ROMATOİD ARTRİTİN KLİNİK TEDAVİSİNDE KULLANILAN DİYET YAKLAŞIMLARININ DEĞERLENDİRİLMESİ

Yıl 2023, , 126 - 132, 03.01.2023

Merve Saraç Dengizek , Burcu Yeşilkaya

https://doi.org/10.18229/kocatepetip.845249

Öz

Romatoid Artit (RA), populasyonun %0.5-1.0’ini etkileyen sistemik inflamasyon, kalıcı sinovit ve diğer komorbiditelerle karakterize bir kronik, otoimmün bozukluktur. Uzun süreli aktif RA şiddetli eklem hasarı, ağrının engellenememesi, yaşam kalitesinde düşüşe neden olmaktadır. RA’nın etiyolojisi tam olarak anlaşılamamıştır ancak doğuştan gelen ve edinilmiş bağışıklık sistemlerinin tepkileri arasındaki etkileşimden kaynaklandığı düşünülmektedir. RA, kan dolaşımında Romatoid Faktör ve antisitrüline peptit antikotlarının varlığı ile karakterize edilmektedir. Ayrıca Romatoid artrit ile ilişkili immünitede bağırsak mikrobiyomunun önemi olduğu vurgulanmaktadır. Mikrobiyotadaki değişikliklerin, hastalığın riski ve şiddeti ile ilgili olduğu düşünülmektedir. Başta akciğerler, ağız mukozası ve gastrointestinal sistem olmak üzere üç bölge, mikrobiyotada görülen değişiklikler ile ilişkilendirilmiştir. RA'nın farmasötik tedavisi genellikle; ağrıyı ve inflamasyonu yönetmek için kullanılan steroidal olmayan anti-inflamatuar ilaçları (NSAID's) ve hastalığı yavaşlatarak ağrıyı azaltan anti-romatizmal ilaçları içerir. Ne yazık ki birçok hastada remisyon olasılığı düşük olmakla birlikte, ilaçlarla ilgili yaygın yan etkiler rapor edilmektedir. Hastalarda bazı çevresel ve yaşamsal değişikliklerin semptomları şiddetlendirdiği ve dolayısıyla RA’nın şiddetini etkilediği düşünülmektedir. Örneğin RA hastaları, kırmızı et, alkollü ve alkolsüz içecek tüketiminin semptomlarını kötüleştirdiğini; balık ve yaban mersini gibi besinlerin ise semptomlarını hafifletmeye yardımcı olduğunu ifade etmektedir. RA’nın semptomlarını yönetmek amacıyla; inflamasyonu azaltmada, antioksidan seviyelerini artırmada ve lipid profillerini iyileştirmede potansiyel diyet değişiklikleri önerilmektedir. Romatoid Artritin hem başlangıcında hem de hastalığın şiddetinde, diyetle ilgili meydana gelen antijenik yük ve gıda sensivitesinin rol oynadığı düşünülmektedir. Bunun yanında RA hastalarında kullanılan NSAID ilaçlar ile hastaların bağırsak mukozasının alerjenlere karşı daha geçirgen olduğu gösterilmektedir. Bu anlamda Eliminasyon diyeti, Akdeniz Diyeti, Vegan/vejetaryen Diyet yaklaşımı; Omega-3 yağ asidi, D vitamin ve probiyotik takviyesinin hastalık aktivitesini azalttığı düşünülmektedir. Bu derlemenin amacı, RA ile ilişkili semptomları azaltmak için kullanılan belirli diyet yaklaşımlarının ve besin takviyelerinin etkinliğini, literatürde bilimsel kanıtlara dayanarak değerlendirmektir.

Anahtar Kelimeler

Artrit Romatoid, Diyet yönetimi, Diyet, Akdeniz, Vejetaryen

AN EVALUATION OF DIETARY APPROACHES USED IN THE CLINICAL MANAGEMENT OF RHEUMATOID ARTHRITIS

Öz

Rheumatoid arthritis (RA) is a chronic autoimmune disorder characterized by systemic inflammation, persistent synovitis, and other comorbidities, that affects 0.5-1.0% of the overall population. Long-term active RA causes severe joint damage, disabling pain and diminished life quality. The etiology of RA is not accurately understood, but it is thought to be due to an interaction between the responses of the innate and acquired immune systems. RA is characterized by the presence of Rheumatoid Factor (RF) and anti citrullinated peptide antibodies in the blood circulation. Also the composition of intestinal the gut microbiome is claimed to be critical in immune responses associated with RA. Changes in the microbiota are thought to be related to the risk and severity of the disease. Three regions; primarily the lungs, oral mucosa and gastrointestinal tract have been associated with changes in the microbiota. Commonly, the pharmaceutical treatment of RA includes non-steroidal anti-inflammatory drugs (NSAIDs) that are used to manage the pain and inflammation associated with RA and disease-modifying anti-rheumatic drugs that reduces pain by slowing down the disease. Unfortunately, remission is not likely in many patients. Moreover, side effects related to drugs are commonly reported. Some alterations in the patients’ life and environment are thought to aggravate symptoms, thus influencing severity of RA. For example RA patients, the participants asserted that consumption of red meat, alcoholic and non-alcoholic beverages worsen their symptoms, while nutrients such as fish and blueberries help alleviate the symptoms. To manage the adverse effects of RA, particular dietary alterations are suggested to be effective in reducing inflammation, increasing antioxidant levels, and improving lipid profiles. Antigenic load and food intolerance are thought to play a role in both the onset of Rheumatoid Arthritis. Besides, it has been shown that the intestinal mucosa of the patients would have become more permeable to allergens due to long term NSAIDs use. In this sense, Elimination Diet, Mediterranean Diet, Vegan/Vegetarian Diet approach, Omega-3 Fatty acids, Vitamin D and probiotic supplementation is thought to reduce disease activity. The purpose of this review is to evaluate the efficiency of certain dietary approaches and supplements used for lessening the RA related symptoms, based on the scientific evidence found in the literature.

Anahtar Kelimeler

Dietary Management, Diet, Mediterranean, Vegaterian, Artrit Romatoid, Diyet yönetimi, Diyet, Akdeniz, Vejetaryen

Kaynakça

• 1. Gibofsky A. Overview of epidemiology, pathophysiology, and diagnosis of rheumatoid arthritis. Am J Manag Care.2014;18(13) :295-302.
• 2. Nikiphorou E, Norton S, Young A, et al. Association between rheumatoid arthritis disease activity, progression of functional limitation and long-term risk of orthopaedic surgery: combined analysis of two prospective cohorts supports EULAR treat to target DAS thresholds. Ann Rheum Dis. 2016;75(12): 2080-86.
• 3. Scott DL, Wolfe F, Huizinga TW. Rheumatoid arthritis. Lancet. 2010;376(9746):1094-108.
• 4. Malmström V, Catrina A, Klareskog L. The immunopathogenesis of seropositive rheumatoid arthritis: from triggering to targeting. Nat Rev Immunol. 2017;17:60–75.
• 5. Petersson S, Philippou E, Rodomar C, Nikiphorou E. The Mediterranean diet, fish oil supplements and Rheumatoid arthritis outcomes: Evidence from clinical trials. Autoimmun Rev. 2018;17(11):1105-14.
• 6. Malm K, Bremander A, Arvidsson B, Andersson M L, Bergman S, & Larsson I. The influence of lifestyle habits on quality of life in patients with established rheumatoid arthritis—A constant balancing between ideality and reality. Int J Qual Stud Health Well-being. 2016;11(1):30534-41.
• 7. Oliviero F, Spinella P, Fiocco U, Ramonda R, Sfriso P, Punzi L. How the Mediterranean diet and some of its components modulate inflammatory pathways in arthritis. Swiss Med Wkly 2015;145:4546-58.
• 8. Badsha H. Role of Diet in Influencing Rheumatoid Arthritis Disease Activity. Open Rheumatol J. 2018;12:19-28.
• 9. Sherman M P, Zaghouani H, Niklas V. Gut microbiota, the immune system, and diet influence the neonatal gut–brain axis. Pediatr Res. 2015;77(1-2):127-35.
• 10. Chow J, Tang H, Mazmanian SK. Pathobionts of the gastrointestinal microbiota and inflammatory disease. Curr Opin Immunol. 2011;23:473–80.
• 11. Firestein G S, McInnes IB. Immunopathogenesis of rheumatoid arthritis. Immunity. 2017;46(2):183-96.
• 12. Liu X, Zou Q, Zeng B, Fang Y, Wei H. Analysis of Fecal Lactobacillus Community Structure in Patients with Early Rheumatoid Arthritis. Curr Microbiol. 2013;67:170–6.
• 13. Alipour B, Homayouni‐Rad A, Vaghef‐Mehrabany E et al. Effects of L actobacillus casei supplementation on disease activity and inflammatory cytokines in rheumatoid arthritis patients: a randomized double‐ blind clinical trial. Int J Rheum Dis. 2014;17(5):519-27.
• 14. Schorpion A, Kolasinski SL. Can probiotic supplements improve outcomes in rheumatoid arthritis? Curr Rheumatol Rep. 2017;19(11):73-80.
• 15. Mohammed A T, Khattab M, Ahmed AM, et al. The therapeutic effect of probiotics on rheumatoid arthritis: a systematic review and meta-analysis of randomized control trials. Clin Rheumatol. 2017;36:2697–707.
• 16. Rudbane S M A, Rahmdel S, Abdollahzadeh S M, Zare M, Bazrafshan A, Mazloomi S. M. The efficacy of probiotic supplementation in rheumatoid arthritis: a meta-analysis of randomized, controlled trials. Inflammopharmacol. 2018;26:67–76.
• 17. Horta-Baas G, Romero-Figueroa MDS, Montiel-Jarquín A J, Pizano-Zárate M L, García-Mena J, Ramírez-Durán N. Intestinal dysbiosis and rheumatoid arthritis: a link between gut microbiota and the pathogenesis of rheumatoid arthritis. J Immunol Res. 2017;2017:1-13.
• 18. Jubair WK, Hendrickson JD, Severs EL, Schulz HM, Adhikari S, Ir D, et al. Modulation of inflammatory arthritis by gut microbiota through mucosal inflammation and autoantibody generation. Arthritis Rheumatol. 2018;70(8):1220-33.
• 19. Tedeschi SK, Frits M, Cui J, et al. Diet and Rheumatoid Arthritis Symptoms: Survey Results From a Rheumatoid Arthritis Registry. Arthritis Care Res (Hoboken). 2017;69(12):1920-25.
• 20. Forsyth C, Kouvari M, D'Cunha NM, et al. The effects of the Mediterranean diet on rheumatoid arthritis prevention and treatment: a systematic review of human prospective studies. Rheumatol Int. 2018;38(5):737-47.
• 21. Alwarith J, Kahleova H, Rembert E, et al. Nutrition interventions in rheumatoid arthritis: the potential use of plant-based diets. A review. Front Nutr. 2019;141(6):1-11.
• 22. Khanna S, Jaiswal KS, Gupta B. Managing rheumatoid arthritis with dietary interventions. Front Nutr. 2017;52(4):1-16.
• 23. O'connor Á. An overview of the role of diet in the treatment of rheumatoid arthritis. Nutrition Bulletin. 2014;39(1):74-88.
• 24. Lidén M, Kristjánsson G, Valtysdottir S, Venge P, Hällgren R. Self-reported food intolerance and mucosal reactivity after rectal food protein challenge in patients with rheumatoid arthritis. Scandinavian journal of rheumatology. 2010;39(4): 292-98.
• 25. Marsh K, Zeuschner C, Saunders A. Health implications of a vegetarian diet: a review. Am J Lifestyle Med. 2012;6(3):250-67.
• 26. Agarwal S. Newer nutritional basis in the management of rheumatoid arthritis. Electronic Physician. 2010;2:33-8.
• 27. Venetsanopoulou AI, Voulgari PV, Drosos AA. Fasting mimicking diets: A literature review of their impact on inflammatory arthritis. Mediterr J Rheumatol. 2020;30(4):201-6.
• 28. Wong M W, Yi C H, Liu T T, et al. Impact of vegan diets on gut microbiota: An update on the clinical implications. Tzu Chi Med J. 2018;30(4):200–3.
• 29. Naska A, Trichopoulou A. Back to the future: the Mediterranean diet paradigm. Nutr Metab Cardiovasc Dis. 2014;24:216–9.
• 30. Ingegnoli F, Schioppo T, Scotti I, et al. Adherence to Mediterranean diet and patient perception of rheumatoid arthritis. Complement Ther. Med. 2020;52:102519-23.
• 31. Porras M, Rada G, & Durán J. Effects of Mediterranean diet on the treatment of rheumatoid arthritis. Medwave. 2019;19(5):e7639.
• 32. Juturu V, Kremer J. Dietary Approaches and Alternative Therapies for Rheumatoid Arthritis. Curr Nutr Food Sci. 2010;6(4):240-55.
• 33. Jalili M, Kolahi S, Aref-Hosseini SR, Mamegani ME, Hekmatdoost A. Beneficial role of antioxidants on clinical outcomes and erythrocyte antioxidant parameters in rheumatoid arthritis patients. Int J Prev Med. 2014;5(7):835-40.
• 34. Lee Y H, Bae S C, Song GG. Omega-3 polyunsaturated fatty acids and the treatment of rheumatoid arthritis: a meta-analysis. Arch Med Res. 2012;43(5):356-62.
• 35. Park Y, Lee A, Shim SC, et al. Effect of n-3 polyunsaturated fatty acid supplementation in patients with rheumatoid arthritis: a 16-week randomized, double-blind, placebo-controlled, parallel-design multicenter study in Korea. J Nutr Biochem. 2013;24(7):1367-72.
• 36. Proudman SM, James MJ, Spargo LD, et al. Fish oil in recent onset rheumatoid arthritis: a randomised, double-blind controlled trial within algorithm-based drug use. Ann Rheum Dis. 2015;74(1):89-95.
• 37. Rajaei E, Mowla K, Ghorbani A, Bahadoram S, Bahadoram M, Dargahi-Malamir M. The Effect of Omega-3 Fatty Acids in Patients With Active Rheumatoid Arthritis Receiving DMARDs Therapy: Double-Blind Randomized Controlled Trial. Glob J Health Sci. 2015;8(7):18-25.
• 38. Zhu H, Deng FY, Mo XB, Qiu YH, Lei SF. Pharmacogenetics and pharmacogenomics for rheumatoid arthritis responsiveness to methotrexate treatment: the 2013 update. Pharmacogenomics. 2014;15(4):551-66.
• 39. Haque UJ, Bartlett SJ. Relationships among vitamin D, disease activity, pain and disability in rheumatoid arthritis. Clin Exp Rheumatol. 2010 ;28(5):745-7.
• 40. Souberbielle JC, Body JJ, Lappe JM, et al. Vitamin D and musculoskeletal health, cardiovascular disease, autoimmunity and cancer: Recommendations for clinical practice. Autoimmun Rev. 2010;9(11):709-15.
• 41. Lin J, Liu J, Davies ML, Chen W. Serum Vitamin D Level and Rheumatoid Arthritis Disease Activity: Review and Meta-Analysis. PLoS One. 2016;11(1):e0146351.
• 42. Hajjaj-Hassouni N, Mawani N, Allali F, et al. Evaluation of Vitamin D Status in Rheumatoid Arthritis and Its Association with Disease Activity across 15 Countries: "The COMORA Study". Int J Rheumatol. 2017;2017:1-8.
• 43. Buondonno I, Rovera G, Sassi F, et al. Vitamin D and immunomodulation in early rheumatoid arthritis: A randomized double-blind placebo-controlled study. PLoS One. 2017;5;12(6):e0178463.
• 44. Chandrashekara S, Patted A. Role of vitamin D supplementation in improving disease activity in rheumatoid arthritis: An exploratory study. Int J Rheum Dis. 2017;20(7):825-31.
• 45. Salesi M, Farajzadegan Z. Efficacy of vitamin D in patients with active rheumatoid arthritis receiving methotrexate therapy. Rheumatol Int. 2012;32(7):2129-33.
• 46. Vadell A K, Bärebring L, Hulander E, Gjertsson I, Lindqvist H M, & Winkvist A. Anti-inflammatory Diet In Rheumatoid Arthritis (ADIRA) a randomized, controlled crossover trial indicating effects on disease activity. Am J Clin Nutr. 2020;111(6):1203-13.
• 47. Philippou E, Petersson SD, Erodotou S, Giallouri E, Rodomar C, Nikiphorou E. Dietary intake, dietary interventions, nutrient supplements and rheumatoid arthritis: systematic review of the evidence. Proc Nutr Soc. 2019;78:1-21.
• 48. Küçükdeveci AA. Nonpharmacological treatment in established rheumatoid arthritis. Best Pract Res Clin Rheumatol. 2020;101482:1-15.
• 49. Smedslund G, Byfuglien MG, Olsen SU, Hagen KB. Effectiveness and safety of dietary interventions for rheumatoid arthritis: a systematic review of randomized controlled trials. J Am Diet Assoc. 2010;110(5):727- 35.