medications. Ulcer complications are certainly potentially life-threatening,but, heart attacks are a much more common and likely risk, especially in older individuals.

Risk factor analysis helps to discriminate those that are at increased danger of developing these complications. Those associated with a higher frequency of adverse events are:

1. Old age
2. Peptic ulcer history
3. Alcohol dependency
4. Cigarette smoking
5. Concurrent prednisone or corticosteroid use
6. Disability
7. High dose of the NSAID
8. NSAID known to be more toxic

Studies clearly show that the non-acetylated salicylates are the safest NSAIDs. Celebrex and Vioxx likely cause the least risk for peptic ulcer. But as mentioned, they pose an increased risk for heart disease. Factoring these newer medications out would leave the following less toxic NSAIDs: Relafen, Daypro, Voltaren, Motrin, and Naprosyn. Meclomen, Indocin, Orudis, and Tolectin are among the most toxic or likely to cause complications. They are much more dangerous than the antibiotics or non-acetylated salicylates. One should run an SMA at least once a year on patients who are on these medications. One must monitor the serum potassium levels if the patient is on an ACE inhibitor as these medications can cause hyperkalemia. One should also monitor their kidney function. The SMA will also show any liver impairment that the drugs might cause.

These medications can also impair prostaglandin metabolism and cause papillary necrosis and chronic interstitial nephritis. The kidney needs vasodilatory prostaglandins (PGE2 and prostacycline) to counterbalance the effects of potent vasoconstrictor hormones such as angiotensin II and catecholamines. NSAIDs decrease prostaglandin synthesis by inhibiting cyclooxygenase, leading to unopposed constriction of the renal arterioles supplying the kidney.

One might consider the use of non-acetylated salicylates such as salsalate, sodium salicylate and magnesium salicylate (i.e., Salflex, Disalcid, or Trilisate). They are the drugs of choice if there is renal insufficiency. They have minimal interference with anticyclooxygenase and other prostaglandins.

Additionally, they will not impair platelet inhibition of those patients who are on every other day aspirin to decrease their risk for stroke or heart disease. Unlike aspirin, they do not increase the formation of products of lipoxygenase-mediated metabolism of arachidonic acid. For this reason, they may be less likely to precipitate hypersensitivity reactions. These drugs have been safely used in patients with reversible obstructive airway disease and a history of aspirin sensitivity.

They also are much gentler on the stomach then the other NSAIDs and are the drug of choice if the patient has problems with peptic ulcer disease. Unfortunately, all these benefits are balanced by the fact they may not be as effective as the other agents and are less convenient to take. One needs to push them to 1.5-2 grams bid and tinnitus is a frequent complication.

One should warn patients of this complication and explain that if tinnitus does develop they need to stop the drugs for a day and restart with a dose that is half a pill per day lower. They repeat this until they find a dose that relieves their pain and doesn't give them any ringing.

Prednisone

One can give patients with severe disease a prescription for prednisone 5 mg. They can take one of them a day if they develop a severe flare-up as a result of going on the antibiotics. They can use an additional tablet at night if they are in really severe flare. Explain to all patients that the prednisone is very dangerous and every dose they take decreases their bone density. However, it is a trade-off. Since they will only be on it for a matter of months, its use may be justifiable. This is the first medicine they should try to stop as soon as their symptoms permit.

Blood levels of cortisol peak between 3 and 9am. It would, therefore, be safest to administer the prednisone in the morning. This will minimize the suppression on the hypothalamic-pituitary-adrenal axis. Patients often ask the dangers of these medications. The most significant one is osteoporosis. Other side effects that usually occur at higher doses include adrenal insufficiency, atherosclerosis acceleration, cataract formation, Cushing's syndrome, diabetes, ulcers, herpes simplex and tuberculosis reactivation, insomnia, hypertension, myopathy and renal stones.

One also needs to be concerned about the increased risk of peptic ulcer disease when using this medicine with conventional non-steroidal anti-inflammatories. Persons receiving both of these medicines may have a 15 times greater risk of developing an ulcer.

If a patient is already on prednisone, it is helpful to give them a prescription for 1 mg tablets so they can wean themselves off of the prednisone as soon as possible. Usually one lowers the dose by about 1 mg per week. If a relapse of the symptoms occurs, than further reduction of the prednisone is not indicated.

Remission

The following criteria can help establish remission:

*A decrease in duration of morning stiffness to no more than 15 minutes
* No pain at rest
* Little or no pain or tenderness on motion
* Absence of joint swelling
* A normal energy level
* A decrease in the ESR to no more than 30
* A normalization of the patient's CBC. Generally the HGB, HCT, & MCV will increase to normal and their "pseudo"-iron deficiency will disappear
* ANA, RF, & ASO titers returning to normal

The natural course of rheumatoid arthritis is quite remarkable. Less than 1% of patients who are rheumatoid factor seropositive have a spontaneous remission. Some disability occurs in 50-70% of patients within five years after onset of the disease. Half of the patients will stop working within 10 years. This devastating natural prognosis is what makes the antibiotic therapy so exciting.

Approximately one third of patients have been lost to follow-up for whatever reason and have not continued with treatment. The remaining patients seem to have a 60-90% likelihood of improvement on this treatment regimen. That is quite a stark contrast to the numbers quoted above.

There are many variables associated with an increased chance of remission or improvement. The younger the patient is the better they seem to do. The more closely they follow the diet, the less likely they are to have a severe flare-up and the more likely they are to improve. Smoking seems to be negatively associated with improvement. The longer the patient has had the illness and the more severe the illness the more difficult it seems to treat.

If patients discontinue their medications before all of the above criteria are met, there is a greater risk that the disease will recur. If the patient meets the above criteria, one can have them to try to stop their anti-inflammatory medication once they start to experience these improvements. If the improvements are stable for six months, then discontinue the clindamycin. If the improvements are maintained for the next six months, one can then discontinue their Minocin and monitor for recurrences. If symptoms should recur, it would be wise to restart the previous antibiotic regimen.

Overall, nearly 80% of the patients do remarkably better with this program. Approximately 5% of the patients continued to worsen and required conventional agents, like methotrexate, to relieve their symptoms. Approximately 15% of the patients who started the treatment dropped out of the program and were lost to follow-up. The longer and more severe the illness, the longer it takes to cure. Smokers tend not to do as well with this program. Age and competency of the person's immune system are also likely important factors.

Dr. Brown successfully treated over 10,000 patients with this protocol. He found that significant benefits from the treatment require on the average one to two years. I have treated nearly over 1,500 patients and find that the dietary modification I advocate accelerates the response rate to several months. The length of therapy can vary widely. In severe cases, it may take up to thirty months for the patients to gain sustained improvement. One requires patience because remissions may take up to 3 to 5 years. Dr. Brown's pioneering approach represents a safer less toxic alternative to many conventional regimens and results of the NIH trial have finally scientifically validated this treatment.

Preliminary Laboratory Evaluation For Non-Rheumatologists

It is important to evaluate patients to determine if indeed they have rheumatoid arthritis. Most patients will have received evaluations and treatment by one or more board certified rheumatologists. If this is the case, the diagnosis is rarely in question and one only needs to establish some baseline laboratory data.

However, patients will frequently come in without having any appropriate workup done by a physician. Arthritic pain can be an early manifestation of 20-30 different clinical problems. These include not only rheumatic disease, but also metabolic, infectious and malignant disorders. These patients will require a more extensive laboratory analysis.

Rheumatoid arthritis is a clinical diagnosis for which there is not a single test or group of laboratory tests which can be considered confirmatory. When a patient hasn't been properly diagnosed, then one needs to establish the diagnosis with the standard Rheumatism Association's criteria found in the table at the end of the article.

One must also make certain that the first four symptoms listed in the table are present for six or more weeks. These criteria have a 91-94% sensitivity and 89% specificity for the diagnosis of rheumatoid arthritis. However, these criteria were designed for classification and not for diagnosis. One must make the diagnosis on clinical grounds. It is important to note that many patients with negative serologic tests can have a strong clinical picture for rheumatoid arthritis.

The metacarpophalangeal joints, proximal interphalangeal and wrists joints are the first joints to become symptomatic. In a way, the hands are the calling card of rheumatoid arthritis. If the patient completely lacks hand and wrist involvement, even by history, the diagnosis of rheumatoid arthritis is doubtful. Rheumatoid arthritis rarely affects the hips and ankles early in its course.

Fatigue may be present before the joint symptoms begin. Morning stiffness is a sensitive indicator of rheumatoid arthritis. An increase in fluid in and around the joint probably causes the stiffness. The joints are warm, but the skin is rarely red. When the joints develop effusions, the patients holds them flexed at 5 to 20 degrees as it is too painful to extend them fully.

The general initial laboratory evaluation should include a baseline ESR, CBC, SMA, U/A, and an ASO titer. One can also draw RF and ANA titers to further objectively document improvement with the therapy. However, they seldom add much to the assessment.

Follow-up visits can be every two months for patients who live within 50 miles, and every three to four months for those who live farther away. An ESR at every visit is an inexpensive and reliable objective parameter of the extent of the disease. However, one should run this test within several hours of the blood draw. Otherwise, one cannot obtain reliable and reproducible results. This is nearly impossible with most clinical labs that pick up your specimen at the office.

Inexpensive disposable ESR kits are a practical alternative to the commercial or hospital labs. One can then run them in the office, usually within one hour of the blood draw. One must be careful to not run the test on the same countertop as your centrifuge. This may cause a falsely elevated ESR due to the agitation of the ESR measuring tube.

Many patients with rheumatoid arthritis have a hypochromic, microcytic CBC. This is probably due to the inflammation in the rheumatoid arthritis impairing optimal bone marrow utilization of iron. This type of anemia does NOT respond to iron. Patients who take iron can actually worsen if they don't need it as the iron serves as a potent oxidant stress. Ferritin levels are generally the most reliable indicator of total iron body stores. Unfortunately it is also an acute phase reactant protein and will be elevated anytime the ESR is elevated. This makes ferritin an unreliable test in patients with rheumatoid arthritis.

Fibromyalgia

One needs to be very sensitive to this clinical problem when treating patients with rheumatoid arthritis. It is frequently a complicating condition. Many times, patients will confuse the pain from it with a flare-up of their arthritis. One needs to aggressively treat this problem. If this problem is ignored, the likelihood of successfully treating the arthritis is significantly diminished.

Fibromyalgia is a very common problem. Some experts believe that 5% of people are affected with it. Over 12% of the patients at the Mayo Clinic's Department of Physical Medicine and Rehabilitation have this problem. It is the third most common diagnosis by rheumatologists in the outpatient setting. Fibromyalgia affects women five times as frequently as men.

Signs And Symptoms of Fibromyalgia

One of the main features of fibromyalgia is the morning stiffness, fatigue, and multiple areas of tenderness in typical locations. Most patients with fibromyalgia complain of pain over many areas of the body, with an average of six to nine locations. Although the pain is frequently described as being all over, it is most prominent in the neck, shoulders, elbows, hips, knees, and back.

Tender points are generally symmetrical and on both sides of the body. The areas of tenderness are usually small (less than an inch in diameter) and deep within the muscle. They are often located in sites that are slightly tender in normal people. Patients with fibromyalgia, however, differ in having increased tenderness at these sites than normal persons. Firm palpation with the thumb (just past the point where the nail turns white) over the outside elbow will typically cause a vague sensation of discomfort. Patients with fibromyalgia will experience much more pain and will often withdraw the arm involuntarily.

More than 70% of patients describe their pain as profound aching and stiffness of the muscles. Often it is relatively constant from moment to moment, but certain positions or movements may momentarily worsen the pain. Other terms used to describe the pain are dull and numb. Sharp or intermittent pain is relatively uncommon. Patients with fibromyalgia often complain that sudden loud noises worsen their pain. The generalized stiffness of fibromyalgia does not diminish with activity, unlike the stiffness of rheumatoid arthritis, which lessens as the day progresses.

Despite the lack of abnormal lab tests, patients can suffer considerable discomfort. The fatigue is often severe enough to impair activities of work and recreation. Patients commonly experience fatigue on arising and complain of being more fatigued when they wake up then when they went to bed. Over 90% of patients believe the pain, stiffness, and fatigue are made worse by cold, damp weather. Overexertion, anxiety and stress are also factors. Many people find that localized heat, such as hot baths, showers, or heating pads, give them some relief. There is also a tendency for pain to improve in the summer with mild activity or with rest.

Some patients will date the onset of their symptoms to some initiating event. This is often an injury, such as a fall, a motor vehicle accident, or a vocational or sports injury. Others find that their symptoms began with a stressful or emotional event, such as a death in the family, a divorce, a job loss, or similar occurrence.

Pain Location

Patients with fibromyalgia have pain in at least 11 of the following 18 tender point sites (one on each side of the body):
1. Base of the skull where the suboccipital muscle inserts.
2. Back of the low neck (anterior intertransverse spaces of C5-C7).
3. Midpoint of the upper shoulders (trapezius).
4. On the back in the middle of the scapula.
5. On the chest where the second rib attaches to the breastbone (sternum).
6. One inch below the outside of each elbow (lateral epicondyle).
7. Upper outer quadrant of buttocks.
8. Just behind the swelling on the upper leg bone below the hip (trochanteric prominence).
9. The inside of both knees (medial fat pads proximal to the joint line).

Treatment Of Fibromyalgia

There is a persuasive body of emerging evidence that indicates that patients with fibromyalgia are physically unfit in terms of sustained endurance. Some studies show that cardiovascular fitness training programs can decrease fibromyalgia pain by 75%. Sleep is critical to the improvement. Many times, improved fitness will correct the sleep disturbance.

Allergies, especially to mold, seem to be another common cause of fibromyalgia. There are some simple interventions using techniques called Total Body Modification (TBM) 800-243-4826 or Neuro Emotional Technique (NET) 800-638-1411. These may be helpful in rapidly resolving the problem.

Exercise For Rheumatoid Arthritis

It is very important to exercise or increase muscle tone of the non-weight bearing joints. Experts tell us that disuse results in muscle atrophy and weakness. Additionally, immobility may result in joint contractures and loss of range of motion (ROM). Active ROM exercises are preferred to passive. There is some evidence that passive ROM exercises increase the number of WBCs in the joint. If the joints are stiff, one should stretch and apply heat before exercising. If the joints are swollen, application of ten minutes of ice before exercise would be helpful.

The inflamed joint is very vulnerable to damage from improper exercise, so one must be cautious. People with arthritis must strike a delicate balance between rest and activity. They must avoid activities that aggravate joint pain. Patients should avoid any exercise that strains a significantly unstable joint.

A good rule of thumb is that if the pain lasts longer than one hour after stopping exercise, the patient should slow down or choose another form of exercise. Assistive devices are also helpful to decrease the pressure on affected joints. Many patients need to be urged to take advantage of these. The Arthritis Foundation has a book, Guide to Independent Living, which instructs patients about how to obtain them.

Of course, it is important to maintain good cardiovascular fitness. Walking with appropriate supportive shoes is also another important consideration.

The Infectious Cause Of Rheumatoid Arthritis

It is quite clear that autoimmunity plays a major role in the progression of rheumatoid arthritis. Most rheumatology investigators believe that an infectious agent causes rheumatoid arthritis. There is little agreement as to the involved organism. Investigators have proposed the following infectious agents: Human T-cell lymphotropic virus Type I, rubella virus, cytomegalovirus, herpesvirus, and mycoplasma. This review will focus on the evidence supporting the hypothesis that mycoplasma is a common etiologic agent of rheumatoid arthritis.

Mycoplasmas are the smallest self-replicating prokaryotes. They differ from classical bacteria by lacking rigid cell wall structures and are the smallest known organisms capable of extracellular existence. They are considered to be parasites of humans, animals, and plants.

In 1939, Dr. Sabin, the discoverer of the polio vaccine, first reported a chronic arthritis in mice caused by a mycoplasma. He suggested this agent might cause that human rheumatoid arthritis. Dr. Thomas Brown was a rheumatologist who worked with Dr. Sabin at the Rockefeller Institute. Dr. Brown trained at John Hopkins Hospital and then served as chief of medicine at George Washington Medical School before serving as chairman of the Arthritis Institute in Arlington, Virginia. He was a strong advocate of the mycoplasma infectious theory for over fifty years of his life.

Culturing Mycoplasmas From Joints

Mycoplasmas have limited biosynthetic capabilities and are very difficult to culture and grow from synovial tissues. They require complex growth media or a close parasitic relation with animal cells. This contributed to many investigators failure to isolate them from arthritic tissue. In reactive arthritis immune complexes rather than viable organisms localize in the joints. The infectious agent is actually present at another site. Some investigators believe that the organism binding in the immune complex contributes to the difficulty in obtaining positive mycoplasma cultures.

Despite this difficulty some researchers have successfully isolated mycoplasma from synovial tissues of patients with rheumatoid arthritis. A British group used a leucocyte-migration inhibition test and found two-thirds of their rheumatoid arthritis patients to be infected with Mycoplasma fermentens. These results are impressive since they did not include more prevalent Mycoplasma strains like M salivarium, M ovale, M hominis, and M pneumonia.

One Finnish investigator reported a 100% incidence of isolation of mycoplasma from 27 rheumatoid synovia using a modified culture technique. None of the non- rheumatoid tissue yielded any mycoplasmas. The same investigator used an indirect hemagglutination technique and reported mycoplasma antibodies in 53% of patients with definite rheumatoid arthritis. Using similar techniques other investigators have cultured mycoplasma in 80- 100% of their rheumatoid arthritis test population.

Rheumatoid arthritis follows some mycoplasma respiratory infections. One study of over 1000 patients was able to identify arthritis in nearly 1% of the patients. These infections can be associated with a positive rheumatoid factor. This provides additional support for mycoplasma as an etiologic agent for rheumatoid arthritis. Human genital mycoplasma infections have also caused septic arthritis.

Harvard investigators were able to culture mycoplasma or a similar organism, ureaplasma urealyticum, from 63% of female patients with SLE and only 4% of patients with CFS. The researchers chose CFS as these patients shared similar symptoms as those with SLE, such as fatigue, arthralgias, and myalgias.

Animal Evidence for The Protocol

The full spectrum of human rheumatoid arthritis immune responses (lymphokine production, altered lymphocyte reactivity, immune complex deposition, cell-mediated immunity and development of autoimmune reactions) occurs in mycoplasma induced animal arthritis. Investigators have implicated at least 31 different mycoplasma species. Mycoplasma can produce experimental arthritis in animals from three days to months later. The time seems to depend on the dose given and the virulence of the organism.

There is a close degree of similarity between these infections and those of human rheumatoid arthritis. Mycoplasmas cause arthritis in animals by several mechanisms. They either directly multiply within the joint or initiate an intense local immune response. Mycoplasma produces a chronic arthritis in animals that is remarkably similar to rheumatoid arthritis in humans. Arthritogenic mycoplasmas cause joint inflammation in animals by many mechanisms. They induce nonspecific lymphocyte cytotoxicity and antilymphocyte antibodies as well as rheumatoid factor. Mycoplasma clearly causes chronic arthritis in mice, rats, fowl, swine, sheep, goats, cattle and rabbits. The arthritis appears to be the direct result of joint infection with culturable mycoplasma organisms.

Gorillas have tissue reactions closer to man than any other animal. Investigators have shown that mycoplasma can precipitate a rheumatic illness in gorillas. One study demonstrated mycoplasma antigens occur in immune complexes in great apes. The human and gorilla IgG are very similar and express nearly identical rheumatoid factors (IgM anti-IgG antibodies). The study showed that when mycoplasma binds to IgG it can cause a conformational change. This conformational change results in an anti-IgG antibody, which can then stimulate an autoimmune response.

The Science of Why Minocycline Is Used

If mycoplasma were a causative factor in rheumatoid arthritis, one would expect tetracycline type drugs to provide some sort of improvement in the disease. Collagenase activity increases in rheumatoid arthritis and probably has a role in its cause. Investigators demonstrated that tetracycline and minocycline inhibit leukocyte, macrophage, and synovial collagenase.

There are several other aspects of tetracyclines that may play a role in rheumatoid arthritis. Investigators have shown minocycline and tetracycline to retard excessive connective tissue breakdown and bone resorption while doxycycline inhibits digestion of human cartilage. It is also possible that tetracycline treatment improves rheumatic illness by reducing delayed-type hypersensitivity response. Minocycline and doxycycline both inhibit phosolipases which are considered proinflammatory and capable of inducing synovitis.

Minocycline is a more potent antibiotic than tetracycline and penetrates tissues better. These characteristics shifted the treatment of rheumatic illness away from tetracycline to minocycline. Minocycline may benefit rheumatoid arthritis patients through its immunomodulating and immunosuppressive properties. In vitro studies demonstrated a decreased neutrophil production of reactive oxygen intermediates along with diminished neutrophil chemotaxis and phagocytosis. Investigators showed that minocycline reduced the incidence of severity of synovitis in animal models of arthritis. The improvement was independent of minocycline's effect on collagenase. Minocycline has also been shown to increase intracellular calcium concentrations that inhibit T-cells.

Individuals with the Class II major histocompatibility complex (MHC) DR4 allele seem to be predisposed to developing rheumatoid arthritis. The infectious agent probably interacts with this specific antigen in some way to precipitate rheumatoid arthritis. There is strong support for the role of T cells in this interaction. Minocycline may suppress rheumatoid arthritis by altering T cell calcium flux and the expression of T cell derived from collagen binding protein. Minocycline produced a suppression of the delayed hypersensitivity in patients with Reiter's syndrome. Investigators also successfully used minocycline to treat the arthritis and early morning stiffness of Reiter's syndrome.

Clinical Studies

In 1970 investigators at Boston University conducted a small, randomized placebo-controlled trial to determine if tetracycline would treat rheumatoid arthritis. They used 250 mg of tetracycline a day. Their study showed no improvement after one year of tetracycline treatment. Several factors could explain their inability to demonstrate any benefits. Their study used only 27 patients for a one-year trial, and only 12 received tetracycline. Noncompliance could have been a factor. Additionally, none of the patients had severe arthritis. Patients were excluded from the trial if they were on any anti-remittive therapy.

Finnish investigators used lymecycline to treat the reactive arthritis in Chlamydia trachomatous infections. The study compared the effect of the medication in patients with two other reactive arthritis infections Yersinia and Campylobacter. Lymecyline produced a shorter course of illness in the Chlamydia induced arthritis patients, but did not affect the other enteric infections-associated reactive arthritis. The investigators later published findings that suggested lymecycline achieved its effect through non-antimicrobial actions. They speculated it worked by preventing the oxidative activation of collagenase.

Breedveld published the first trial of minocycline for the treatment of animal and human rheumatoid arthritis. In the first published human trial, Breedveld treated ten patients in an open study for 16 weeks. He used a very high dose of 400 mg per day. Most patients had vestibular side effects resulting from this dose. However, all patients showed benefit from the treatment. All variables of efficacy were significantly improved at the end of the trial. Breedveld concluded an expansion of his initial study and observed similar impressive results. This was a 26-week double-blind placebo-controlled randomized trial with minocycline for 80 patients. They were given 200 mg twice a day. The Ritchie articular index and the number of swollen joints significantly improved (p < 0.05) more in the minocyline group than in the placebo group.

Investigators in Israel studied 18 patients with severe rheumatoid arthritis for 48 weeks. These patients had failed two other DMARD. They were taken off all DMARD agents and given minocycline 100 mg twice a day. Six patients did not complete the study, three withdrew because of lack of improvement, and three had side effects of vertigo or leukopenia. All patients completing the study improved. Three had complete remission, three had substantial improvement of greater than 50% and six had moderate improvement of 25% in the number of active joints and morning stiffness.

Criteria For Classification Of Rheumatoid Arthritis

Morning Stiffness Morning stiffness in and around joints lasting at least one hour before maximal improvement is noted.

Arthritis of three or more joint areas At least three joint areas have simultaneously had soft-tissue swelling or fluid (not bony overgrowth) observed by a physician. There are 14 possible joints: right or left PIP, MCP, wrist, elbow, knee, ankle, and MTP joints.

Arthritis of hand joints
At least one joint area swollen as above in a wrist, MCP, or PIP joint

Symmetric arthritis
Simultaneous involvement of the same joint areas (as in criterion 2) on both sides of the body (bilateral involvement of PIPs, MCPs, or MTPs) is acceptable without absolute symmetry. Lack of symmetry is not sufficient to rule out the diagnosis of rheumatoid arthritis.

Rheumatoid Nodules
Subcutaneous nodules over bony prominences, or extensor surfaces, or in juxta-articular regions, observed by a physician. Only about 25% of patients with rheumatoid arthritis develop nodules, and usually as a later manifestation.

Serum rheumatoid factor
Demonstration of abnormal amounts of serum rheumatoid factor by any method that has been positive in less than 5% of normal control subjects. This test is positive only 30-40% of the time in the early months of rheumatoid arthritis.

Radiological Changes
Radiological changes typical of rheumatoid arthritis on PA hand and wrist X-rays, which must include erosions or unequivocal bony decalcification localized to or most marked adjacent to the involved joints (osteoarthritic changes alone do not count).

Note: Patients must satisfy at least four of the seven criteria listed. Any of criteria 1-4 must have been present for at least 6 weeks. Patients with two clinical diagnoses are not excluded. Designations as classic, definite, or probable rheumatoid arthritis is not to be made. 

Partial Bibliograpy