What is the Best Option for Osteoarthritis?
Dr. Hamid R. Bafandeh
Ph.D., University of Massachusetts, USA
Certified Natural Health Consultant and Herbalist, Canada
The most common forms of joint diseases are usually classified as rheumatoid arthritis, osteoarthritis and gout. Osteoarthritis is the most common type of joint disorder. It is caused by wear and tear in various joints, such as the hips or knees. As we age, we are more at risk. Previous injury to any joint or those who are overweight or have very active manual jobs can be more susceptible to osteoarthritis.
Although the main cause of osteoarthritis has not yet been scientifically explained, the following explanation seems consistent with all the known facts:
Cartilage, a slippery, load-bearing covering on the ends of the bones that form joints, is subject to a lot of wear and tear. Synovial fluid provides the cushioning and the lubrication necessary for healthy, pain-free functioning. It exists in a state of dynamic equilibrium. It is constantly being eroded away by the activity of everyday living. The body removes the worn out cartilage with the help of some enzymes. At the same time, the body is constantly reconstructing new cartilage. As long as these two processes remain in balance, our joints remain healthy.
In a normal situation the body both produces and ingests the building blocks of cartilage (glucosamine), which it then uses to build new cartilage to replace the old. As we get older, our bodies often can't produce enough glucosamine to maintain the necessary balance. The result of this imbalance is called osteoarthritis, or in short arthritis.
However, aging is not the only factor in arthritis. Sports injury and other physical impacts may also contribute. 1
It has been shown that glucosamine sulfate, MSM and other nutritional supplements such as calcium, magnesium, zinc, etc., are needed to overcome nutritional deficiencies, and to regain the necessary balance between cartilage production and destruction.
Synovial membranes are the membranes surrounding the joints, which form a capsule around the ends of the bones. This membrane secretes a liquid called the synovial fluid. This fluid carries out many functions, but the most important of them are:
- Shock absorber
- Nutrient carrier
A healthy joint is lubricated; meaning it provides the cushioning and the lubrication necessary for healthy joints. It is thick and makes the joints rub against each other, smoothly. When our bodies can't produce enough specific materials such as glucosamine and chondroitin, the synovial fluid becomes thin and watery. In this state, it can't do the job it was intended to do as a lubricant.
Synovial fluid has remarkable properties as a shock absorber. When we walk, run, jump, or do vigorous exercise, it become thicker or more viscous in order to protect our joints. When the pressure or shear is gone, It instantly becomes thin again and returns to its normal viscosity to resume its lubricating function between shocks. All this happens over and over again, in a fraction of a second. When our bodies can't produce enough nutrient carriers, this whole mechanism breaks down. The viscosity is dramatically reduced, giving thin, watery synovial fluid, which fails to act as the shock absorber and lubricant as it is supposed to be, causing pain, stiffness and decreased mobility in our joints.
The synovial fluid is a liquid without any blood vessels that carry the raw materials from the blood to the cartilage via diffusion and convection mechanisms. Diffusion is a rather slow process in this case but convection is more efficient through exercise. During exercise the synovial fluid (nutrient-containing synovial fluid) is constantly washing over the cartilage and all the dissolved nutrients such as glucosamine, calcium, phosphorus, zinc, etc. in our synovial fluid are, constantly supplying our cartilage.
With this newly acquired abundance of nutrients, plus the exercise to supply them efficiently to our cartilage, our own body can re-build and replace the worn-out cartilage as fast as possible.
What are the options?
- Joints are well supplied with nerves so pain is a common symptom of joint wear. Treatments such as local heat, massage, use of a walking stick and various medications can help.
- Anyone who has experienced the pain due to arthritis knows how wonderful it is to find relief, even though temporary, from Aspirin, Ibuprofen, or some other NSAIDs (non-steroidal anti-inflammatory drugs). After awhile, however, the pain returns, and your first inclination is to take another dose of the NSAID. Problems begin when the need for painkillers is frequent, and perhaps growing, as in a chronic disease, such as arthritis.
Therefore in the short-term, using NSAIDs may be useful, but as in osteoarthritis, long term use of high dosages can be very dangerous. Following are some examples of the harm they can cause.
- Kidney damage
- Liver damage
- Gastrointestinal damage
- Asthmatic attacks
- Ringing in the ears
Acetaminophen is another pain-killer that is not an NSAID. It has its own problems, however. For example, a combination of alcohol and acetaminophen can be deadly. Tylenol (acetaminophen) is not a problem-free solution. Never take acetaminophen if you are consuming anything containing alcohol. Always read the labels for contents. Since rheumatoid arthritis is a long-term condition with a high level of symptoms, potent drugs inevitably have side effects.
This is most recent approach to pain relief is a class of compounds known as COX-2 inhibitors. COX-2, an enzyme, stands for "cyclo-oxygenase of the second type". There is also another enzyme called COX-1, that is, "cyclo-oxygenase of the first type". These enzymes are compounds that help our bodies to produce another class of compounds called prostaglandins.
Prostaglandins are short-lived, active, hormone-like chemicals that are found in every cell of the body. They regulate cell activities and are essential for maintaining health. There are several classes of prostaglandins: PG1, PG2 and PG3. PG1 and PG3 have beneficial effects that we will talk about later. Prostaglandin series 2 (often referred to as 'bad guys') are associated with pain and swelling. These are produced with the aid of the COX-2 enzyme. COX-2 inhibitors also inhibit the production of a prostaglandin 2 derivative called prostacyclin. It possibly leads to clotting inhibition and cardiovascular problems, such as heart attacks and strokes. Other prostaglandins are produced with the aid of the COX-1 enzyme and are responsible for protecting your gastrointestinal tract from digesting itself. With the help of the goblet cell, they continuously renew the mucous lining of the GI tract. When the production of these prostaglandins is inhibited, then, gastrointestinal bleeding is one of the possible consequences. 26
Unfortunately most NSAIDs, even those of this "second generation type", are not perfectly selective in their inhibition of the two enzymes.
While Steroids such as cortisone, prednisone, etc., are not NSAIDs, they act like a COX-2 inhibitor. Cortisol therapy over 6 months can cause osteoporosis. Corticosteroids cause osteoporosis and fractures in a high percentage of patients. Direct inhibition of osteoblast function, inhibition of gastrointestinal calcium absorption and inhibition of gonadal hormones are just a few of the several adverse effects of these steroids. 23
If you are on long-term steroids, it is worth checking that your doctor has considered taking action to avoid osteoporosis.
It should be reminded that those methods are actually not a treatment for osteoarthritis. NSAIDs and anti-inflammatories affect the cyclooxygenase pathway by inhibition or suppression of the prostaglandin-2. The continued use of NSAIDs may actually increase inflammation due to the leukotriene formation (a critical factor in asthma and allergy conditions) through the lipoxygenase formation.
Various other treatments are available including herbal medicines, whose effectiveness is well documented. These include herbal medicines, which are often used in conjunction with other nutritional supplement such as glucosamine sulphate, MSM (Methyl Sulfonyl Methane), Serrapeptase™, essential fatty acids, high potency vitamins, minerals and enzymes.
Glucosamine is an amino-polysaccharide (a combination of the amino acid, glutamine and glucose). Glucosamine is a substance found naturally in the body. It is concentrated in joint cartilage where it is incorporated in longer chains known as glycosaminoglycans and finally into very large structures known as proteoglycans. The proteoglycans function to attract water into the joint space for lubrication of the cartilage during movement and is believed to play a role in cartilage formation and repair. It is believed to reverse osteoarthritis, protects joints and tendons from injury and decrease inflammation in joints, tendons, cartilage and soft tissue. Some people get almost complete restoration. Others may experience relief from pain, better mobility than before and the prevention of further deterioration. 9, 21
Glucosamine sulphate is also recommended for athletes as it stimulates the production of cartilage, improves joint function and reduces swelling of sports injuries as well as arthritis. Glucosamine sulphate plays a key role in the restoration of cartilage and joint structures. 6, 19, 24
The effectiveness and tolerability of oral glucosamine sulphate in the treatment of arthritis was assessed in an open study in Portugal, 1208 patients received 1.5 g daily in 3 divided doses over a mean period of 14-30 days. The results were analyzed and showed that the symptoms of pain at rest, on standing and on exercise and limited active and passive movements improved steadily through the treatment period. The improvement obtained lasted for a period of 6 to 12 weeks after the end of treatment. The therapeutic efficacy was rated as good in 59% of the patients, and sufficient in a further 36%. Oral glucosamine was fully tolerated by 86% of patients, a significantly larger proportion than that reported with other previous treatments. The onset of possible side effects was significantly related to pre-existing gastrointestinal disorders and related treatments, and to concomitant diuretic treatment. 25
Glucosamine is a precursor in the manufacture of chondroitin and provides the necessary nutrients to the cartilage and soft tissues. Glucosamine is a nutritional supplement that is extracted from crab, lobster or shrimp's shells and has no infective or allergenic components.
Chondroitin sulphate improves cartilage function and is a popular nutritional supplements for the management of arthritis. These products are composed of large molecules and are very difficult to absorb. The oral absorption of chondroitin is extremely low (5%). The absorption rate of the smallest molecules are estimated to be between zero to 8%, while for glucosamine sulphate, when orally administrated, is about 98%, according to pharmacokinetic studies in animals and humans. 22
Chondroitin from shark cartilage is very expensive, and most manufacturers use refined bovine or pig trachea to make chondroitin sulfate. which increases the risk of cross contamination of tissues prepared for human consumption, 3. Excess amount of chondroitin sulfate may also increase prostate cancer progression and the growth of other malignancies. 2
Therefore, if you wish to take glucosamine to help your joints, it is strongly advised to take 100% pure glucosamine, rather than mixed with chondroitin sulphate. There are no known side effects and it can be taken with any other medication that may be prescribed.
The ratio of the glucosamine to sulphate is very important. The highest quality available is 75% glucosamine to 25% sulphate.
MSM (Methyl Sulfonyl Methane) is a naturally occurring organic sulfur compound found in all living plant and animal tissues. Sulfur is important in the formation of collagen and glucosamine. It helps nutrients and fluids to flow through cells and removes toxins from the cells by increasing permeability, this leads to a reduction in pain and inflammation and maintenance of healthy bones, joint, ligaments and tendons. MSM gives up its sulfur to the essential amino acids methionine, cysteine and other serum proteins, eventually finding its way into the collagen of skin, joints and blood vessels. It is also incorporated into the keratin of hair and nails. 4
Glucosamine supports and stimulates the manufacture of soft tissue and helps transport MSM (a sulphur) into the tissue. As we age, our body may not manufacture enough glucosamine and our tissues begin to deteriorate (arthritis).
Animal sources and impure synthetic grades should be avoided. Some MSM may contain heavy metals that can be revealed only with high specification laboratory analysis.
The combination of glucosamine sulphate and MSM will be a more effective aid for arthritis and general pain relief.
Serratia Peptidase is a powerful proteolytic enzyme known as Serrpeptase that acts as anti-inflammatory, anti-edemic and fibrinolytic. It may reduce pain, inflammation and prevent swelling and fluid retention . 28,29,32,33. Many studies show that proteolytic enzymes might be helpful for various forms of chronic pain, such as osteoarthritis, back pain, neck pain and could be used as alternative to NSAID’s without any negative side effect. It can break all non-living tissue, such as arterial plaque and all different kinds of inflammation. Serrpeptase is absorbed in the intestine and enters the bloodstream, if it is not destroyed by the acid in the stomach. Therefore it is crucial to administrate Serrpeptase in a special enteric-coated capsule in the empty stomach.30,31
Dietary supplementation for the prevention and the treatment of arthritis
Poor nutritional status is linked to the presence of rheumatoid arthritis. The continuous chain reaction of free radical formation and molecular damage can lead to extensive damage of cell membranes, DNA, and tissue proteins at the joint linings. This results in the accumulation of fluids and swelling in the joints, causing pain in patients suffering with rheumatoid arthritis.
Dietary intake of antioxidants such as selenium, vitamin E and vitamin C, can be an effective adjunct therapy. 18,16
Ascorbic acid (vitamin C) helps the body absorb iron and is a also a highly useful antioxidant. It is also an important factor for the reformation of collagen found in bones, muscles and teeth. Citrus bioflavonoids are a group of compounds that help limber the joints and provide powerful free radical scavenging.
Adequate intake of calcium and vitamin D will help prevent bone loss in the body. The ratio of calcium to phosphorus in the blood, for a normal person is about 10:4. A high ratio of phosphorus to calcium increases inflammatory tendencies in the body. Low levels of vitamin D also contribute to an increased risk of osteoporosis and arthritis. 13
Calcium is the principal mineral in bones and teeth and contributes to normal muscle contraction and proper nerve functioning. Calcium is also necessary for normal blood clotting.
Consuming foods high in phosphorus and low in calcium for a long period of time depletes calcium and other minerals and increases the tendency towards inflammation.
The proper calcium/phosphate balance in the body can help alleviate arthritis. Excessive phosphorus levels often occur in people who consume large amounts of soft drinks (soda pop), fast foods and meat. A proper balance of phosphorus, calcium and magnesium is necessary because these nutrients are crucial to bone health. Excess consumption of phosphorus may lead to osteoporosis and poor bone maintenance. 10
People with a weak carbohydrate metabolism cannot properly oxidize glucose to carbon dioxide and water. The excess glucose of the sweet foods will partly metabolized to form organic acids and cause the body to feel pain. If the alkaline reserve is insufficient to neutralize these acids, more and more calcium will be mobilized from the bones causing the bones to become brittle and the tissues and joints to calcify.
Copper is an essential mineral that provides dietary support for the synthesis of collagen, a main component of connective tissue.
Magnesium is needed for muscle contraction, normal nerve transmissions, enzyme action and bone mineralization.
Nutrient deficiencies such as vitamin D, folic acid, vitamin B6, vitamin C, iron, selenium, copper, zinc and magnesium could contribute to the development of rheumatoid arthritis. Increasing the intake of trace minerals might improve some of the symptoms of arthritis . 13, 16 Supplementation with folic acid and B12 might lessen joint tenderness. In many cases, this kind of therapy is as effective as other drug treatments. 8, 15
Many different kinds of commercial forms of multiple vitamins and minerals are available in the market.
To ensure the bioavailability and the higher absorption rate of the minerals, we should select the high quality form of products. For example, amino acid chelated minerals in the form of HVP (Hydrolyzed Vegetable Protein) are more rapidly absorbed, more easily digested and assimilated by the body than other forms such as carbonate and oxides. Additionally, choose formulas that provide the plant enzymes, as these are critical to the digestion of food. Natural forms of vitamin E (d-Alpha tocopherol) have much greater benefit than synthetic forms (dl-Alpha tocopheryl).
EPA, or eicosapentaenoic acid, is the precursor of the series 3 prostaglandins, which block the usually detrimental prostaglandin series 2 from being made in the body. EPA protects the body against high blood pressure, sticky platelets, water retention, lowered immune function and inflammation, 13. The anti-inflammatory agents, EPA & DHA and GLA have been found very effective in managing rheumatoid arthritis and psoriases. Patients with rheumatoid arthritis often require lower doses of anti-inflammatory medications if dietary intakes of omega-3 fatty EPA acids is increased. 14, 27, 12
PG1 is derived from GLA, or gamma-linolenic acid. GLA is the active component of evening primrose oil (EPO) and borage oil. GLA is also important for collagen formation. 7
Dietary Recommendations and Dosage information for the prevention and the treatment of arthritis
Suggested optimal daily dose for an average person
|Pantothenic Acid (B5)
ESSENTIAL FATTY ACIDS
|+Hydrolyzed Vegetable Protein Chelate (HVP)
The initial dose of glucosamine sulphate for the treatment of arthritis is based on body weight (20mg/kg body weight/day) and the effective half-life of the interaction of glucosamine in the body. For an average 75kg person, 1500mg per day - usually in 3 divided doses of 500mg each, for the first 60-90 days of the regimen may be used. While this level appears to be an effective dose, there is no information to suggest that a higher does would work better or faster. 5, 20
Following the initial 60-90 day period, dosage levels can be increased or decreased by 500mg/day the to the maintenance level based on individual pain and stiffness levels.
There is a wide range of purity and effectiveness among different brands. Nutritional supplements focus on the cause of the arthritis (i.e. a nutritional deficiency). While they work more quickly for some than for others. So far, almost everyone who has tried glucosamine sulphate has benefited from it. The amount of time it takes to see improvement is dependent on how far your arthritis has progressed, as well as upon many other factors.
Vitamins and minerals such as vitamin D, vitamin D, folic acid, vitamin B6, vitamin C, calcium, iron, selenium, copper, zinc and magnesium, organic silica, plus essential fatty acids such as omega 3 (EPA/DHA) from fish body oils such as salmon, and omega 6 (GLA) from primrose or borage oil, will enhance improvement. It is beneficial to incorporate a daily regime of multiple vitamins, chelated minerals and enzymes.
Osteoarthritis is a common type of joint disorder. It is caused by wear and tear in various joints, such as the hips or knees.
Taking NSAIDs, or pain-killers such as Aspirin and Celebrex will, in the short term, bring relief from the pain of osteoarthritis, but in a long run, one needs more doses to achieve the same level of relief. Taking a high dose may result in kidney damage, liver damage, hypertension, gastrointestinal damage; asthmatic attacks, ringing in the ears, etc.
Steroids, such as cortisone, prednisone, etc., act like a COX-2 inhibitor. They seem to be effective and helpful, if used for a short period of time. They will do more harm than good if you are taking large doses for a prolonged period of time.
Glucosamine sulphate plays a key role of the restoration of cartilage and joint structures. When orally administrated, the absorption rate is about 98%. Many health professionals recommend glucosamine along with MSM as a supplement to be taken after surgery instead of anti-inflammatories and steroids. There are no known side effects reported and it has no contra indications with other medicines.
Chondroitin products are composed of large molecules and the oral absorption of chondroitin is extremely low (5%). Chondroitin products obtained from bovine and pig trachea have a possible risk of cross contamination of human tissues.
A combination of glucosamine sulphate and MSM will be more effective as an aid for osteoarthritis and general pain relief.
Serrapeptase™ can be used as an effective pain reliever and anti-inflammatory substance as an alternative choice to NSAID’s without any side effects along with other health beneficial properties. Due to the breakdown of Serrapeptase™ in stomach acid, Serrapeptase™ should be administrated in a special enteric-coated capsule in the empty stomach.to allow absorption in the small intestine.
Taking high potency chelated multiple vitamins-minerals-enzymes and high quality essential fatty acids, such as salmon oil and evening primrose oil will be beneficial.
- Bucci, Luke R. 1995. Nutrition Applied to Injury Rehabilitation and Sports Medicine. Boca Raton, FL. CRC Press.
- C. Ricciardelli, et al., "Elevated stromal chondroitin sulfate glycosamino-glycan predicts progression in early-stage prostate cancer" Clin Cancer Res 3: 983-92, 1997.
- Chondroitin Sulfate Manufacturing and Risk of Mad Cow Disease. http://www.stoneclinic.com/chondroitin_extraction.htm
- Collagen of skin, joints and blood vessels
- Delafuente JC. Glucosamine in the treatment of osteoarthritis. Rheum Dis Clin North Am. 2000 Feb; 26(1): 1-11.
- Drovanti, A, et al. therapeutic activity of oral glucosamine sulfate in osteoarthritis: a placebo-controlled double-blind investigation. Clin. Ther. 3 (4) 260-272 (1980)
- Geusens P, Wouters C, Nijs J, Jiang Y, Dequeker J. Long term effects of omega-3 fatty acid supplementation in active Rheumatoid Arthritis. A 12 month, double-blind, controlled study. Arthritis Rheum.37(6):824-9.1994.
- Haugen M, hoyeraal H, Larsen, et al: Nutrient intake and nutritional satus in children with juvenile chronic artheritis. Sc J Rhum 1992;21:165-170
- Houpt JB, McMillan R, Wein C, Paget-Dellio SD. Effect of glucosamine hydrochloride in the treatment of pain of osteoarthritis of the knee. J Rheumatol. 1999 Nov; 26(11): 2423-30.
- Kirschmann, G. & J. Nutrition Almanac, 4th ed. New York: McGraw Hill, 1996.
- Kjeldson-Kragh J, Lund J, Riise T, et al: Dietary omega-3 fatty acid supplementation naproxen treatment in patient with rheumatoid arthritis. J Rheumatol 1992; 19:1521-1536.
- Kremer J: Omega-3 fatty acids and rheumatoid arthritis: Current status. Nutr Rep 1988; 6:33,36,40.
- KrogerH, Penulla I, Alhava E: Low serum vitamin D metabolites in women with rheumatoid arthritis. Sc. J Rheum 1993; 22:172-177
- Makela A, Hyora H, Vuorinen K, et al: Trace elements 9Fe, Zn, Cu, and Se) in serum of rheumatoid children living in western Finland. Scad J Rheum 1984;S53: 94
- Morgon S, Alarcon G Krumdieck C: Folic acid supplementation during methotrexate therapy: j Rheumata 1993:20: 929-930
- Munthe E, Aaseth J: Treatment of rheumatic arthritis with Seleniun and vitamin E. Sc J Rheum 1984:S53:103.
- Panush R: Nutritional therapy for arthritis. Nutr Rep 1988:6:17,24
- Peretz A, Neve J, Fameay J: Selenium in rheumatic disease. Sem Arth Rheum 1991;20:306-316.
- Pujalte, J. M. et al. Double blind clinical evaluation of oral glucosamine sulfates in the basic treatment of osteoarthritis. Curr. Med. Res. Opin. 7 (2) 110-114 (1980)
- Qiu, G. X. Efficacy and safety of glucosamine sulfate versus ibuprofen in patients with knee osteoarthritis. Arzneimittelforschung 48 (5) 469-474 (1998)
- Rindone JP, Hiller D, Collacott E, Nordhaugen N, Arriola G. Randomized, controlled trial of glucosamine for treating osteoarthritis of the knee. West J Med. 2000 Feb; 172(2): 91-4.
- Setnikar I. et al, pharmacokinetics og glucosamine in the dog and man. Arzneim Forsch 36(4): 729-35. 1986.
- Steroid-induced osteoporosis )
- Apadinhas, MJ. et al. Oral Glucosamine sulfates in the management of arthritis: report on a multi-center open investigation in Portugal. Pharmatherapeutica 3 (3) 157-168 (1982)
- Tapadinhas MJ, Rivera IC, Bignamini AA. Oral glucosamine sulphate in the management of arthrosis: report on a multi-centre open investigation in Portugal. Pharmatherapeutica 3:157-168; 1982.
- The Wall Street Journal, April 20, 1999. All that Celebrex promised to do was to relieve the pain while eliminating, or minimizing, GI bleeding.
- Yoshina S, Ellis E: Effect of dietary fish oil derived fatty acids on inflammation and immunological processes. Fed Proc 1987; 46:1173.
- Mazzone A, Catalani M, Costanzo M, Drusian A, Mandoli A, Russo S, Guarini E, Vesperini G. Evaluation of Serratia peptidase in acute or chronic inflammation of otorhinolaryngology pathology: a multicentre, double-blind, randomized trial versus placebo. J Int Med Res. 1990; 18(5):379-88.
- Mazzone A, et al. Evaluation of Serratia peptidase in acute or chronic inflammation of otorhinolaryngology pathology: a multicentre, double-blind, randomized trial versus placebo. J Int Med Res. 1990; 18(5):379-88.
- Miyata, K. Intestinal absorption of Serratia Peptidase. J Appl Biochem. 1980;2:111-16.
- Deitrick RE. Oral proteolytic enzymes in the treatment of athletic injuries: a double-blind study. Pa Med. 1965;68:35-37.
- Tassman GC, Zafran JN, Zayon GM. Evaluation of a plant proteolytic enzyme for the control of imflammation and pain. J Dent Med. 1964;19:73-77.
- Deitrick RE. Oral proteolytic enzymes in the treatment of athletic injuries: a double-blind study. Pa Med. 1965;68:35-37.