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| From Consumer Reports, January 2002 |
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JOINT REMEDIES
Glucosamine and Chondroitin
Supplements Appear to Ease Arthritis Symptoms and Possibly Fight the Disease Itself |
| Conventional treatments for osteoarthritis, the most common type of arthritis, leave a lot to be desired. Chronic use of oral drugs (both over-the-counter and prescription) that relieve pain and inflammation can have serious side effects. When pills don't work, the only major options that mainstream medicine offers are shots in the joint, which provide only temporary relief, or surgery. |
| The shortcomings of conventional medications have created fertile soil for the growth of alternative arthritis remedies, particularly glucosamine and chondroitin, whose efficacy is backed by a substantial amount of scientific research. First popularized by the 1997 best-seller "The Arthritis Cure," by Jason Theodosakis, M.D., these supplements racked up combined sales of $640 million in 2000, according to the Nutrition Business Journal, which tracks the supplement industry. |
| Glucosamine is a basic building block of the cartilage that cushions the joints, while chondroitin is a component of that cartilage; the body manufactures both. Studies have shown that glucosamine supplements (derived from shellfish shells) and chondroitin supplements (generally derived from cow cartilage) can each relieve arthritis pain and stiffness without the side effects of conventional analgesics. While the supplements work more slowly than standard medications, they produce longer lasting relief. |
| More importantly, some research suggests that glucosamine may slow the progression of the underlying disease. The best evidence of that possible benefit comes from a Belgian clinical trial published last year in The Lancet, a respected British medical journal. It found that glucosamine may reduce the incidence of serious progression by about 50 percent. That finding convinced the Arthritis Foundation, the leading nonprofit information and advocacy group for people with arthritis, to issue a statement last June calling the supplement "an appropriate treatment" for osteoarthritis. |
| Many physicians continue to reserve judgment. The American College of Rheumatology, the specialty group for physicians who treat arthritis, says it is awaiting the findings of a large study of glucosamine and chondroitin, funded by the National Institute of Health (NIH), before making specific recommendations. |
| TESTING THE SUPPLEMENTS |
| While the government enforces standardization of over-the-counter drugs by periodically checking whether they contain the labeled amounts, it does not do that for nutritional supplements. So consumers have almost no protection against inaccurate labeling or substandard preparations. "There's a real concern about the quality of the products that are out there," says Andrew Weil, M.D., the alternative medicine guru, who is professor of public health at the University of Arizona College of Medicine. Over the past several years, our tests have found that the amounts of the key ingredients in the supplements SAM-e, kava, saw palmetto, ginkgo biloba, echinacea, and ginseng can vary considerably from brand to brand and from the amounts listed on the labels. |
| The results for glucosamine and chondroitin were also mixed. Most of the products were reasonably well standardized, delivering at least 90 percent of the amount of glucosamine or chondroitin promised on the label, thereby meeting a new standard for the supplements proposed by the US. Pharmacopeia, which sets standards for drugs, and proposes them for supplements. But four products failed to meet that standard: |
| Now Double Strength Glucosamine & Chondroitin |
| ArthxDS Glucosamine Chondroitin |
| Solgar Extra Strength Glucosamine Chondroitin Complex |
| Now Chondroitin Sulfate |
| Two products recommended too few pills per day to supply the dose used in the successful clinical trials: |
| Solgar Extra Strength Glucosamine Chondroitin Complex |
| Twinlab CSA (Chondroitin Sulfate) |
| Several others listed the recommended number of pills as a range that permits consumers to take a dose that may be inadequate. |
| PAINFUL JOINTS |
| Osteoarthritis can strike any joint, but it's most common and debilitating in the hips and knees. In a healthy joint, a thick pad of cartilage protects each end of the facing bones. But injury or wear and tear, (particularly in people who have misaligned joints or who are obese, out of shape, or genetically predisposed) can eventually roughen and erode the cartilage, causing the characteristic symptoms of osteoarthritis: pain, stiffness, and, in many cases, inflammation. |
| About 21 million Americans have osteoarthritis, including 30 percent of women and 17 percent of men over age 60. "But osteoarthritis is not an inevitable result of aging," says John Klippel, M.D., Medical Director of the Arthritis Foundation. Nor does having the disease necessarily doom patients to unremitting or crippling pain and immobility. Osteoarthritis tends to be progressive and can be disabling, particularly if you lose so much cartilage that the bones start grinding together. But most arthritic joints will either remain stable for many years or worsen very gradually. Symptoms may ease or even disappear for long periods of time. |
| Nondrug measures can help stave off the disease in susceptible individuals and, once it develops, reduce reliance on medication and possibly slow its progression. Shedding extra pounds eases stress on weight bearing joints. While doctors used to warn arthritis patients not to put pressure on affected joints, clinical trials have clearly shown that a properly designed exercise regimen (including aerobics: low-impact but still weight-bearing, strengthening routines, and stretching) can ease pain and increase mobility. So can stabilizing devices such as braces and wedged insoles. |
| Cognitive behavioral approaches to stress control, and relaxation methods such as guided imagery, hypnosis, meditation, and biofeedback, can also ease arthritis pain, an NIH panel concluded. Acupuncture helps some people sometimes, though our review of the evidence found only weak support for its efficacy. But even with optimal nondrug measures, most people with osteoarthritis need to take pills: conventional medication, supplements, or both. |
| SUPPLEMENTAL RELIEF |
| The body uses glucosamine and chondroitin to build or maintain cartilage. So there is a theoretical basis to explain how the supplements might fight osteoarthritis (but probably not rheumatoid arthritis, a more severe but less common disease ion which cartilage damage plays a lesser role). Laboratory studies suggest that glucosamine, au amino acid, may stimulate production of cartilage building proteins. Other research suggests that chondroitin, a carbohydrate that's part of the cartilage, may inhibit production of cartilage destroying enzymes and fight inflammation, too. |
| Veterinarians have long used both supplements to treat osteoarthritis in animals, and a few well-designed studies back that approach. In humans, glucosamine and chondroitin have been studied and used in Europe for many years, where in some countries they're available only by prescription. More recently, mainstream U.S. researchers have begun paying attention to those supplements. In March 2000, for instance, the Journal of the American Medical Association published a review of 15 clinical trials of glucosamine or chondroitin, mostly from Europe. Overall, the researchers said, "It seems probable that these compounds do have some efficacy in treating osteoarthritis symptoms." |
| The best and longest study of either supplement so far is the Belgian trial of glucosamine published last year in The Lancet. The three year, double-blind clinical trial, involving 212 people with osteoarthritis, found that symptoms improved 20 to 25 percent in the glucosamine group, while they worsened slightly in the placebo group. The most striking finding showed up on x-rays of the knee. Narrowing of the joint space on x-rays indicates loss of cartilage; it's the key indicator of osteoarthritis progression. Serious narrowing occurred in only half as many patients taking glucosamine as in those receiving the placebo. |
| As for chondroitin, a recent analysis of the combined results of seven randomized, controlled trials indicated that the supplement may reduce osteoarthritis symptoms and improve function by an average of some 50% (though the study had flaws that may exaggerate the benefits). A number of published studies pitting either glucosamine or chondroitin against various medications have found that the drugs worked faster than the supplements. They also found that several months after treatment ended, the analgesic effects of the supplements remained stronger. |
| While both supplements apparently can help relieve osteoarthritis, no one knows whether glucosamine, chondroitin, or the two combined work best. Now a pivotal $14 million dollar study by the NIH's National Center for Complimentary and Alternative Medicine, and the National Institute of Arthritis and Muskuloskeletal and Skin Diseases is under way to answer that question. Final results are expected in March 2005. |
| None of the studies so far has found any serious side effects from either supplement. However, animal research has raised the possibility that glucosamine may worsen insulin resistance, a major cause of diabetes. So far, studies in humans have not substantiated that risk. Nevertheless, people with diabetes should monitor their blood-sugar level particularly carefully when using that supplement. There have been no reports of allergic reactions to glucosamine. But since it's made from shellfish shells, people who are allergic to seafood should use it cautiously, watching for reactions, or avoid it entirely. As for chondroitin, it can cause bleeding in people who have a bleeding disorder or take a blood-thinning drug. |
| The Arthritis Foundation has alerted members that there is "some risk" however small, that chondroitin made from cow cartilage originating in countries affected by bovine spongiform encephalopathy (BSE), or "mad cow disease" might be contaminated with the infective agent. There have been no reported cases of BSE resulting from supplement use. We contacted the manufacturers of all the chondroitin products we.tested, and received assurances along with documentation ranging from internal policies to import documents that their source material comes from non-BSE countries. Our medical consultants say that at present, the risk of getting BSE from chondroitin seems remote. |
| Note that two other supplements may possibly help ease the symptoms of osteoarthritis, although the evidence is quite preliminary. A few human studies have suggested that a compound called SAM-e might help relieve the pain and inflammation. And two observational studies suggest that getting enough vitamin D from diet, sunlight, or, if necessary, supplements might slow the progression of osteoarthritis, in theory because the vitamin is needed for healthy cartilage and bone. |
| RECOMMENDATIONS |
| As our tests indicate, makers of some glucosamine and chondroitin products need to do a better job of producing standardized, appropriately labeled products. The long-term safety and efficacy of glucosamine and chondroitin remain unclear. Still, our medical consultants say there's enough evidence to conclude that products containing the amounts of glucosamine, chondroitin, or both that worked in the clinical trials might be worth trying. for people with osteoarthritis, particularly if they've experienced or are likely to experience significant side effects from conventional painkillers. (Those amounts were 1,500 milligrams per day of glucosamine salt, glucosamine bound to another molecule, and 1,200 milligrams of chondroitin salt.) |
| While no one knows which formulation works best, it makes sense to try one of the least expensive combination products, such as Puritan's Pride Maximum Strength Glucosamine Chondroitin or Spring Valley Glucosamine Chondroitin Double Strength; they deliver both of the ingredients at lower cost than the chondroitin only products and, in most cases, at a similar cost to the glucosamine only products. For those who are concerned mainly with cost, however, Spring Valley Glucosamine Complex was the least expensive product we tested (although to get the clinical-trial dosage, you need to ignore the range of daily pills recommended on the label and take the maximum, three per day). |
| It may take two months for glucosamine and chondroitin to produce any significant improvement. If you see no effect by then, it's probably best to try a different approach. |
| DOUBTS ABOUT THE ANTI-INFLAMMATORIES |
| When osteoarthritic joints are painful and inflamed (red, hot, and swollen) standard anti-inflammatory drugs such as aspirin, ibuprofen (Advil, Motrin-IB), and naproxen (Aleve) can relieve the symptoms. But chronic use of such drugs can cause stomach bleeding, killing an estimated 16,500 people with arthritis a year in the U.S. and hospitalizing more than 100,000, according to a 1999 review article in The New England Journal of Medicine. |
| The newest class of anti-inflammatories, the COX-2 inhibitors, including celecoxib (Celebrex) and rofecoxib (Vioxx), are apparently easier on the stomach. That likely advantage has rapidly made them the best-selling prescription pain relievers, with combined sales of $3.5 billion in 2000. But a large clinical trial published in November 2000 in The New England Journal of Medicine has linked rofecoxib with an increased risk of heart attack compared with prescription naproxen. Whether the difference in risk occurred because rofecoxib increases the chance of heart attack (in theory by increasing the chance of blood clots) or because the older drug reduces that chance (by inhibiting blood clots) has not been determined. |
| For now the evidence that at least one of the COX-2 inhibitors increases heart attack risk is too tenuous to urge all people to avoid the COX-2s, particularly those who are already taking them and getting good results. However, people who have coronary disease or a high risk for it should consider sticking with traditional anti-inflammatory drugs, or asking their doctor about switching to those drugs until further research clarifies the safety of the COX-2s. |
| Note that when arthritic joints are not inflamed, ordinary acetaminophen (Panadol, Tylenol) can relieve moderate pain with minimal risk of gastrointestinal complications. Acetaminophen and other nonprescription analgesics are relatively inexpensive: for arthritis, typically about $5 to $20 per month. Prescription analgesics can cost substantially more: about $20 to $100 per month. |
| BEYOND PILLS: SHOTS IN THE JOINTS |
| When pills don't work, doctors can inject stronger anti-inflammatory medication, (corticosteroids such as methylprednisolone or triamcinolone) into the arthritic joint, at about $5 to $10 per shot. However, the injections help for only a few months, and they may damage the cartilage if repeated too often. Injections of a lubricant called hyaluronate (Hyalgan, Synvisc) provide somewhat longer lasting relief than steroids, and appear to be safer. The cost for a series of shots is about $330 to $350. |
| Prescription drug costs provided by Scott-Levin's Source Prescription Audit, October 2000 to September 1001 |
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