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7 Best Supplements for Arthritis

You may believe that once you get arthritis in a joint, there’s nothing you can do about it.

That’s probably what you saw happening to your grandparents. As they aged, the body they had became an accumulation of nothing but injuries, scars and pain.

Every time they moved, their movement was restricted – and you may have watched some of them become disabled because of knee arthritis, shoulder arthritis or arthritis plus bursitis in the hip.

Most likely, your grandparents with arthritis may have gone to the grave with arthritis. It never went away.

Why Your Joints Scream When You Have Arthritis

Things are different now. The reasons why joints hurt when there’s an underlying arthritis condition have become known in this day and age of information.

Diagram Of Normal Joint Versus Joint With Arthritis

Here are a few of them:

  • As we age, our stem cells decrease in number. Stem cells regenerate tissues, including cartilage, bone, tendons and ligaments but if the cell turnover in these tissues is low, no progress can be made in the health of the tissues. Consequently, the arthritis and pain experienced worsens over time.
  • A poor diet – one that is similar to the standard American processed food diet – is high in omega 6 fats and low in omega 3 fats. The omega 6 fats create plenty of inflammation in the body – and joints with ongoing disease are one of the main places the inflammation attacks. In one study, small amounts of omega 3 fats in a high fat diet were enough to mitigate injury-induced osteoarthritis and significantly enhanced wound repair. (5)
  • A poor diet is also low in vitamins and minerals. Many vitamins and minerals – calcium, magnesium, pantothenic acid, vitamin D, vitamin A, vitamin C, and vitamin E, as examples play an important role in joint health. If you’re missing any of the nutrients joints need, then you become susceptible to arthritis and other joint disorders.
  • The wrong types of prostaglandins are created in the body, when the wrong types of fats are consumed. Not only can you have an imbalance of omega 6 to omega 3 fats but also you can eat far too many fats that generate free radicals or prostaglandins that cause inflammation. This means you will wake up the next day with more pain in your joints. (5)
  • Lack of complete healing of injuries when they occur also is a reason why arthritis can easily set in to joints.
  • Food sensitivities can release inflammatory compounds that accumulate in the joints and in any weakened areas of the body.

Hidden Truth About Arthritis

What you may not have had a chance to learn about arthritis yet is that someone can have an advanced case of arthritis that is very obvious on x-rays but produces very little pain. They may get along fine during their day and movement may be minimally restricted.

I learned this firsthand when I saw patients who fit this description to the letter. They were actually in my office for other reasons, not arthritis.

This gives us a clue that if we change our diet in some major ways to hit the different reasons why inflammation can run rampant in the body, then we can affect our own arthritis pain on a day-to-day level.

It means there’s a lot of hope for those with arthritis.

Different Types of Arthritis

The two main types of arthritis are osteoarthritis and rheumatoid arthritis. This doesn’t mean there aren’t other forms of arthritis. There are.

Gouty Arthritis

Diagram Of Gout Arthritis

You could have gouty arthritis, a type of joint disorder where painful crystals form in the joint and cause disability. Gouty arthritis is commonly seen in the big toe but it may be found in other joints.

However, again, the underlying diet changes and supplement changes you make are what lower the frequency of gout attacks.

One of the main culprits of gout attacks is high fructose corn syrup (HFCS), and this is why even children younger than 15 years old are being diagnosed with gouty arthritis.

The kids drink far too many beverages that contain the manmade sugar, as well as plenty of foods that are processed and packaged with HFCS as a primary ingredient.

In fact, it would be good for you right now to check your cupboard stashes of food and see which ones contain this arthritis-causing ingredient.

Psoriatic Arthritis

There’s also a type of arthritis called psoriatic arthritis. It’s one that shows up as arthritis in the joints and also a rash called psoriasis. This is the fish scale type of rash; the one that gets silvery tones to the rash as well as it can be quite red.

It can spread to different parts of the body, and when it does, the person doesn’t want anyone to even catch a glimpse of the rash.

Osteoarthritis

Diagram Of Osteoarthritis

Now back to the two main types of arthritis – osteoarthritis and rheumatoid arthritis – so that you understand these as well.

The word, “osteoarthritis” is composed of “osteo” and “arthritis”.  It means inflammation of the bone and joint. In an injured joint, the damaged part of the bone may end up closing down the joint space.

The purpose of the joint space is to cushion the joint during motion. Thus, with less joint space between two bones, bones can start to wear on each other. This causes inflammation and erosion of the joint space.

That’s when you need high nutrition to get the repair process going. One nutrient is not enough – you need ALL of them in order to heal completely.

Osteoarthritis usually occurs to one-sided joints. This means that it can occur in your left knee but not the right, your right wrist but not the left, or your left hip and not the right. This is because the injury was to one side, not both.

However, it’s certainly possible that if you are active in sports, you would potentially injure both knees, feet, or hips. The difference is that the arthritis disease process may be at different stages in the joints.

What Causes Osteoarthritis?

Some of the possible types of injuries that can cause osteoarthritis are ones you may not generally consider:

  • Direct blow or trauma to the joint, such as in a work injury or sports injury
  • Direct blow or trauma to a joint from a car injury or head injury
  • Repetitive motion injuries such as ones where you are repeating the same motion at work 20 or 40 hours a week. (Any number of hours could cause osteoarthritis as long as it’s repetitive.)
  • Obesity (4)
  • Poor arches in your feet. When you have poor arches in your feet, your foot bones collapse and don’t support your feet. This then leads to your knees misaligning, which causes wear and tear on certain parts of the knee. If left untreated for longer periods of time, the misalignment then causes a misalignment in the hips, then in the lumbar vertebrae and finally the neck. You could actually end up with headaches because your feet aren’t right!
  • Poor shoes that don’t support your feet.
  • Muscle imbalances are one additional cause of osteoarthritis. If one muscle is pulling on a joint in a direction more than it should, an imbalance will occur, exposing a part of the joint that can become injured.

Kinesiologists are the type of healthcare professional that can do an excellent job in diagnosing what muscle imbalances someone has.

Chiropractors also are excellent, as are some top level athletic trainers.

Symptoms of Osteoarthritis

The symptoms of osteoarthritis are generally the following:

  • pain when the person wakes up
  • the pain relieves itself after the person starts moving around, although it may never go away completely
  • a feeling of heat in the joint
  • a feeling of stiffness in the joint
  • restricted range of movement in the joint

Rheumatoid Arthritis

Diagram Of Rheumatoid Arthritis

Rheumatoid arthritis is a lot different than osteoarthritis although it has one thing in common – painful joints! However, the pain of a rheumatoid joint is usually a lot greater than the pain of osteoarthritis arthritis.

Osteoarthritis is nagging pain that can become great. Rheumatoid arthritis pain is very severe pain that can become relentless.

That’s why a lot of patients with rheumatoid arthritis are on steroids to tamper the inflammation.

Why People Get Rheumatoid Arthritis

Rheumatoid arthritis is believed to be caused by a few different things:

  1. It could be genetic. This is obvious when children as young as 5 years old end up with a diagnosis of rheumatoid arthritis.
  2. It could be bacterial or microbial in nature. Microbes can cause joint disorders and become systemic, wreaking havoc with the whole body.
  3. It could be an autoimmune disorder. I recall one of my first patients who had food sensitivities that were clearly related to the joint damage of her disabling rheumatoid arthritis. Unfortunately, she wouldn’t give up the tomatoes, eggplant, and wheat because her family was Italian even though she saw distinct improvement that was rapid when she first eliminated the foods related to her sensitivities.
  4. It could be a combination of these causes plus nutritional or unknown causes (8).

Symptoms of Rheumatoid Arthritis

The symptoms of rheumatoid arthritis include:

  • joints that are affected bilaterally
  • joints that turn bright red, are inflamed and hurt badly
  • disability because of the joint disease
  • joint deformity, such as the wrist, fingers, and knees start bulging at places they shouldn’t bulge
  • symptoms come on at different times, not necessarily in the morning

Both types of arthritis can cause disability but the disability is always greater with rheumatoid arthritis because of the deformities in the joints.

7 Most Helpful Supplements for Arthritis

What natural herbs & supplements would be the best for you to take for arthritis?

Obviously the answer has to be tailored to your individual needs and nutritional status as well as health history.

One Egyptian researcher went so far as to state that the majority of nutraceuticals studied possess beneficial effects toward chronic inflammatory diseases. He believes this is true because food is a rich source of antioxidants and anti-inflammatory constituents (26).

However, a review of different clinical research studies tells us what arthritis supplements are making progress for a lot of patients. Let’s find out about a few of them right now.

Omega-3s

Omega 3 Fatty Acids

During the past three decades, there have been several clinical trials of how fish oil, containing omega-3 fatty acids affects rheumatoid arthritis and osteoarthritis. (1)

There have been 20 clinical trials in rheumatoid arthritis, and 16 of them showed significant improvements.

Four clinical trials were done on osteoarthritis, and three of them exhibited significant improvements in at least one clinical parameter tested. (1)

How does omega-3 fight arthritis?

The way fish oil supplements and omega-3 fats work is suppressing the production of cytokines that cause inflammation, creating a more anti-inflammatory state. (1)

You Have to Eat Healthy Fats

Chinese researchers reported in 2015 that a low ratio of omega 6 fats compared to omega 3 fats – which means a good healthy fat consumption pattern – reduces arthritis in rats by suppressing enzymes called matrix metalloproteinase 13 found in the chondrocyte (cartilage) cells (7).

Benefit is Pain Relief

Denmark scientists combed the research for evidence of studies on fish oil supplements and their ability to reduce pain as well. They found 30 clinical trials that recorded complete data on pain. Rheumatoid arthritis patients had significant effects from the omega 3 on their pain. (3)

Another Benefit is Halting Degeneration of the Cartilage

Studies on dogs with arthritis in Thailand have shown that the DHA and EPA found in omega-3 in fish oil and krill oil stop cartilage degradation.

It does this by significantly lowering levels of sulfated glycosaminoglycans and preserving uronic acid and hydroxyproline content. They downregulated genes that destroyed the cartilage and upregulated genes that regenerated cartilage. (2)

When omega-3 supplements were added to 1500 mg glucosamine supplements daily in 177 patients with moderate to severe hip or knee osteoarthritis over 26 weeks, great results were seen.

There was a decrease in morning stiffness and pain in the hips and knees by 48.5% to 55.6% from the combination of the supplements compared to 41.7% to 55.3% in the glucosamine alone group (6).

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Protein Intake (Whey protein or collagen)

Protein Powders

In Denmark, doctors tested the protein metabolism of muscles in 13 rheumatoid arthritis patients compared to healthy people without rheumatoid arthritis.

They found that the rate of protein synthesis in the muscle was different from normal in those with arthritis.

The doctors also found that protein intake could stimulate the rate of muscle synthesis in those with arthritis, and it would do this more than in those who are healthy.

Physical exercise also stimulated muscle synthesis, and if exercise was combined with protein the response in the body equaled the normal rate of protein synthesis in healthy individuals (9).

Related

Branched Chain Amino Acids (BCAAs)

Branched chain amino acids are a group of three different amino acids that have a particular chemical structure that other amino acids don’t have.

The BCAA include leucine, isoleucine and valine. BCAAs plus the other 17 amino acids that are building blocks for protein are ones that must be provided by your diet for you to sustain life.

The amino acid leucine is important for muscles to grow. It enhances muscle protein synthesis and increases the amount of strength the muscle has (10).

BCAAs are also important for good joint function in frail and pre-frail elderly people requiring long-term care.

Japanese researchers put elderly individuals on an exercise program that they weren’t used to – 3 sets of exercises at 30% maximum contraction for five different body parts, one set of aerobic exercise and one set of balance training.

You might think this amount would be enough to kill them! However, it was designed only to make them stronger. The researchers gave 6 grams BCAAs or placebo 10 minutes before starting exercise.

Those who received the supplement were 10% stronger in lower limb muscle strength on the leg press and knee extension and better balance ability (16).

BCAAs can naturally be found in eggs, meat and dairy products. They are also found in dietary supplements, ones that may be taken by athletes and non-athletes, those who are sick and those who are healthy.

What Happens When You Take BCAAs?

In one study performed in Japan, researchers followed 15 young men who exercised and took BCAA at different times of the day.

The participants performed 30 repetitions of exercise with their non-dominant arm, which emphasized eccentric contractions. Eccentric contractions are more difficult than concentric.

For example, a concentric movement is curling a weight with your wrist and forearm toward your shoulder while an eccentric movement is holding the weight and slowly bringing it back towards the starting position.

The Japanese researchers found that supplementation before exercise was more beneficial to delayed onset muscle soreness and exercise-induced damage. This study shows us that the best time to take BCAA is before damage occurs or before any type of exercise (14).

How Do Amino Acids Differ in Those With or Without Arthritis?

There’s a difference in amino acid profiles in those with rheumatoid arthritis compared to those without the disease. When arthritis patients fasted for 7 days in a hospital setting, their amino acid levels were monitored.

They had higher levels of taurine, glutamate, aspartate, glycine, 1-methyl histidine, isoleucine and arginine. Smaller levels of increase were seen in leucine, methionine, serine, threonine, cysteine, and citrulline.

The increase of sulfur-containing amino acids may have been because of greater glutathione breakdown; the change in the branched amino acids suggests that rheumatoid arthritis patients react to valine like other patients who have muscle-wasting diseases (12).

What About Those Who Are Critically Ill?

BCAAs are especially important for critically ill patients, reports professors at Rutgers University in New Jersey.  When someone is critically ill – and this includes those with rheumatoid arthritis – inflammation occurs throughout the whole body.

This changes carbohydrate, protein and energy metabolism. When these changes persist for too long, the body loses lean body mass, multiple organs start to fail and eventually death occurs.

Nutritional supplementation in these cases can offset the severe loss of protein, and BCAAs may be especially beneficial.

How Are They Metabolized?

BCAAs are metabolized in two major steps, one that involves muscle first and then the liver. The BCAA are involved in protein translation, insulin signaling, and oxidative stress after infections and injury (15).

Scientists collaborating from Des Moines University, the Imperial College in London, the Pasteur Institute in Rome, and the Queen Mary University of London reported in 2017 in a medical journal that the enzymes that affect the metabolism of branched chain amino acids work inside macrophages.

The macrophages are the immune system’s “Pac men” that scavenge up microbes and waste matter that needs to be removed from the body to prevent infection and inflammation. These amino acids reduce the severity of arthritis and kidney disease in animal models (11).

Osteoarthritis patients may also have alterations in the metabolism and profiles of amino acids, report Chinese researchers. The scientists concluded in the Amino Acids journal in 2016 that some amino acids have the potential to act as immunomodulators, working against inflammation in the joints. (13).

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Vitamin D

Sources Of Vitamin D

Patients with rheumatoid arthritis are notorious for their low levels of vitamin D. In one Moroccan study of children with the disease, 75% of them were deficient in this important vitamin (18).

In Brazil, scientists discovered that there are effects of vitamin D on the immune system. The vitamin enhances the ability of the macrophages and monocytes to fight infection in the body.

Patients with rheumatoid arthritis are often given treatments that suppress the immune system, leaving the joints open for attack by microbes.

In fact, researchers agree that the lower the vitamin D levels in a rheumatoid arthritis patient, the more severe the clinical manifestations of the disease will be (22, 23).

Scientists also confirmed that neuropathic pain – pain that is caused by disease and affects the nervous system causing odd sensations like heat, cold, prickly sensations, and more – was 5.8 times higher among rheumatoid arthritis when their vitamin D levels were less than 20 ng/ml than in patients barely into the normal reference range of 30 ng/mL (24).

It’s not only rheumatoid arthritis where this is true.

In Thailand, researchers found that low vitamin D levels are common in patients with osteoarthritis, too. Fifty-nine percent of their 175 patients with knee arthritis had deficient levels.

Yet, after supplementation, for six months, the vitamin D levels were only at 32 ng/mL, just barely into the normal range. During the 40,000 IU vitamin D supplementation per week period, the patients’ pain level and quality of life improved significantly. Their grip strength also improved (21).

Vitamin D supplementation is effective in improving the stiffness, pain and function of those with osteoarthritis in the knee, according to Chinese researchers analyzing studies totaling 1136 patients with the condition (25).

However, they commented that there’s a lack of evidence proving that it prevents the progression of the condition.

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Vitamin C

Sources Of Vitamin C

In an old laboratory study from the late 1970s, two researchers discovered and reported in the medical literature that high levels of vitamin C eradicated arthritic cells.

It didn’t cause negative effects on normal cells. However, interestingly, aspirin reduced the number of both normal cells and arthritic cells by about 20% as compared to controls (27).

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Multivitamins

Multivitamins For Women

If you had an 83.5% chance of improving your joint symptoms, would you try a therapy that included a multivitamin, elimination of milk, wheat, rye, barley, oats, sugar and yeast, and added supplements of omega 3 fats and curcuminoids and probiotics?

One hundred four patients agreed in Helsinki, Finland (19) – and 88.6% of them reported distinct benefits; one of them being a lesser need for conventional medications. Side effects were few and mild.

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Multiminerals

Multiminerals

Although studies are in no way complete for assessing the effects of all minerals on the health of those who have arthritis, some things are known.

Researchers at the Albany Medical College reported in 1996 (20) that patients with rheumatoid arthritis are deficient in magnesium and zinc if the Recommended Daily Allowance levels are considered. If the typical American diet is considered, then copper will also be low.

Researchers from multiple universities worldwide reported in the Journal of Trace Elements in Medicine and Biology journal in 2018 that selenium levels may play a role in the connection between cardiac disease and rheumatoid arthritis. When selenium levels rise, there appeared to be a decrease of ESR and CRP levels, both which are inflammatory markers (28).

Selenium is one of several antioxidants the body uses for good health and to combat oxidative stress.

Trace elements such as copper and zinc also fulfill this function in the body. This is why scientists in the U.K. designed a study to see whether or not trace element status is involved in the development of rheumatoid arthritis or the progression of it over time (29).

Comparing about 100 patients with rheumatoid arthritis to another hundred healthy individuals, they found that low levels of zinc and selenium and high levels of copper were associated with the presence of rheumatoid arthritis.

Another study showed a significant correlation between selenium levels and the number of joints affected with active arthritis as well as the limitation of movement in those joints (30). Other scientists believe that the lower levels of selenium – and zinc – in patients with rheumatoid arthritis are probably due to the disease and mediated by inflammatory-like substances (31).

Osteoporosis is common in Chinese patients with rheumatoid arthritis. This suggests multiple vitamin and mineral deficiencies.  One study of 304 patients with rheumatoid arthritis found that supplementation with calcium and vitamin D decreased the risk of developing bone density issues in patients with the disease (17).

In fact, 20% of the group that took supplements experienced low bone density after four years of supplementation, compared to 64% of the group that did not take supplements at all.

Where to Go From Here

These are only a few of the many supplements you can start taking that could be beneficial if you have arthritis. However, they are some of the best.

If you begin taking omega 3 fats in the form of fish oil, protein supplements such as whey, and branched chain amino acids, you’ll most likely see a big difference.

Test it yourself and keep your own records on what works for you. The answers are waiting for you to discover them!

Keep Reading: 10 Natural Supplements That Boost the Immune System

ⓘ Any specific supplement products & brands featured on this website are not necessarily endorsed by Donna.

References
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  2. Buddhachat, K., et al. Effects of different omega-3 sources, fish oil, krill oil, and green-lipped mussel against cytokine-mediated canine cartilage degradation. In Vitro Cell Dev Biol Anim 2017 May;53(5):448-457. https://www.ncbi.nlm.nih.gov/pubmed/28078500
  3. Senftleber, N.K., et al. Marine oil supplements for arthritis pain: a systemic review and meta-analysis of randomized trials. Nutrients 2017 Jan 6;9(1). https://www.ncbi.nlm.nih.gov/pubmed/28067815
  4. Perea, S. Nutritional management of osteoarthritis. Compend Contin Educ Vet 2012 May;34(5):E4. https://www.ncbi.nlm.nih.gov/pubmed/22581724
  5. Wu, C.L., et al. Dietary fatty acid content regulates wound repair and the pathogenesis of osteoarthritis following joint injury. Ann Rheum Dis 2015 Nov;74(11):2076-83. https://www.ncbi.nlm.nih.gov/pubmed/25015373
  6. Gruenwald, J., et al. Effect of glucosamine sulfate with or without omega-3 fatty acids in patients with osteoarthritis. Adv Ther 2009 Sep;26(9):858-71. https://www.ncbi.nlm.nih.gov/pubmed/19756416
  7. Yu, H., et al. A low ratio of n-6/n-3 polyunsaturated fatty acids suppresses matrix metalloproteinase 13 expression and reduces adjuvant-induced arthritis in rats. Nutr Res 2015 Dec;35(12):1113-21. https://www.ncbi.nlm.nih.gov/pubmed/26675329
  8. Lopez, H.L. Nutritional interventions to prevent and treat osteoarthritis. Part I. focus on fatty acids and macronutrients. PM R 2012 May;4(5 Suppl):S145-54. https://www.ncbi.nlm.nih.gov/pubmed/26675329
  9. Mikkelsen, U.R., et al. Preserved skeletal protein anabolic response to acute exercise and protein intake in well-treated rheumatoid arthritis patients. Arthritis Res Ther 2015 Sep 25;17:271. https://www.ncbi.nlm.nih.gov/pubmed/26407995
  10. Martin, N.R.W., et al. Leucine elicits myotube hypertrophy and enhances maximal contractile force in tissue engineered skeletal muscle in vitro. J Cell Physiol 2017 Oct;232(10):2788-2797. https://www.ncbi.nlm.nih.gov/pubmed/28409828
  11. Papathanassiu, A.E., et al. BCAT1 controls metabolic reprogramming in activated human macrophages and is associated with inflammatory diseases. Nat Commun 2017 Jul 12;8:16040. https://www.ncbi.nlm.nih.gov/pubmed/28699638
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  13. Li, Y., et al. Alterations of amino acid metabolism in osteoarthritis: its implications for nutrition and health. Amino Acids 2016 Apr;48(4):907-14. https://www.ncbi.nlm.nih.gov/pubmed/26767374
  14. Ra, S.G., et al. Effect of BCAA supplement timing on exercise-induced muscle soreness and damage: a pilot placebo-controlled double blind study. J Sports Med Phys Fitness 2018 Nov;58(11):1582-91. https://www.ncbi.nlm.nih.gov/pubmed/28944645
  15. Mattick, J.S.A., et al. Branched-chain amino acid supplementation: impact on signaling and relevance to critical illness. Wiley Interdiscip Rev Syst Biol Med 2013 Jul-Aug;5(4):449-460. https://www.ncbi.nlm.nih.gov/pubmed/23554299
  16. Ikeda, T., et al. Effects and feasibility of exercise therapy combined with branched chain amino acid supplementation on muscle strengthening in frail and pre-frail elderly people requiring long-term care: a crossover trial. Appl Physiol Nutr Metab 2016 Apr;41(4):438-45. https://www.ncbi.nlm.nih.gov/pubmed/26963483
  17. Peng, J., et al. Bone mineral density in patients with rheumatoid arthritis and 4-year follow-up results. J Clin Rheumatol 2016 Mar;22(2):71-4. https://www.ncbi.nlm.nih.gov/pubmed/26906298
  18. Bouaddi, I., et al. Vitamin D concentrations and disease activity in Moroccan children with juvenile idiopathic arthritis. BMC Musculoskelet Disord 2014 Apr 1;15:115. https://www.ncbi.nlm.nih.gov/pubmed/24690195
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  24. Yesil, H., et al. Association between serum vitamin D levels and neuropathic pain in rheumatoid arthritis patients: A cross-sectional study. Int J Rheum Dis 2018 Feb;21(2):431-439. https://www.ncbi.nlm.nih.gov/pubmed/28857474
  25. Gao, X.R., Chen, Y.S., and Deng, W. The effect of vitamin D supplementation on knee osteoarthritis: a meta-analysis of randomized controlled trials. Int J Surg 2017 Oct; 46:14-20. https://www.ncbi.nlm.nih.gov/pubmed/28797917
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  28. Deyab, G., et al. Effect of anti-rheumatic treatment on selenium levels in inflammatory arthritis. J Trace Elem Med Biol 2018 Sep;49:91-97. https://www.ncbi.nlm.nih.gov/pubmed/29895378
  29. Sahebari, M., e al. Serum trace element concentrations in rheumatoid arthritis. Biol Trace Elem Res 2016 Jun;171(2):237-245. https://www.ncbi.nlm.nih.gov/pubmed/26450515
  30. Tarp, U., et al. Low selenium level in severe rheumatoid arthritis. Scand J Rheumatol 1985;14(2):97-101. https://www.ncbi.nlm.nih.gov/pubmed/4001893
  31. Onal, S., et al. Effects of different medical treatments on serum copper, selenium and zinc levels in patients with rheumatoid arthritis. Biol Trace Elem Res 2011 Sep;142(3):447-55. https://link.springer.com/article/10.1007%2Fs12011-010-8826-7

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