Friday, April 22, 2016

Supplementation in Osteoarthritis

  • role of diet or dietary supplements in the treatment of osteoarthritis (OA) remains unclear.
  • Research into diet as an independent factor has focused on antioxidants (eg, vitamins C and E) and on vitamin D.
  • use of glucosamine and chondroitin for osteoarthritis (OA) has been controversial, and these widely used remedies are of uncertain benefit; results of randomized trials have varied
Chondroitin and Glucosamine
  • Glucosamine typically been studied at a dose of 500 mg three times daily, and chondroitin at a dose of 400 mg three times daily.
  • Glucosamine should not be administered to patients who are allergic to shellfish.
  • The balance of evidence from high-quality trials has shown little to no evidence of clinically meaningful benefit
Evidence
  • A 2015 Cochrane review of 43 randomized trials including 9110 patients with mostly knee OA found that chondroitin, either alone or in combination with glucosamine, resulted in a statistically significant improvement in pain scores in studies with <six months of follow-up. 
    • Although the benefit was considered clinically meaningful, the effect was small, with an 8-point greater improvement of pain (range 0 to 100) from mostly low-quality trials
  • In a multicenter randomized non-inferiority trial, 606 patients with severe pain from knee OA were treated with either the combination of chondroitin sulfate and glucosamine or celecoxib. At six months follow-up, there were no significant differences between the two groups in reduction in pain, stiffness, functional limitation, and joint swelling. 
    • However, important limitations of the study design include the lack of a placebo arm as well as the preparation of the chondroitin and glucosamine, which may not be generalized to other compound mixtures
Vitamin C
  • analyzed data strongly suggested a relationship between vitamin C intake and progression of OA; the risk of progression was reduced threefold in patients with mean vitamin C intakes above 152 mg per day.
Vitamin E and Beta Carotene
  • may also reduce the risk of progression, but the data on these nutrients were less consistent.
  • In comparison, intake of these three nutrients did not affect the rate of development of OA
  • In contrast to the observational data, the administration of vitamin E (500 international units per day) for six months did not provide pain relief or prevent radiographic progression
Vitamin D
  • risk of OA progression increased threefold in patients with low vitamin D intake
  • Other observational data have also suggested an association with pain and radiographic
  • low intake and serum levels of vitamin D did not increase the risk for developing OA in the Framingham follow-up analysis
  • several randomized trials of vitamin D treatment have found no benefit from this approach, although one trial reported a small degree of symptomatic improvement
Recommendations
  • Not routinely recommend to use glucosamine and chondroitin for OA these medications, but there appear to be few risks associated with their use. 
  • In patients who use these medications we advise their discontinuation if significant relief is not achieved after a six-month trial
  • Supplementation with these agents for the treatment of OA is not suggested; randomized trials have failed to confirm that dietary supplementation with such agents can provide the potential benefits suggested by data from observational studies
References

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