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LE Magazine October 1999
Osteoarthritis
& Rheumatoid Arthritis
Continued from Article Osteoarthritis & Rheumatoid
Arthritis
There are many studies confirming the excellent effect and
safety of glucosamine
sulfate. In one well designed study of 178 patients
suffering from osteoarthritis of the knee (Qiu GX et al.,
1998), one group was treated for 4 weeks with glucosamine
sulfate 1500 mg daily and the other group with ibuprofen at
1200 mg per day. Glucosamine relieved the symptoms as
effectively as ibuprofen, and was significantly better
tolerated than ibuprofen. The safety and tolerability of
glucosamine can easily be explained by the fact that it is a
physiological substance normally used by the body.
As with most natural remedies the therapeutic effect of
glucosamine does not come immediately, and usually takes some
weeks to appear (1-8 weeks). Once achieved, it tends to
persist for a notable time even after discontinuation of the
treatment.
| A Healthy Joint |
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To understand the pathological processes in the joint, we
need to take a look at the normal healthy joint. Joints are
held together by a joint capsule and designed to allow
smooth movement between adjacent bones. In the type of
joint commonly affected by arthritic diseases, the highly
movable joints, we find the bone ends covered by articular
cartilage and the joint space enclosed by a synovial
membrane. This thin membrane secretes synovial fluid that
lubricates the space between the cartilage-covered
joint-forming bones. The cartilage contains no blood
vessels or nerves and receives its nutrients by diffusion
from the synovial fluid and from the bone.
Joint function depends on the health of the cartilage in
the joint. Cartilage is a gel-like substance that acts as a
shock absorber, essential for smooth and easy movement in
the joint. Cartilage gets its elasticity from collagen
fibers and its sponge-like quality from water, held by a
structure of big molecules called proteoglycans. Collagen
and proteoglycans are produced by special cells, called
chondrocytes, in the cartilage. Joints can withstand
enormous pressure by slowly releasing water from the
cartilage.
As we age the ability to restore and maintain a normal
cartilage structure begins to decline. The activity of
important repair zymes is reduced, the water content
diminished, and the joints become more prone to damage. But
the full pathological mechanism for development of
arthritis is not yet known.
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Chondroitin sulfate
Chondroitin sulfate is a major component of cartilage. It is a
very large molecule, composed of repeated its of glucosamine
sulfate. Like glucosamine, chondroitin sulphate attracts water
into the cartilage matrix and stimulates the production of
cartilage. Likewise it has the ability to prevent enzymes from
dissolving cartilage. Although the absorption of chondroitin
sulfate is much lower than that of glucosamine (10-15% versus
90-98%), a few recent studies have shown very good results
from long-term treatment with chondroitin sulfate, reducing
pain and increasing range of motion.
- A one-year long, double blind clinical study including 42
patients with osteoarthritis showed that chondroitin sulfate
was well tolerated and significantly reduced pain and
increased joint mobility. The patients were given 800 mg
chondroitin sulphate per day or placebo (Uebelhart D et al.,
1998).
- In another double-blind study 119 patients with
finger-joint osteoarthritis were followed for 3 years. The
chondroitin dosage was 400 mg three times daily. X-rays of the
finger joints were carried out at the start and at yearly
intervals. The number of patients that developed progression
of the disease was significantly less in the group treated
with chondroitin sulfate (Verbruggen G et al., 1998).
- The improvement in walking time was studied in 80
patients with osteoarthritis in the knee. In this double-blind
study the treatment period was 6 months and the chondroitin
sulfate dosage 400 mg twice daily. The minimum time to perform
a 20 meter walk showed a constant reduction of time only in
the chondroitin group. Lower consumption of pain-killing drugs
and excellent tolerability was also observed (Bucsi et al.,
1998).
Glucosamine alone or in combination with chondroitin
sulfate is more and more becoming recognized as the treatment
of choice for osteoarthritis even in the United States. Its
ability to actually repair and improve joint function in
addition to providing pain relief gives it a significant
advantage compared to conventional treatment.
Willow bark
Salicylic acid, the basis of aspirin, was first prepared
from willow bark by an Italian chemist in 1838. The name of
the compound is derived from Salix, the Latin name for the
willow genus. Aspirin, or acetylsalicylic acid, is a synthetic
form of salicylic acid. Willow bark is rich in salicin and
related salicylates that metabolize into salicylic acid. Many
plants, such as meadowsweet and wintergreen, also contain
these compounds. They have a long tradition of use in Europe,
and far fewer side effects than aspirin.
While aspirin/salicin has been shown to have a lowering
effect on some of the pro-inflammatory factors, it can also
increase ukotriene LTB4, which is a major inflammation
promoting mediator. An interesting study (Engstrom K et al.,
1997) compared the effect on pro-inflammatory substances of
aspirin alone with a combination of low-dose aspirin and fish
oil. The results showed that the combination of fish oil and
low-dose aspirin has significantly more favorable effects on
the pattern of pro-and anti-inflammatory factors than the
aspirin alone. LTB4 increased 19% when aspirin was taken by
itself, but decreased 69% after intake of aspirin and fish oil
together.
| Current Medical Treatment |
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The basic conventional treatment for both osteoarthritis
and rheumatoid arthritis consists of NSAIDs including
aspirin. Even stronger drugs such as corticosteroids, gold
salts and methotrexate are often prescribed for RA in an
aggressive attempt to stop the development of the disease.
These drugs are all aimed at alleviating pain and reducing
inflammation. They can sometimes be effective, but more
often, however, they prove unsatisfactory and many times
intolerable due to toxicity. Aspirin, for example, which is
the most commonly used, is quite effective, but it often
causes gastric irritation and tinnitus (ringing in the
ears) with the high dosages needed. Other NSAIDs may be
somewhat better tolerated but have an even greater risk for
serious side effects, which limits their use. These
treatments are only symptomatic, because they do not act on
the causes of arthritis and do not stop the progression of
the disease. In fact, the opposite has proven to be true.
It has been demonstrated in many studies that NSAIDs
actually have an inhibitory effect on cartilage repair and
accelerate cartilage destruction (Brooks PM et al., 1982;
Shield MJ, 1993; Newman NM et al., 1985; Solomon L, 1973;
Ronningen H et al., 1979). How can it be that NSAIDs help
and destroy at the same time?
NSAIDs exert their analgesic and anti-inflammatory
effects through the inhibition of the enzyme cyclooxygenase
(COX). The discovery (Needleman P et al., 1979) that two
forms of COX exist, COX-1 and COX-2, has clarified the dual
nature of NSAIDs. While relieving pain and inflammation
through COX-2 blockade, they also block, via COX-1, the
biotransformation of arachidonic acid to substances that
carry out various homeostatic (balancing) physiological
functions, one of which is to protect the gastrointestinal
mucosa and limit gastric acid output. While NSAIDs inhibit
prostaglandin and leukotriene synthesis through COX-2
blockade, they fail to influence the TNF-a and IL-1b
activation of cartilage destroying enzymes.
With this enhanced understanding of the underlying
mechanisms for current medical treatment, researchers are
now looking for new compounds that will relieve pain and
inflammation and enhance the repair process in the joints,
without inhibiting important physiological functions. A
COX-2 -specific inhibitor has recently come out on the
pharmaceutical market and other products are underway.
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Fish oil
It is established that dietary fatty acids determine the
composition of lipids in the cell membranes, which influences
the production of prostaglandins and leukotrienes that
regulate inflammation, a fact that has given rise to interest
in the potential of these dietary substances.
Omega-3-oils, such as fish
oil (EPA and DHA) and flax
seed oil, have the ability to suppress the production of
inflammatory mediators and thereby influence the course of
chronic inflammatory diseases such as RA. (Kremer JM et al.
1985 and 1992).
 A new enteric-coated fish-oil preparation was
used in a one-year, double blind study of 78 patients with
inflammatory bowel disease. The absorption rate and
tolerability was high with this preparation, and after one
year 59% of the fish-oil group remained in remission compared
to 36% in the placebo group, indicating a significant
anti-inflammatory effect (Belluzzi A et al., 1996)
In recent studies, dietary omega-3 oils have shown a
suppressive effect on the production of the cytokines IL-1b
and TNF-a, which stimulate the production of collagenase and
pro-inflammatory prostaglandins (PGE2) (James MJ et al., 1997;
Caugey GE et al., 1996). When fish oil supplementation was
given to rheumatoid arthritis patients, arachidonic acid
levels were reduced by 33% compared to presupplement values
(Sperling RI et al., 1987), suggesting that increase of
dietary omega-3 oils can be complementary in treating
rheumatoid arthritis.
A large number of publications from around the world have
confirmed the usefulness of dietary supplementation with
omega-3 oils in relieving tender joints and morning stiffness
in patients with RA, in some cases eliminating the need for
NSAID medication (Kremer JM et al., 1995). Skoldstam et al.
(1992) and Lau et al. (1993) found that patients consuming
fish oil were able to significantly reduce their NSAID dose
compared with a control group.
Of 12 published double blind and placebo-controlled studies
with a duration of 12-52 weeks, decreased joint tenderness was
the most common favorable outcome reported. Fish oil
supplementation significantly decreased the use of NSAIDs in
the three studies in which NSAIDs were used. Unlike NSAID use,
fish oil consumption is not associated with gastrointestinal
toxicity. The results of the studies suggest that the
effective dose of fish oil is approximately 3-6 grams per day.
Higher dosages did not give better results. There are
indications that the combination of EPA and DHA, as it is
found in fish oil, has a synergistic effect (Robinson DR et
al., 1989).
A study by James MJ et al. (1997) emphasizes the potential
for increased efficacy of anti-inflammatory drugs, when using
omega-3 oils in the diet. It was observed that diets rich in
omega-3 oils and low in omega-6 fats had a drug sparing effect
with decreased side effects. Drug toxicity is estimated to
contribute 60% of the total cost of treating RA patients in
the United States (Prashker MJ et al., 1995). Use of
omega3-oils in the diet would appear to offer a simple, safe
and inexpensive way to reduce toxicity and side effects from
RA medications.
Oxidative damage
Food is not conventionally accepted as influential in the
course of inflammatory or degenerative diseases (in contrast
to diabetes and vascular heart
disease).
We know, however, that oxidative stress or free radical
damage is a factor of importance in the development of
osteoarthritis, just as it is a major cause of most chronic
degenerative diseases as well as aging. There is also strong
evidence that oxidative damage occurs in RA patients.
Increased oxidation of lipids (peroxidation) as well as
depletion of ascorbate in serum and synovial fluid has been
observed. High doses of vitamin
E, which is a powerful antioxidant, are reported to
diminish pain. Most importantly, tumor necrosis factor alpha
(TNF-a), which plays a key role in RA, is well-known to cause
oxidative stress.
In order to counteract free radical damage, antioxidants
are needed. A diet rich in vegetables and fruits is likely to
add important antioxidants to the body. This may not always be
enough, however. Vitamin
C and vitamin E supplements have been studied and found to
be important in the treatment of osteoarthritis. Deficient
vitamin C intake, which is common with elderly people, impairs
the synthesis of collagen, the main protein of cartilage
(Bates CJ, 1977). Studies on vitamin E have shown its ability
to stimulate the production of cartilage components, such as
glycosaminoglycans, as well as to inhibit the breakdown of
cartilage.
Healthy food and a minimum of toxins may be more important
for our health than we want to believe. The body strives to
heal itself, whether it is a cut finger, a cold or a damaged
or inflamed joint. It makes sense to find ways to support the
body with natural substances that the body can use in the
healing process.
Recent research has provided us with new insights into the
mechanisms of arthritis, and left us with a scientific
understanding of how natural remedies work in harmony with the
body rather than against it.
Product Information:
ArthroPro System
For Joint Health & Comfort
Continuation of Article Osteoarthritis & Rheumatoid
Arthritis
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