Episode 49: Rheumatoid Arthritis with Dr. Melissa McNamara

Q&A with a Paleo Rheumatologist

Finding a rheumatologist who combines paleo principles with functional medicine to address root causes, and conventional medicine to control symptoms when necessary, feels very much like finding a unicorn. One of my blog readers let me know about Dr. Melissa McNamara, who practices in the Bay Area of California but also consults with people worldwide. She took time out of her busy schedule to share her treatment philosophy, when it comes to rheumatoid arthritis (RA).

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Show Notes

• Intro (0:00)
• Thank You to our Podcast Sponsor – Paleo on the Go (1:38)
  • A frozen meal delivery service, they have a large menu of items for the paleo autoimmune protocol (AIP).
  • Use the code PHOENIX for 10% off your first order.
• Meet Dr. McNamara (2:29)
  • She received her medical degree from the University of Florida and her Rheumatology fellowship through UCLA.
  • She has a private practice in San Ramon, California, called the Arthritis and Rheumatology Center. However, she also consults with people around the world. Contact her office for more information.
  • When she started her practice, she treated RA from a conventional medicine perspective, focusing on suppressing the immune system rather than looking for root causes. When a patient approached her about the possibility of dietary healing, instead of dismissing that patient, she started researching the idea further. This led to a complete shift in her treatment paradigm. Now trained in functional medicine as well, she treats patients from both points of view.
• Gluten-Free as the Starting Place for RA Treatment (7:17)
  • For patients who are willing, she starts them on a 3-month gluten-free trial. She does a muscular-skeletal ultrasound and a doppler ultrasound to the affected joints at the start and end of the 3-months, to assess effectiveness. With prescription medication, the hope is to see 20% improvement in that period of time. Dr. McNamara has seen gluten-free give some patients as much as 50% improvement.
• RA Autoimmune Spectrum (12:23)
  • Dr. McNamara sees RA as having a spectrum of severity.
  • At the mildest side is a positive rheumatoid factor and some joint pain, but no fluid pockets or signs of inflammatory arthritis. Many people are told this is a “false positive” for the rheumatoid factor. Dr. McNamara sees it as early detection, showing you are at risk of manifesting RA and it’s a good place to take steps for prevention.
  • At the other end of the spectrum is RA diagnosis: (1) arthritis in multiple joints with fluid pockets (2) usually affecting the hands, wrists and feet, although other joints can be involved as well (3) arthritis appearing on both sides of the body (4) present for more than 6 months (5) usually accompanied by a positive rheumatoid factor (although not always).
• What Rheumatoid Arthritis Does to the Body (16:18)
  • RA causes an inflammatory cascade within the body that focuses especially on the joints, leading to high levels of pain, and if left unchecked – disability.
  • However, the inflammation also affects the rest of the body, and systemic inflammation increases the risk for heart disease and cancer.
• Conventional vs Alternative Tests for RA Activity (20:50)
  • For RA diagnosis, most rheumatologists test for positive rheumatoid factor and anti-ccp antibodies. Dr. McNamara does as well. However, she tests for individual rheumatoid factors in addition to the combined rheumatoid factor that is more typically ordered. She has seen the individual markers elevated where the combined came back negative.
  • Most rheumatologists track CRP and ESR to measure bodywide inflammation, but these can be normal even when inflammation is present. Dr. McNamara tracks 12 additional inflammation markers through the Vectra DA blood test.
  • Most rheumatologists use x-rays to track joint damage. Dr. McNamara uses musculoskeletal ultrasound and doppler ultrasound. X-rays offer just a few views of a joint, whereas ultrasound can offer a 180-degree view. The ultrasound can catch bone erosions sooner. It also measures fluid pockets (an active sign of inflammation), and has no radiation exposure whereas x-rays do.
• Are Joint Erosions Permanent or Can They Be Reversed? (25:28)
  • If an erosion is 2ml or greater, it’s probably permanent. But Dr. McNamara has seen smaller erosions reverse and the bone rebuild. Ultrasound allows her to catch erosions when they are small enough to reverse the process.
• Dr. McNamara’s Dietary Protocol for Autoimmune Healing (26:20)
  • While not all of her patients are interested, she does recommend diet as part of her RA treatment plan. She starts people with less restrictions first, only adding more if they don’t get results with the first steps:
  • Step 1: Go gluten-free. Dr. Alessio Fasano has shown that gluten causes leaky gut, and leaky gut needs to be present for autoimmune disease to develop. I interviewed him in Episode 32 of this podcast.
  • Step 2: Go rice-free. Since rice contains arsenic, and heavy metal toxicity can interfere with autoimmune healing, she recommends removing rice from the diet altogether. For more information on white rice – the pros and cons – read this article: What’s Up With White Rice?
  • Step 3: Limit intake of all forms of sugar and high-glycemic foods.
  • Step 4: Go dairy-free.
  • Step 5: Go grain-free.
  • Step 6: She doesn’t believe most people need to do the complete paleo autoimmune protocol. In her practice, she doesn’t see much difference between paleo and AIP in terms of results – with one exception. She does recommend people eliminate nightshades and then reintroduce them one at a time, to test for tolerance. Her paleo autoimmune recommendations are more in line with the Wahls Protocol.
• Alternative Medications for Rheumatoid Arthritis (40:46)
  • Low-Dose Naltrexone: She has seen it help patients with pain. Her only reservation is that there is limited research on its long-term impact on the body or the disease process. She expects the downside is minimal, but she wants more data.
  • Low-Dose Antibiotics: Research has shown that this is an effective disease-modifying treatment. Her only concern is that antibiotics cause leaky gut. However, every medication is a matter of weighing the risks vs. benefits and she has patients who respond very well to this protocol.
  • Medical Marijuana: She only recommends topicals or edibles. Data shows clearly that smoking and vaping marijuana is carcinogenic. There is no question that it can help pain for some people, but she hasn’t seen it affect the disease process itself. It also causes heartburn in some patients, which she finds concerning.
• Functional Medicine Interventions (47:49)
  • Dr. McNamara tests and treats a wide variety of things that can affect autoimmune expression, and it can take time to address all of these layers. (Which can explain why sometimes we don’t respond to diet and/or medication alone.):
  • Hormone Balance
  • Adrenal Fatigue
  • SIBO
  • Gut Dysbiosis
  • Gut Infections
  • Nutrient Malabsorption
  • Lyme Disease
  • MTHFR Mutation
  • Checking for Other Autoimmune Diseases
  • Pre-Diabetes
  • Vitamin Deficiencies
  • Heavy Metal Toxicity
• The Role of Conventional Medication (54:48)
  • While Dr. McNamara’s goal is to help people reduce and/or eliminate their need for conventional medication, there are times when medication is necessary.
  • If a new patient is presenting with extreme pain, they aren’t going to have time for the functional medicine to work, so medication is an appropriate first step.
  • Other times, a patient has tried both diet and functional medicine but is still showing signs of inflammation and disease activity that can damage the joints. Medication is the right choice then also.
  • Dr. McNamara doesn’t see medication as a life sentence. It can be helpful either short or longterm. She likes her patients to commit to medication for at least a year to get their disease under control, before trying to reduce it. They can work on functional medicine during that year as well, to treat the root causes in the background.
  • While her hope is to eventually get most of her patients off medication, that has only happened for a small minority at this point.
• Is Remission Possible? (59:11)
  • Absolutely. Remission doesn’t just happen one day. It’s a process that happens slowly over time, and functional medicine is key to that.
  • Dr. McNamara has a high number of patients in her practice who are in remission, and she measures that by having no swollen joints at all. Some of these patients are on medication and some aren’t.
  • She can’t think of one patient who has diligently pursued the healing of root causes, who still has an out-of-control disease process. This is very different than when she first started her practice and could only treat people with medication alone.
• Outro (58:45)
  • Dr. Melissa McNamara is accepting new patients and does consult with people worldwide. Visit her website for more information: ImmunologyGlobal.com.
  • Eileen (your podcast host) is the author of multiple books, written to help people thrive with autoimmune disease. Learn more on the Books Page.
  • If you like this podcast, follow or subscribe through your favorite podcast app. You can also subscribe to Eileen’s biweekly newsletter.
  • Check out the entire archive of podcast episodes.

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