Homeopathic Treatment for Immune-Mediated Polyarthritis, by Sarah Stieg, DVM, MRCVS; Lisa Melling, DVM, CVH; Todd Cooney, DVM, CVH

ABBREVIATIONS
IMPA = Immune Mediated Polyarthritis
IPA = Idiopathic Polyarthritis
ANA = Antinuclear Antibody

Introduction:

Immune-mediated diseases are a frustrating and often elusive diagnosis for veterinarians. Clinical symptoms may wax and wane, diagnostics may be inconclusive, and invasive, costly tests such as joint and spinal taps may be required to reach a conclusive diagnosis. Allopathic treatment of immune-mediated disease is aimed at long term immunosuppression. In the treatment of immune-mediated polyarthritis, some of the drugs that are indicated to manage polyarthritis are the same drugs that are suggested as a potential cause of the illness. Alternatively, homeopathy provides an individualized approach that does not suppress the patient, but stimulates the immune system to heal the underlying cause of the disease. The homeopathic approach to autoimmune disease is to use the symptoms of the patient to find a medicine that stimulates the body to heal, thereby removing the need for the continuous use of immunosuppressant drugs. The following article will discuss polyarthritis, one of the many types of immune-mediated disorders, and how this condition may be treated successfully with homeopathy.

Immune-MediatedPolyarthritis:

Polyarthritis is a condition in which 2 or more joints are inflamed. This may be sub-categorized as infectious or immune-mediated, the latter of which will be the focus of this discussion. IMPA may be further categorized as erosive (e.g. Rheumatoid arthritis) or non-erosive (e.g. idiopathic; Systemic lupus erythematosus), depending on whether the joint cartilage and bone are affected. Risk factors for IMPA include recent vaccination, treatment with sulfonamides or other antibiotics and infections. IMPA is a reactive disorder involving the deposition of immune complexes into the joints and may be associated with breeds such as the Akita, Weimaraner and Boxer (1). Idiopathic polyarthritis includes all forms of non-erosive IMPA that cannot be classified into other groups. IPA may be categorized as Types I-IV. IPA type I or uncomplicated IPA is the most common, accounting for 50% of all idiopathic cases in dogs, and is often considered a diagnosis of exclusion. Type II is the reactive form associated with infectious disease outside the joints. Type III is the entero/hepatopathic form associated with gastrointestinal disease, and type IV is the paraneoplastic form associated neoplasia outside the joints (2).

Patients with IMPA often have a history of stiffness after rest, intermittent lameness, and swelling, pain, and heat in one or more joints. The distal limbs are most often affected, and it is common to see bilateral symmetrical joint involvement. Systemic signs may be intermittent and include fever, lethargy, poor appetite and lymphadenopathy (3). Physical examination may reveal multiple, symmetric joint involvement with pain and swelling, often in the distal aspects of the limbs. Both carpi should be firmly flexed in patients exhibiting mild symptoms of pain to aid in diagnosis. In some cases, fever is present even in cases where joint pain is not observed.

Polyarthritis can be suspected with history and examination alone when there is fever, lethargy, lameness and the presence of painful or swollen joints, especially if the affected joints are in the distal aspect of the limbs. The diagnosis is confirmed by arthrocentesis and fluid analysis of multiple joints, specifically from the carpi and tarsi joints.

In order to definitively rule out other causes of joint inflammation, numerous other tests should be considered. Radiology of affected limbs distinguishes between neoplasia and polyarthritis, and identifies the presence of bone degeneration in erosive IMPA. Patients should be further tested for the presence of rheumatoid factor, and biopsy and culture of the synovium should be considered. In cases where no erosions are identified on radiographs and no recent vaccination has been administered, additional diagnostics may be necessary to identify the etiology. Infectious causes such as tick-borne diseases should be ruled out, and ANA titers may be helpful to support a diagnosis of immune-mediated disease (4).

Allopathic treatment depends on the etiology, but in cases of IPA type 1, a course of immunosuppressive corticosteroids is required for an average of 3–6 months, while maintenance therapy is important to prevent relapses due to the high rate of reoccurrence (2, 5). In cases where relapses occur, therapy may need to be life-long and may require multiple drugs to control the symptoms. Immunosuppressive drugs that are used for IPA type 1 include prednisone with or without azathioprine, cyclosporine, cyclophosphamide and leflunomide (2, 5).

What is Homeopathy?

Homeopathy means similar suffering, and centers on the Law of Similars, i.e. Similia Similibus Curantur or Like Cures Like. This universal natural law demonstrates that any substance which causes symptoms in a healthy organism can also cure those same symptoms in a diseased organism. The similar or homeopathic medicine stimulates the healing process by establishing an artificial disturbance which is similar to the natural disease. This stimulates the body to mount a response that results in becoming well or balanced again. The following corrections in health are the result of this stimulation of the life force, also known as Chi (Qi) in Chinese medicine. This process is simple in theory, but requires skill and experience to practice, particularly in complex chronic conditions such as immune-mediated diseases.

Homeopaths do not need to name diseases using allopathic nomenclature. The homeopathic understanding of disease views the patient as a whole, or as one disease which comprises the totality of symptoms of the patient: mental, emotional, and physical. Disease originates as an energetic disturbance of the vital force, resulting in symptoms, and eventually causing functional changes and pathological lesions. These resulting lesions, or disease processes, receive labels in allopathic nomenclature, such as arthritis. While allopathic nomenclature may be helpful to understand a clinical situation, general disease labels are not needed to find an accurate prescription as they do not describe what is unique to the individual patient. For example, “immune mediated polyarthritis” describes a disease condition, but does not tell us any detail of the individual case. In order to identify the precise homeopathic remedy to treat this patient from all the homeopathic remedies which treat this type of disease process, e.g. arthritis, the practitioner needs to examine that which makes this patient unique in order to find the corresponding medicine.

Classical homeopathic prescribing considers the total symptom picture of the patient, called the “totality of symptoms,” and attempts to find the simillimum, or the medicine that most closely matches the disease state of the patient. A single medicine is chosen, as well as potency (strength) and dosing schedule, with consideration for the vitality of the patient. Administering only a single medicine at a time, waiting, and then evaluating the patient’s response are critical elements which set classical prescribing apart from other approaches, such as the use of combination homeopathic products. The foundation and principles of the science of homeopathy are clearly laid out in Hahnemann’s classical text The Organon of the Medical Art (6). Homeopaths strive to follow these principles very closely, to achieve predictable, reliable results and the potential for the highest level of cure in the patient.

Evaluating the Patient:

The homeopath must carefully evaluate the changes that occur after each homeopathic prescription. The medicine stimulates the recovery of health over the time necessary for the body to repel the disease and repair damaged tissues. This can take weeks to months, depending on how long the illness has been present. Any treatment, homeopathic or allopathic, can result in 3 possible outcomes: cure, palliation, or suppression. It is important to understand how these differ and how to interpret patient response after a remedy.

Cure is a process, returning the body to health over a period of time. This is characterized by increased overall well-being while showing signs of physiological resistance to disease. There is ongoing reduction and resolution of disease symptoms and return of healthy behavior patterns. Curative responses will tend to follow Hering’s Law of Cure, which describes the return of health in the following order: from inward to out, from top to down and from most recent to oldest symptom (7). The mental/emotional sphere will improve first, followed by physical signs. For example, a dog with polyarthritis may have improved energy, appetite, and mobility while still having some joint swelling.

Palliation is the most common outcome of successful allopathic treatment and is seen as a rapid response or alleviation of some, but not all, physical symptoms. Little to no improvement in the mental/emotional aspect of the disease occurs, and the response does not follow Hering’s Law of Cure. A hallmark of palliation is quick return of symptoms when treatment is stopped, requiring more frequent repetitions of medicine in higher doses to maintain any improvement. Over time the case deteriorates, even when the medicine is continued. The patient eventually presents with crises of a new disease, often involving deeper and more vital organs.

Suppression is the worst possible outcome and can be caused by medicine, including incorrectly prescribed homeopathy, or surgery. One or more symptoms disappear rapidly and permanently in this situation. The medicine does not have to be repeated continually as in palliation. The patient’s well-being is not enhanced, and no improvement of mental/emotional aspects of the case occurs. As the disease deepens, usually a crisis appears, often after a period of apparent wellness, with the development of a new, more severe set of symptoms. Suppression of one form of illness, such as a bladder infection with antibiotics, may lead to a deeper degree of illness such as polyarthritis.

Curing the Patient:

Homeopathic treatment of polyarthritis is a gentle yet powerful method that always aims to cure the patient. Unlike allopathic treatments that require repetitive doses of drugs for many months, a homeopathic veterinarian will prescribe only a single dose of a medicine. To decide which medicine is to be used, the homeopath will create a list of the patient’s current signs in combination with the entire health history. The signs enable the selection of a homeopathic medicine that is an exact match to the patient’s lifetime of illness, enabling the ability to stimulate healing and return the patient to health as discussed previously. The goal of homeopathic treatment is always to cure the patient, without causing harmful effects or requiring repetition of medicine.

The following case demonstrates how the homeopathic treatment of IMPA successfully returned the patient to health and provided an increased quality of life without immunosuppressive medication or harmful side effects.

Case 1

Signalment:

Approximately 2-year-old male, neutered Boxer dog.

History:

In April 2012, the dog was found as a stray in Ireland and re-homed through a United Kingdom breed rescue organization to his current owner in England. At the time of adoption, he was very malnourished and could not support his weight on his hind legs.

The dog was neutered and received a full vaccination booster series (Canine Distemper, Adenovirus 2, Parainfluenza, Canine Parvovirus and 2 serovars of Leptospirosis) after adoption in April 2012, as required by the breed rescue organization. According to the owner, after his second vaccination he formed a “tennis ball” sized swelling at his injection site, which developed 2 “crater-like openings” and discharged yellow purulent material. This injection site reaction cleared over the course of 1 month with no treatment.

During the summer of 2012, the dog developed signs of atopy, exhibiting pruritus and skin eruptions of hives and small pimples. These signs were predominantly tempered with chlorpheniramine, once with cephalexin and a dexamethasone injection, and resolved when the season changed from summer to fall. He also had 3 episodes of bilateral catarrhal ear discharge which were treated with a combination ear drop medication, containing fusidic acid, framycetin, nystatin and prednisolone (a), for each episode. The local veterinarian noted that the dog had narrow ear canals. His atopy signs reappeared in March 2013, with the resumption of itching and chewing his paws.

The dog was being fed a homemade balanced raw diet since his adoption.

Presenting Complaint: Immune-Mediated Polyarthritis

Within 10 days of itching and chewing his paws in March 2013, he began exhibiting joint pain and the development of an intermittent, shifting lameness. His stifles and elbows appeared to be most affected. His pads began to crack and split open and the skin between his pads became very red. At his worst, he seemed to be lame on three legs (rotating which was worst), his joints were hot and swollen to touch, and he had a diminished appetite, refusing to eat in the mornings.

On physical exam on April 5, 2013, his local veterinarian appreciated swollen stifle joints, crepitus of the affected joints, cracking of his digital pads and a temperature of 39.3 C (102.7 F). A complete blood screen and urinalysis were performed and results were found to be within normal limits. The client declined further diagnostic evaluation. A tentative diagnosis of immune-mediated polyarthritis was made and treatment was initiated by the local veterinarian with an injection of dexamethasone and oral prednisolone (25mg q 12 h). While his lameness started to diminish, the dog developed multiple side effects of the prednisolone including polyuria, polydypsia, panting and tachycardia. These side-effects were intolerable to his owner and the prednisolone was discontinued after less than 2 weeks. The owner tried nutritional supplementation with shark cartilage and flax oil to minimal effect, as well as a product containing transfer factor which actually resulted in a worsening of his signs and thus was discontinued.

The dog presented on August 28, 2013, for homeopathic treatment of suspected immune-mediated polyarthritis. His signs had been continuous for over 5 months, and he was currently chewing his feet, had cracked pads and an intermittent, shifting lameness. His owner remarked that his left front paw always seemed to be worse, and he would often be non-weight bearing on the left hind (though he could be non-weight bearing on other limbs). Some days he would almost tiptoe on his front feet, unable to walk on rough terrain like gravel, and was hardly able to do any exercise, while other days he appeared almost sound. If approached to touch his paws, he would yelp and pull away. His behavior had deteriorated since he had been unwell to being “miserable, disinterested, looking fed up, and wanting to be left alone.” Previously, the dog was a very happy, playful, affectionate Boxer once he had settled from adoption.

Physical exam appreciated mucus discharge from both eyes; erythematous chin; muscle spasms in the lumbar region, right worse than left; crepitus in the right stifle, elbow and carpus; all pads dry and cracked, some cracks deep and wet; interdigital erythema; and mildly swollen nail beds. His gait analysis observed: left elbow abducted, head nod on the right fore, and lack of engagement of the left stifle (flexion, extension) with the left hind moving predominantly from the hip. At trot, all abnormalities at walk were accentuated, and he was primarily weight-bearing on the right limbs in all gaits.

Further options for diagnosis were discussed with his owner, including radiographs, repeating a full blood profile, serology for Lyme Disease, ANA and Rheumatoid Factor, and arthrocentesis of affected joints. The client declined further invasive testing at the time but consented to repeat blood work and serology. A complete blood profile was again found to be within normal limits and the serology for Lyme Disease, ANA, and Rheumatoid factor were all negative. This ruled out Lyme disease which is the most likely infectious cause of polyarthritis in the UK, but the negative results for ANA and Rheumatoid factor did not definitely rule out IMPA. No further diagnostic clarification could be obtained without further invasive diagnostics or a general anesthetic and radiographs. At this time, the patient was given the diagnosis of suspected IPA Type 1.

Homeopathic Assessment and Analysis:

Diagnostic terminology is helpful for communicating to other veterinarians, but does not provide enough specific information necessary for homeopathic treatment. The whole case must be analyzed to include the patient’s previous medical history and any characteristics which make this case unique from other patients with the same diagnosis.

The primary affinities of this case were in the joints and the skin. The dog suffered from a vaccination reaction and had never been well since being in a severely malnourished state at the time of his adoption. His joints were intermittently swollen, hot and painful and demonstrated crepitus upon range of motion. His pads were extremely dry and were cracking. His history of atopy signs included increased ear wax/catarrh, mucoid ocular discharge, pruritus and urticaria.

On further questioning, the dog was noted to be noise-sensitive, startling easily at any unexpected loud noises. On adoption, he took over 1 month to bond with his owners and displayed signs of fear-aggression toward strangers. After 1.5 years he still displayed anxiety with strangers. While he no longer barked aggressively, if approached he would cower, shy away from touch, and potentially bolt.

Once the key symptoms and characteristics of a case are identified, they are translated into rubrics to prepare for analysis. A rubric is an “abbreviated symptom,” cataloged in a repertory, which is followed by a list of homeopathic medicines that have been shown to produce this symptom in a trial or proving or have cured this symptom in a patient clinically. The medicines in each rubric are graded in relation to the intensity of the indication for the symptom listed. The analysis (Figure 1) (utilizing Kent’s Repertory (b) and Radar (c) repertory software) was obtained by translating the key signs of this patient into fitting rubrics.

FIGURE 1. HOMEOPATHIC ANALYSIS: (Using Radar (b) Repertory Software)

Silica (Sil) was selected as the best fitting medicine for the case due to its affinities for abscesses post-vaccination, malnourished states, noise sensitivity and anxious/startling behavior, diseases of the bone and cartilages, chronic arthritic and rheumatic afflictions and skin complaints such as dry cracked finger tips (8).

Sil was administered in a single dose of 200C potency on September 11, 2013. Within the first week, his owner noticed his general mood was much improved; he seemed happier, became more comfortable walking and began playing with other dogs. By 7 days post remedy, his owner reported that he was like his old self again, wanting affection and cuddling and with no signs of depression.

Two days post remedy administration, he had had a day of very intense paw-chewing followed by lessening of this chewing and then commencement of healing of the cracks on his pads. During the first week, a curative medicine will often produce a reaction-response, called a counter-action, in which a symptom briefly flares, such as this patient’s paw-chewing, and then all symptoms steadily improve/resolve.

Over the next few weeks, his generalized stiffness and paw-chewing gradually decreased as his energy and playfulness steadily increased. The lameness disappeared completely 3 weeks post remedy, and only mild inconsistent stiffness remained with occasional licking of his paws rather than chewing.

One month post-treatment, he displayed minor generalized stiffness only on a few occasions after playing hard with other dogs. He was hardly licking his paws, but the skin around his pads was still red.

By 3 months post-treatment his owners reported he was like a normal dog again: active, playful, and showing signs of increasingly confident behavior (e.g. standing up for himself with other dogs, coping better with strangers and accepting them more quickly, and not startling as easily). His owner only noted 1 day of stiffness in the previous month, most likely from over-exercise and rough play. No crepitus, heat or swelling was appreciated in any joint. His pads were completely healed. While licking his paws was still occurring, predominantly in the mornings, this was not observed to occur every day. He also exhibited a regular small amount of mucoid eye discharge.

At this point in time, the dog’s deeper signs of polyarthritis had resolved, and his remaining signs were of mild atopy. The dog was demonstrating a curative response to Sil by his mental well-being and physical energy improving first, and his physical signs following Hering’s Law of Cure in their resolution (e.g. his deeper and most recent signs resolving first).

At the end of December 2013, the dog had a flare of discharge and inflammation in his right ear and a bloom of dandruff. This brief return of historic signs only lasted for 1 day. In general, during the process of cure old symptoms that were previously treated in a suppressive manor will return briefly for a few hours to a few days, and following their resolution, the patient will continue on to further improvement. This brief reappearance of previous suppressed symptoms followed by the patient continuing on to improved heath is called a return of old symptoms and should not be treated as this is a sign that the patient is responding curatively to their homeopathic medication. This dog continued to improve throughout January and February of 2014, displaying only minor ocular mucus and licking his paws and his owner described him as having become a “bomb-proof dog” that could be taken everywhere.

At the end of February 2014, one of the senior dogs in the home passed away. The deceased dog and the patient had been very bonded since the patient’s adoption, and after his death, the patient seemed depressed and inappetant. Three weeks later, he had improved in his depression, but started exhibiting a flare of his older signs: increased licking of his paws, erythematous interdigital skin, increased ocular discharge of creamy mucus, generalized dandruff, chin redness, minor stiffness and lethargy in the evenings.

The dog had suffered from a mental/emotional shock after losing his primary pack-mate. This type of acute trauma can disturb the vital force of the patient causing their chronic case progression to be interrupted. This dog, however, still demonstrated that he was progressing in a curative manner, as his signs did not return to pre-homeopathic treatment state, but rather primarily remained in the sphere of his atopy symptoms (more external disease signs, e.g. skin, eye discharge, etc.) with minor stiffness. This dog had 6 months of progressive improvement from initial treatment before this acute shock, thus Sil was repeated in a single dose of a higher potency, 1M, on March 17, 2014.

The dog displayed a counter-action to the medicine again during the first 4 days after the homeopathic medicine was repeated. He slept more, had an increase in stiffness, paw-licking and associated erythematous interdigital skin, and clear watery ocular discharge. These signs gradually diminished over the first week and the dog returned to his normal very happy and playful self again.

Over the next 3 months, the dog’s allergy signs diminished despite entering the high pollen counts of spring and early summer. He also began to fill out his frame with increased muscle mass, and his owner noted his appetite had improved and he began asking for more food.

On June 23, 2014, the dog had an acute interruption to his treatment. He went on a day trip to the seaside and drank an exceptional amount of seawater, becoming acutely ill on returning home that night. He was nauseous, persistently vomiting, and became dehydrated over the next 24 hours. He was treated with the homeopathic remedy Nux vomica 200C and his signs completely resolved after 3 doses over a period of 8 hours.

If a homeopathic patient needs acute emergency treatment as in this case, treatment must be provided to stabilize the patient. Once the acute crisis is settled, the patient may need a repetition of their homeopathic medicine for their chronic disease treatment to return the patient to their previous state of balance. Thus, the practitioner will observe the patient coming due for a repetition of their homeopathic medicine sooner than otherwise expected.

This patient did very well post-salt water toxicity until September 2014. He started intensely licking his paws causing mild erythema, seemed mildly stiff in his hind-end during the evenings, was avoiding walking on gravel, and was irritable with other dogs. Since the dog had an acute interruption and his signs still fit Sil (Sil patients can be irritable and irascible when aroused) (8), the same potency was repeated and a single dose of Sil 1M was given on September 5, 2014.

Within 24 hours after the Sil 1M, the dog’s behavior was observed to return to his normal sweet and playful nature. During the first week, a counter-action was noted. His right ear flared producing dark brown discharge, but when cleaned with a gentle ear cleaner, no further discharge was produced. After 3 weeks, all paw-licking and stiffness had resolved, and the dog was happily walking on any terrain.

From early September to the end of November 2014, the dog has continued to improve, with his owner noting that he has been well since repeating his remedy. His ears have remained clean. He has no eye discharge and no paw-licking or chewing except minor self-grooming. He is extremely active and playful, accompanying his owner daily in her dog-walking business, covering a minimum of 12 miles every day, enjoying off-lead free running with other large-breed dogs. His chin is still slightly erythematous and will continue to be monitored.

The previous 15 months of treatment have demonstrated that the dog’s health, strength and vitality have all increased over time, moving him from a deeper more destructive disease process of polyarthritis to his previously mild atopy signs. This patient is not considered completely cured at this point in time, as he is still demonstrating mild chin erythema, thus his case requires continued monitoring for signs that an additional prescription may be needed. However, this case does provide an excellent example of how skilled homeopathic prescribing offers a simple and elegant treatment approach to the curative treatment of polyarthritis.

ENDNOTES

a. Canaural, Dechra Veterinary Products, Shrewsbury, Shropshire, England.
b. Kent, J.T. Repertory of the Homeopathic Materia Medica. B. Jain Publishers (P) Ltd. New Delhi, India. 2007.
c. Radar Repertory Program, Release 10.5.002. Archibel Homeopathic Software. Assesse, Belgium. 2009.

REFERENCES

1) Cote, E. Polyarthritis. In: Clinical Veterinary Advisor, Dogs and Cats, 2nd ed. Mosby, Elsevier, St. Louis, MO; 2011: pp. 894-896.

2) Kohn, B. Update on canine immune-mediated polyarthritis. Proc. World Small Animal Veterinary Association, Oct 14-17, 2011, Jeju, Korea.

3) Kiss, CM. Recognizing and treating canine immune-mediated polyarthritis in dogs. DVM360 Magazine Vet Med; March 1, 2011.

4) Davies, C, Shell, L. Common Small Animal Diagnoses; an Algorithmic Approach. WB Saunders Company, Philadelphia, PA; 2003: pp. 32.

5) Johnson, KC, Mackin, K. Canine Immune-mediated polyarthritis: Part 2: Diagnosis and treatment. J Am An Hosp Assoc. 2012;48:72-81.

6) Hahnemann, S. In: Organon of the Medical Art, 6th ed, Brewster- O’Reilly, W. (ed.) Birdcage Books, Palo Alto, CA; 1996: pp. 141.

7) Vithoulkas, G. The Science of Homeopathy, 5th ed. Grove Press, New York, NY; 2009: pp. 231.

8) Murphy, R. Nature’s Materia Medica, 3rd ed. Lotus Health Institute, Blacksburg, VA; 2006: pp. 1502-1512.