by Jeniffer George, PharmD student
An estimated 27 million adults in the United States suffer from osteoarthritis of the knee or hip which is commonly seen in patients 65 and older.1 Osteoarthritis is the breakdown in cartilage that covers the ends of the bone to where they meet and form a joint to allow movement.1 As of today, researchers have not found a set cure for arthritis, however, mild pain relief can be found from the use of NSAIDS, acetaminophen and combination products such as glucosamine and chondroitin. In addition, with the increase in obesity in the United States, exercise can relieve stress that is placed on the knees for patients with osteoarthritis. A survey conducted by the Centers for Disease Control and Prevention showed 53% of patients with arthritis didn’t walk at all for exercise, and 23% meet the current recommendation for activity—walking for at least 150 minutes a week.2 So the question I pose is: as future pharmacists, should we recommend glucosamine and chondroitin or exercise to patients with osteoarthritis?
For almost 20 years, the nutritional supplement glucosamine and chondroitin has been marketed to the public for joint health. Glucosamine is an amino sugar that can help renew cartilage while chondroitin is thought to be a complex carbohydrate that helps cartilage retain water.3 Glucosamine and chondroitin are found as natural substances in and around the cells of cartilage.3
NPR recently released an article that presented a study published by the New England Journal of Medicine (NEJM) and another study by the Journal of American Medical Association (JAMA). The study found in NEJM, involved 1,583 randomly selected patients receiving glucosamine and chondroitin with placebo.4 They found that glucosamine/chondroitin, in comparison with placebo seemed to show no effect on patients with osteoarthritis, however, a smaller subgroup characterized with moderate to severe pain showed a significant reduction of knee pain after the use of glucosamine. The study was conducted well, however, patients measured at baseline reported having mild knee pain, as compared with that in classic studies of osteoarthritis, in which a criterion for entry was a disease flare after the discontinuation of NSAIDs.4 In general, the evidence on glucosamine/chondroitin is varied, leaving it difficult to answer if the use of supplements are proven to be effective.
The second study presented in JAMA, included 399 participants that are overweight and presented with knee osteoarthritis. Participants in the study endured 18 months of combined intense diet and exercise modifications to see if there would be an increase in knee function and reduction in pain. Participants in the diet and exercise and diet groups had greater reductions in Interleukin 6 (used to measure inflammation) levels than those in the exercise group; those in the diet group had greater reductions in knee compressive force than those in the exercise group.5 The article does a great job on emphasizing the importance of exercise, however, patients with moderate to severe osteoarthritis, who may have difficulty exercising were excluded from the study.
I agree with most of the content in the article and seem to agree with the studies associated with the material. As a future pharmacist, I would recommend using glucosamine and chondroitin in conjunction with exercise while living a healthy dietary lifestyle to help patients with osteoarthritis. It is human nature to avoid doing things when you are in pain. Patients with osteoarthritis may avoid exercise when a hip, knee, or other joints hurt. As shown in the NEJM study, patients with moderate-to-severe pain saw a reduction in pain after using glucosamine and chondroitin. Recommending glucosamine and chondroitin can help patients have temporary relief in pain, which can enable them to engage in low impact activities, get the heart rate up and burn calories. If exercise is not an option for the patient, guiding the patient in dietary modifications can help in weight reduction. Other treatment options include: rest which helps reduce stress and tension that is put on the knees, hot and cold therapy to help increase blood flow and reduce inflammation near the joint area, and to avoid standing in one position for an extended time.
With studies like these, would you suggest glucosamine and chondroitin as a form of therapy? How can you advise a patient that is adamant on not losing weight due to the pain they are experiencing?
- National Center for Complementary and Alternative Medicine. http://nccam.nih.gov/research/results/gait/qa.htm. Published May 2002. Updated October 2008. Accessed November 1, 2013.
- Skerrett PJ. Exercise is good, not bad, for arthritis. Harvard Health Publication Web site. http://www.health.harvard.edu/blog/exercise-is-good-not-bad-for-arthritis-201305086202. Published May 8,2013. Accessed November 21, 2013.
- Patti Neighmond. National Public Radio. National Public Radio Website. http://www.npr.org/blogs/health/2013/10/14/231451187/exercise-may-help-knees-more-than-glucosamine-and-chondroitin?utm_content=socialflow&utm_campaign=nprfacebook&utm_source=npr&utm_medium=facebook. Published October 14, 2013. Accessed November 1, 2013
- Clegg DO, Reda DJ, Harris CL, et al. Glucosamine, Chondroitin Sulfate, and the Two in Combination for Painful Knee Osteoarthritis. N Engl J Med. 2006;354(8):795-808.
- Messier SP, Mihalko SL, Legault C, et al. Effects of Intensive Diet and Exercise on Knee Joint Loads, Inflammation, and Clinical Outcomes Among Overweight and Obese Adults With Knee Osteoarthritis: The IDEA Randomized Clinical Trial. JAMA. 2013;310(12):1263-1273. doi:10.1001/jama.2013.277669.Accessed November 1, 2013.