Rheumatoid Arthritis

By Mariano Garcia de Palau

Born in Barcelona, 17 February 1956. Graduated in medicine and surgery from the University of Barcelona in 1979. For 38 years has worked as an emergency physician in the area of occupational medicine. He became interested in cannabis by chance, and for the last 15 years has studied its therapeutic uses. He currently works at Kalapa Clinic, where he advises on treatments with cannabinoids, performs clinical work with patients and collaborates with different organisations and associations such as Catfac. He is a member of the Spanish Observatory for Medicinal Cannabis. He is a regular member of IACM.

Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disease. It is characterised by affecting multiple joints simultaneously and by the presentation of diverse general non-specific symptoms and manifestations in other parts of the body. Without proper treatment, in its advanced phases, the disease can result in major physical limitations and a marked deterioration in quality of life.

RA is typically manifested through pain, swelling and stiffness or difficulty in moving different large and small joints. In some cases, the joints affected follow a characteristic pattern. The general symptoms, which sometimes precede manifestations of the disease in the joints and tend to persist throughout its development, basically include general tiredness, malaise, slight fever, loss of appetite and loss of weight. Extra-articular manifestations —which normally occur after the disease is fully established— mainly affect the skin, blood vessels, heart, lungs, eyes and blood.

RA is much more frequent among women than men and tends to appear in elderly patients, although it can begin at any stage of life and can affect anyone, regardless of race, sex or occupation.

The most frequent initial symptom is morning stiffness (especially in the joints of the hands and feet), experienced after night-time rest. This entails considerable difficulty in moving the joints accompanied by pain. Morning stiffness may be accompanied by tiredness, fever, loss of appetite and muscle weakness (which sometimes appear weeks or months before the pain) as well as indications of inflammation of the joints — swelling, warmth and redness of the affected joints.

The course of the disease varies greatly; in some people, advance of the lesions stops spontaneously, whereas in others it continues throughout their lives. In the most common scenario, the disorder develops over many years or throughout the patient's entire life, alternating between periods of relative or complete calm and other periods –known as "flare-ups"– when symptoms are exacerbated. Flare-ups normally last a few weeks or even months.

During flare-ups, the joints affected become swollen and hot and are painful and difficult to move, especially on waking in the morning. Without proper treatment, these flare-ups tend to become more frequent and longer-lasting. As a result, the affected joints gradually lose mobility, with the appearance of very characteristic deformities which distinguish RA from other forms of arthritis. Without treatment, RA usually results in a significant deterioration in functionality and quality of life.

Treatment for RA consists of a series of general measures related to lifestyle, rest and exercise, combined with pharmacological therapy, in which a wide range of drugs may be used; in some cases, surgical intervention may be recommended. Unfortunately, there is still no cure for the disease. However, taken together, all the therapeutic measures currently available can alleviate the symptoms and improve the prognosis, with a very positive impact on the patient's quality of life.

The best therapeutic results are achieved with early diagnosis and when treatment is established in the initial phases of the disease.

Autoimmune diseases constitute a major group of illnesses. For reasons that are not fully understood, the immune system, responsible for defending the body erroneously identifies certain tissues as being foreign and reacts against them as if they posed a threat.

Cannabinoids and rheumatoid arthritis

Cannabinoids such as THC and CBD can be useful for treating rheumatoid arthritis. RA is an autoimmune disease and we know that cannabinoids act by modulating the activity of the immune system. When the immune system over-reacts and its activity increases, autoimmune diseases may occur. The immune system erroneously identifies normal structures and tissues in the body as being foreign and rejects them. This is what happens after a transplant, and it is why immunosuppressant drugs are administered to prevent the tissue or organ from being attacked and destroyed by the patient's own immune system.

Cannabinoids modulate the activity of the immune system. We know that the endocannabinoid system regulates activity of the immune system, and in autoimmune diseases, they have an immunosuppressive effect, reducing the activity of the system, and thus contributing to improvement in such pathologies.

Although cannabinoids are immunosuppressive, there is no evidence that already immunodepressed subjects (e.g. patients with HIV) suffer more opportunistic infections as a result of consuming cannabis. Indeed, cannabis is commonly used among HIV patients to alleviate symptoms, increase appetite and improve general quality of life.

Cannabinoids also have an analgesic effect which is mainly attributed to THC, but can be implemented by using different ratios of THC/CBD. By managing the relative proportions, it is possible to minimise the psychoactive effect of THC without reducing its analgesic effect.

In this way, the patient's activity will not be limited by psychoactive effects (which many find unpleasant). In RA, the analgesic effect is very important, since the essential problem is inflammation, which causes varying degrees of pain, moderate or severe in some cases.

When working with RA patients, it is also important to treat the inflammation with the fewest possible side effects. We know that corticoids can be effective in acute phases of the disease. Nonsteroidal anti-inflammatory drugs, or NSAIDs (aspirin, ibuprofen, diclofenac, indometacin, etc.) can also be used. However, nearly all these drugs are gastrolesive and in the medium term can result in metabolic overload in the liver. In addition, they inhibit the action of THC when administered with it.

Lifetime treatment with corticoids or NSAIDs should therefore not be considered, given their side effects.

In analgesic doses, cannabinoids have never posed a metabolic problem in the liver, which is where they too are metabolised. Similarly, no problem of renal excretion or toxicity has ever been detected with such treatments.

Patients suffering chronic pain may also suffer sleep alteration. In the case of RA, nocturnal pain may also prevent proper rest and the structuring of the different sleep phases. The result is that sleep is non-restorative. Cannabinoids can be of use in improving sleep quality. By using THC and CBD, it is possible to induce sleep quite effectively, determining the night-time dose with different proportions of THC/CBD.

Proper rest is very important and for many patients, it is the first problem that needs to be addressed. Without restorative rest, little improvement can be expected in the other symptoms.

Appetite loss can also be a problem for many patients. Small doses of THC administered half an hour before meals increase appetite and ensure the patient does not suffer pathological weight loss. For some patients, THC/CBD treatment improves appetite. However, in some cases, it may be necessary to resort to THC on its own, administered before meals.

Because the doses of THC involved are low (around 5 mg), there is no limiting psychoactive effect, given that CBD is also being taken, which minimises any such effect.

Mood alteration is another issue for some people with RA, a chronic autoimmune disease, for which treatments are currently only available for the symptoms (pain and inflammation), but not the underlying cause. In such cases, the anxiolytic and anti-depressant effect of CBD may be very useful.

One of the great advantages of using cannabinoids is that many different symptoms can be treated with the same family of molecules. This aids better tolerance and makes management easier for the doctor as well.

Because of their low toxicity, cannabinoids have no potentially serious toxic side effects. This is another reason why they may be very useful for RA patients. Nonetheless, it should be noted that, the results of studies in this area with RA patients have not been as satisfactory as hoped, although they have been very positive for some patients. It is also important to remember that treatment may require therapeutic tools, as well as pharmaceuticals.