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From Boswellia to Vitamins: Arthritis Solutions Are Many

By Yousry Naguib, Ph.D.

Vitamin Retaler magazine, January 2003

Arthritis is a prevalent and debilitating disease that affects articulating joints. The joint is where bones connect with each other, such as the knee, hip or elbow. The most common forms of arthritis are osteoarthritis, which occurs as a result of wear and tear of the joints as we age, and rheumatoid arthritis (autoimmune disease).

Osteoarthritis (OA) accounts for more than half of all arthritis cases in the United States. About 20 million Americans, mostly women over the age 45, suffer from osteoarthritis, and with baby boomers aging, that number is on the rise.

OA develops when the linings of joints degenerate, leading to pain and decreased mobility. The onset of OA is gradual and results from progressive loss of cartilage proteoglycans (cartilage breakdown). Cartilage is a highly differentiated tissue that cushions and protects joints against the friction caused by the rubbing together of bones. OA most commonly affects the hands, knees, hips, shoulders, and spine.

The typical clinical symptoms are pain, followed by inflammation, swelling, and stiffness as the disorder progresses making it difficult to walk up and down stairs or using hands, thus altering the patientís quality of life.

The other common form of arthritis is rheumatoid arthritis (RA), which is an inflammation of the joints, causing swelling and pain. According to the Arthritis Foundation, RA affects an estimated two million Americans and usually strikes in middle age (35 to 50 years old). Women are three times more likely than men to develop RA.

It is believed that RA occurs when the body's immune system turns against itself and starts to damage joint tissues. RA can begin very gradually or it can strike without warning. The first symptoms are pain, swelling, and stiffness in the joints. The most commonly involved joints include hands, feet, wrists, elbows, and ankles. RA usually affects same joint on both sides of body. This means that if the right wrist is involved, the left wrist is also involved.

Most treatments of arthritis include a combination of medication, exercise, and rest, use of heat and cold, joint protection techniques and sometimes surgery. Drugs most commonly prescribed are non-steroidal anti-inflammatory drugs (NSAIDS), which can alleviate arthritis pain but also upset stomachs, even causing ulcers and impaired kidney function. NSAID include aspirin and aspirin like drugs that help reduce joint pain, stiffness, and swelling, but don't promote healing. Cortico-steroid drugs are also prescribed to reduce inflammation, but these also have serious side effects. Surgical treatment of OA includes removing joint spurs, realigning the joint and joint replacement.

Alternative Therapies

Alternative therapies include a variety of nutritional supplements: chondroitin sulfate, glucosamine sulfate, SAMe, fish oil, methylsulfonylmethane (MSM); and herbs such as Cayenne (topical, for pain only), Devilís claw, nettle, willow; boswellia, catís claw, horsetail, meadowsweet, yucca.

Many people with arthritis have severe calcium deficiencies. To prevent this, supplements that are high in bone-building calcium, and magnesium, which is needed for proper absorption of calcium, are recommended.

Coral calcium (from Soft Gel Technologies, Los Angeles, California) has been touted as the best source of providing calcium and magnesium in the desired ratio of two to one. Vitamin D also required for the body to utilize calcium, which is manufactured in the body with the help of a brief dose of sunshine. A prospective observational study, known as the Framingham study, involving 500 participants (mean age 70 years) found that low intake and low serum levels of vitamin D appear to be associated with an increased risk for progression of osteoarthritis of the knee [1]. Vitamin D is recommended in a dose of 400 to 800 international units per day to aid absorption of calcium.

Oils like borage, black currant, evening primrose, and walnut can help to reduce pain and swelling. These oils are rich in the essential fatty acid gamma-linolenic acid (GLA), which is converted by the body to a prostaglandin E1, which may account for its ability to reduce inflammation. In a double-blind trial, fifty-six patients with active RA received either a 2.8g daily of GLA or sunflower seed oil (placebo) for six months. At the end of the trial, the GLA-group showed progressive improvement in the symptoms of RA [2].

Fish oil EPA and DHA in a dose of 3 grams daily have been shown to reduce joint tenderness and the morning stiffness, and to reduce the dose of non-steroidal anti-inflammatory drugs in patients with rheumatoid arthritis [3].

Another study also reported that the use of omega-3 supplements, 360 mg / day of EPA and 240 mg / day of DHA, appeared to decrease production of pro-inflammatory prostaglandin E2 in bone, and significantly stopped bone loss [4].

Glucosamine and Chondroitin

Americans spend more on natural remedies for osteoarthritis than for any other medical condition. In treating OA, glucosamine and chondroitin sulafte are the most commonly used alternative supplements. Both glucosamine sulfate (GS) and chondroitin (CS) are present in the joints and are the building blocks of cartilage. GS and CS come from animal sources: glucosamine sulfate comes from chitin, a tissue found in shellfish; and chondroitin comes from the cartilage of sharks, cows and pigs. Recently, Cargill introduced a shellfish-free Glucosamine, under the trade name RegenasureTM.

Chondroitin sulfate (CS) is an important component of the bodyís natural building blocks for the cartilage found in joints. CS is a glycosaminoglycan, a polymeric material consisting of repeating glucuronic acid and N-acetylgalactosamine units. The N-acetylgalactosamine is substituted with sulfate at either the 4- or 6-position, with approximately one sulfate being present per disaccharide unit.

Glucosamine acts as the building block for the biosynthesis of glycosaminoglycans needed for the formation of proteoglycans that are important constituents of the cartilage. Studies have shown Glucosamine sulfate to relieve arthritis symptoms and help the body to repair damaged joints [5].

The first US six-months trial on the efficacy of chondroitin sulfate in the treatment of knee osteoarthritis is reported in the journal of Osteoarthritis Cartilage 2000, September issue. In a randomized, placebo-controlled study, 93 patients with OA of the knee were given a combination of low molecular weight sodium chondroitin sulfate (800mg), glucosamine hydrochloride (1000mg), and manganese ascorbate (152mg) twice daily. After 6 months, a significant improvement in the severity of the OA of the knee was observed in patients with mild to moderate OA of the knee [6].

In a study on the effect of long-term treatment with glucosamine sulfate on the progression of knee osteoarthritis, two hundred patients were randomly assigned to receive either an oral glucosamine sulfate (1500 mg once a day), or placebo. After three years, there was a progressive joint space narrowing with the placebo group, but no change in joint space narrowing in the GS group. Symptoms improved modestly with the placebo group, and as much as 20% to 25% with the GS group. These results indicate that use of GS in knee osteoarthritis prevents joint space narrowing and improves symptoms [7].

In a recent study, subjects with a regular knee pain were randomly supplemented with either glucosamine (24 subjects) or placebo (lactose (22 subjects) for 12 weeks at a dose of 2,000 mg per day. The functional ability and degree of pain felt by individuals who took glucosamine were improved with time, with the majority of improvements are achieved after eight weeks. The study suggested that glucosamine supplementation could provide some degree of pain relief and improved function in people with regular knee pain [8].

Most of the clinical trials were on osteoarthritis of the knee. The potential of GS and CS against symptomatic spinal disc degeneration has been demonstrated in a case study. The water content of the inter-vertebral disc is a reliable measure of its degeneration/regeneration status, and can be determined by Magnetic Resonance Imaging (MRI).

In the study, a 56 year-old man with frequently recurrent low-back pain, which existed for more than 15 years, took a daily glucosamine and CS capsules for 2 years. Each capsule provided 500 mg glucosamine hydrochloride and 400 mg of 95% low molecular weight (16kDa) sodium chondroitin sulfate (from bovine trachea), and 60 mg manganese ascorbate. The patient took 3 capsules (2 in the morning, one in the evening) during the first nine months; and 2 capsules (in the morning) for the remainder of the 2 years period. The patient felt a gradual improvement in the function of his back, with less pain starting after 6 months. At the end of the 2 years period, his back felt stronger and more flexible. During the two years time period, improvement of the structural quality of the disc cartilage was ascertained by the increase in the water content as witnessed by MRI. These results illustrate the possible efficacy of glucosamine and CS in the case of spinal disc degeneration [9].

To assess the ability of a topical cream containing glucosamine sulfate and chondroitin sulfate in reducing the pain associated with osteoarthritis of the knee, sixty-three patients were randomly assigned to either a topical cream of GS and CS or placebo for 8 weeks. After 4 weeks, the GS/CS-group showed a greater reduction in pain as compared to the placebo-group [10].

Most manufactures recommend 500 milligrams of glucosamine and 400 milligrams of chondroition three times daily.

MSM

Methyl sulfonyl methane, also known as dimethyl sulfone, is a naturally occurring sulfur compound found in a variety of foods, including fruits and vegetables, milk, meat, seafood, eggs, grains, legumes, onions, garlic, asparagus, cabbage, sprouts, and broccoli. It is also found in human body fluids, tissues, and urine.

MSM has been claimed to play an important role in collagen synthesis, which helps arthritis. In a double-blind study, Ronald Lawrence at UCLA School of Medicine found that about 80 percent of patients with arthritis who ingested 2,250 mg of MSM a day for six weeks showed improvement in their pain symptoms, while those on the placebo experienced on average an 18 percent improvement at six weeks. Daily dosages of 2 to 4 grams are recommended.

S-Adenosylmethionine (SAMe)

SAMe appars to act like glucosamine in the treatment of OA [11]. SAMe has been shown in a double-blind study to increase cartilage formation in fourteen patients with OA of the hands [12]. In another double-blind trial, SAMe (400mg three times per day) was found to reduce pain and symptoms of OA similar to NSAID, such as aspirin, ibuprofen, indomethacine, and naproxen [13]. In a recent meta-analysis of randomized controlled trials of SAMe versus placebo or NSAID for the treatment of OA, SAMe was found to be as effective as NSAID in reducing pain and improving activity limitation in patients with OA without the adverse effects associated with NSAID therapies [14].

Soy

Soy isoflavones have also been found to promote healthy bones. Research has shown diminished levels of estrogen due to menopause, exercise and excessive protein intake, all exert deleterious effects on bone integrity. To reduce these negative effects, the use of soy protein in combination with calcium has been suggested as an advantages way of promoting calcium uptake and bone strength.

Preliminary human studies showed that isoflavones are able to increase bone density in postmenopausal women [15]. Hormone replacement therapy (HRT) with estrogen or a combination of estrogen and progestins has been recommended for treating osteoporosis. In recent years, isoflavones have emerged as a natural alternative to HRT, for treating osteoporosis. Ginestein is the main isoflavone present in soy that appears to bind to the estrogen receptor, and in animal studies it appears to be effective in preventing bone loss caused by estrogen deficiency [16].

Avocado/Soybean

Avocado/Soybean un-saponifiables (ASU) are extracted from a mixture of avocado and soybean oil (in a ratio of either one or two parts of avocado oil to three parts of soybean). ASU has been shown to be effective in the treatment of osteoarthritis. In a randomized, double-blind, placebo-controlled trial, researchers in France examined the effect of avocado/soybean un- saponifiables on OA symptoms of the hip in 163 patients. Patients were assigned to either 300mg capsules of ASU or placebo for 2 years. At the end of the study, the joint space loss in patients with advanced joint space narrowing was significantly greater in the placebo group than in the ASU group. The study suggested that ASU could have a beneficial effect in people with advanced joint space loss [17].

Botanicals

Some botanicals may also reduce inflammation and boost the healing process of arthritis. Ginger inhibits pain-producing prostaglandins. A new extract of ginger, called Zinaxin, works just like NSAIDs, but without the toxicity, by interfering with the production of a hormone called prostaglandin, which plays a major role in inflammation.

Other anti-inflammatory herbs include boswellia, Ashwagandha, nettle, turmeric, cayenne, white willow, Catís Claw, and Devilís Claw. Turmeric (Curcuma longa), an orange-colored spice, reduces inflammation. Boswellia serrata, an Ayurvedic herb, has shown good results in reducing inflammation and improving blood supply to the joint tissues. Boswellia contains boswellic acids, which was shown to reduce symptoms in both osteoarthritis and rheumatoid arthritis.

Cayenne obtained from the dried, ground fruit of various red pepper species (especially Capsicum frutescens) was found to stimulate circulation, aid digestion, and promote sweating. Cayenne is also used topically for pain relief since the active chemical, capsaicin, alters the action of compounds in the body that transfer pain messages to the brain, thus reducing pain and inflammation. When applied topically, capsaicin may initially cause the skin to become red and inflamed and produce pain and burning. Over time, this initial reaction lessens and underlying pain and inflammation is reduced. Thus, capsaicin has become accepted as the active ingredient in over-the-counter creams used topically to treat not only arthritis but also other skin conditions.

In a study reported in Clinical Therapeutics (May-June 1991), researchers randomly assigned 101 arthritis patients to use either a topical cream containing capsaicin or a placebo cream daily for four weeks. Those smearing on the capsaicin reported significantly more relief than those using the placebo cream. Twenty-three of the 52 capsaicin-treated patients felt a temporary burning sensation when they applied the cream; two of them withdrew from the study because of this side effect [18].

Devilís claw (Harpagophytum procumbens) is a plant native to Africa. It contains anti-inflammatory compounds, called iridoid glycosides, which have been shown to possess anti-rheumatic, analgesic, anti-arrhythmic and hypotensive actions. A recent review of two clinical trials found that people who took capsules containing either 335mg or 400mg of devilís claw extract three times a day, for either three weeks or two months experienced pain relief. People with moderate OA were more likely to experience relief, but some people with severe arthritis also felt an improvement [19]. Devilís claw preparations with 50 to 100mg of harpagoside or willow bark extract with 120 to 240mg salicin proved efficacious as anti-rheumatics in clinical trials [20,21].

Chinese herb commonly known as ďthunder god vine,Ē Tripterygium silfordii, has been suggested as a possible treatment for rheumatoid arthritis [22].

A proprietary extract from the bark of the Chinese tree Phellodendron amurense developed by Next Pharmaceuticals, and marketed under the trade name Nexrutine, has been shown in a clinical trial involving fifty-three subjects to relieve pain without causing gastrointestinal irritation, a common side effect of aspirin and non-steroidal anti-inflammatory drugs, such as ibuprofen.

Type-II Collagen

There are several types of collagen; the main ones are designated Type-I, Type-II and Type-III. Type-II collagen is found predominantly in articular cartilage and is sold as dietary supplements, such as Biocell Collagen-II (hydrolyzed collagen type II protein), and UC-II (not hydrolyzed). In a recent study, researchers found that 39 percent of 54 rheumatoid arthritis patients treated orally with undenatured (not hydrolyzed) Type-II collagen demonstrated significant improvement while only 19 percent of 57 rheumatoid arthritis patients taking placebo showed improvement [23].

Complementary medicine holds promising solutions for the treatment of arthritis, without the side effects associated with non-steroid anti-inflammatory drugs.

References

[1] McAlindon TE et al. Relation of dietary intake and serum levels of vitamin D to progression of osteoarthritis of the knee among participants in the Framingham study. Ann Intern Med 1996; 125:353

[2] Zurier RB et al. Gamma-linolenic acid treatment of rheumatoid arthritis. A randomized, placebo-controlled trial. Arthritis Rheum 1996; 39:1808

[3] Kremer JM. N-3 fatty acid supplements in rheumatoid arthritis. Am J Clin Nutr 2000; 71(1 suppl):349S

[4] Requirand P, et al. Serum fatty acid imbalance in bone loss: example with periodontal disease. Clin Nutr 2000; 19:271

[5] Phoon S, Manolios N. Glucosamine. A nutraceutical in osteoarthritis. Aust Fam Physician 2002; 31:539

[6] Efficacy of a combination of FCHG49 glucosamine hydrochloride, TRH 122 low molecular weight sodium chondroitin sulfate, and manganses ascorbate in the management of knee osteoarthritis. Das et al. Osteoarthritis Cartilage 2000; 8:343

[7] Pavelka K et al. Glucosamine sulfate use and delay of progression of knee osateoarthritis: a 3-year, randomized, placebo-controlled, double-blind study. Arch Inten Med 2002; 162:2113

[8] Braham R et al. The effect of glucosamine supplementation on people experiencing regular knee pain. Br J Sports Med 2003; 37:45

[9] van Bitterswijk WJ et al. Glucosamine and chondroitin sulfate supplementation to treat symptomatic disc degeneration: Biochemical rational and case report. BMC complementary and Alternative Medicine 2003; 3:2

[10] Cohen M et al. A randomized, double blind, placebo controlled trial of a topical cream containing glucosamine sulfate, chondroitin sulfate, and camphor for the osteoarthritis of the knee. J Rheumatol 2003; 30:523

[11] Harmand MF et. Effects of S.Adenosylmethionine on human articular chondrocyte differentiation. Am J Med 1987; 83 (Suppl 5A):48

[12] Konig H et al. Magnetic Resonance Tomography for finger arthritis. Morphology and cartilage signals after adenothionine therapy. Aktuelle Radiol 1995; 5:36

[13] Muller-Fassbender. Double-blind trial of SAMe versus Ibuprofen in the treatment of osteoarthritis. Am J Med 1987; 83 (Suppl 5A):81

[14] Soeken KL et al. Safety and efficacy of S-adenosylmethioninein (SAMe) for osteoarthritis. J Fam Pract 2002; 51:425

[15] Brynin R. et al. Soy and its isoflavones: a review of their effects on bone density. Altern Med Rev 2002; Aug. 317

[16] Albertazzi P. Purified phytoestrogens in postmenopausal bone health: is there a role for genistein?. Climacteric 2002; 5:190

[17] Long L, Soeken K, Ernst E. Herbal medicines for the treatment of osteoarthritis, a systematic review. Rheumatology 2001; 7:779

[18] Deal CL et al. Treatment of arthritis with topical capsaicin: a double-blind trial. Clin Ther 1991; 13 (May-June):383

[19] Atal, C.K., and A.E. Schwarting, Ashwagandha: An Ancient Indian drug. Economic Botany (1961), 16: 256-63

[20] Lanhers et al. Anti-inflammatory and analgesic effects of an aqueous extract of Harpagophytum procumbens. Planta Med 1992; 58

[21] Chrubasik S, Pollak S. Pain management with antirheumatic drugs.Wien Med Wochenschr 2002; 152:198

[22] Cibere J, Deng Z et al. A randomized double-blind, placebo-controlled trial of topical Tripterygium wilfordii in rheumatoid arthritis: reanalysis using logistic regression analysis. J Rheumatol 2003; 30:465

[23] Barnett et al. Treatment of Rheumatoid arthritis with oral type-II collage. Arthritis Rheum 1998; 141:290

 

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