Do glucosamine and chondroitin sulfate reduce arthritis pain?
Many people use glucosamine and chondroitin sulfate as a natural therapy to treat their arthritis pain. This seems like a reasonable thing to do since glucosamine is a critical building block for cartilage, and chondroitin can help keep joints properly hydrated. And as we know, osteoarthritis is caused by joint wear and tear and decreased cartilage health.
Unfortunately, the research results have been fairly underwhelming.
Here is how one author* summarized the latest research:
“It seems prudent to tell our patients with symptomatic osteoarthritis of the knee that neither glucosamine hydrochloride nor chondroitin sulfate alone has been shown to be more efficacious than placebo for the treatment of knee pain. If patients choose to take dietary supplements to control their symptoms, they should be advised to take glucosamine sulfate rather than glucosamine hydrochloride and, for those with severe pain, that taking chondroitin sulfate with glucosamine sulfate may have an additive effect. Three months of treatment is a sufficient period for the evaluation of efficacy; if there is no clinically significant decrease in symptoms by this time, the supplements should be discontinued. Furthermore, there is no evidence that these agents prevent osteoarthritis in healthy persons or in persons with knee pain but normal radiographs.”
So I guess the bottom line is that these supplements are no magic cure for knee pain – they aren’t known to be harmful (except to the wallet) but they aren’t sure to be helpful either.
*Hochberg, Marc C.
Nutritional Supplements for Knee Osteoarthritis — Still No Resolution
N Engl J Med 2006 354: 858-860
Val Jones is a licensed practitioner of Rehabilitation Medicine and Senior Medical Director of Revolution Health’s portal. No information in this blog is intended to diagnose or treat any condition. The opinions expressed here are Val’s and do not necessarily reflect those of Revolution Health.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
I have significant osteoarthritis in one knee, to the point that I was contemplating a total knee operation. I was taking ibuprofen daily and having enough pain on walking that I was not able to exercise to the level I needed to stay healthy. My ortho doc suggested I add Glucosamine/Chondroitin sulfate 1500 mg a day, and cautioned that it may take weeks or months to take its full effect.
I, too, was underwhelmed for awhile but, after being patient and consistent for six months, I began to notice significant improvement in my pain, to the point that exercise was tolerable again.
So, I have maintained this regimen (800 mg of ibuprofen, along with 1500 mg of CS/G) every day for several years and have been able to stave off my total knee.
I exercise by either walking, biking, or aerobic machines, 40 to 60 minutes, 5 or 6 days a week.
So, at any rate, I believe that the jury is still out on this. For all I know, there may have been some other factor that resulted in my improvement. But, the options for treatment of osteoarthritis, beyond NSAID’s and surgery, are limited so I consider this to be one helpful addition to the regimen.
As you appropriately point out, Clegg et al chose a different formulation (glucosamine hydrochloride instead of glucosamine sulfate) for this study- why should we care? The best studies used the sulfate formulation and the majority (admittedly not all) showed pain, function, and disease modifying effects (slowed joint space narrowing in Reginster Lancet article) when compared with placebo.
Lancet study URL: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstra ctPlus&list_uids=11214126&query_hl=1&ito ol=pubmed_DocSum
Does it matter what the formulation is?…absolutely.
What has the preponderance of rigorous clinical trials shown for this compound? Considering the more than 40 clinical trials (over 15 RCTs), it improves function, usually reduces pain, and slows joint narrowing. It’s quite safe and little concerns for interactions with other cmpds. As a editor for the Natural Standard review on chondroitin sulfate, we concluded there was sufficient evidence to support it’s use, and we found this compound quite safe in clinical trials.
What are your alternatives? As Dr. smith pointed out, NSAIDS are frequently the mainstay of therapy. There is no question that these compounds have significantly greater risk for toxicity of the kidney, and lining of the stomach (bleeding, pain). And as we all know, a certain class of NSAIDs (COX-2 inhibitors) have been associated with increased risk of heart attacks.
I feel evidence is best for the following options:
Glucosamine/chrondrotin
Acupuncture (See Brian Berman’s recent study in the Annals of Int Med 2005)
Leg strengthening exercises
For those interested in the methodological issues on the glucosamine/chondroiting issue:
The more recent clinical trials have been of superior methodological quality, while some of the older trials have serious methodological flaws possibly resulting an in an overestimatation of benefits. Most of the randomized control trials are of a relatively short (<1 year) to moderate (2 year) duration, although a few long term studies (beyond 3 years) have been performed and no significant adverse effects have not been documented. The body of research published to date support the claim that glucosamine and chondroitin sulphate are likely effective in the treatment of OA without well-supported evidence for significant adverse events, toxicity, or interaction with other compounds
• There have been multiple clinical trials performed since 1980. The limitations of studies published prior to 2000 include: (1) many studies were not evaluated on an intention-to-treat basis (2) allocation concealment was not described in many of the studies (3) most of the primary studies were of small sample size (20-100 patients), although meta-analysis often resulted sample sizes ranging from 300-700 (4) The large meta-analysis studies concluded large benefits but noted publication bias leading to an exaggeration of the magnitude of the benefit; however, a statistically significant and clinically meaningful effect remained (5) A wide range of outcome variables (e.g., pain, mobility, NSAID use, and functional indices) were assessed making meta-analysis difficult and (6) relationships between study investigators and manufacturers were often not clarified.
Thanks, Dr. Brad, for your very thorough response. There is another review of the subject that may be of interest: http://www.quackwatch.org/01QuackeryRelatedTopics/DSH/glucosamine.html
Personally, I think it’s fine for folks with arthritis to try these supplements (providing they have no shellfish allergies – glucosamine is derived from shellfish shells – and are not strict vegetarians – chondroitin comes from cow cartilage). But folks should be aware that the best they can expect (based on the Lancet article) is a possible ~20% improvement in their symptoms. Other studies have shown no improvement over placebo.