MSK 17: Natural Health Products Flashcards
What are the sources of glucosamine?
–
What is the MOA of glucosamine?
- precursor to many glycosaminoglycans (GAG) – chondroitin sulphate, hyaluronic acid (increase joint lubrication/synovial fluid), keratin sulphate
- increase cartilage production
- needed for maintenance of healthy joints
- inhibits inflammatory mediators
What is the evidence for glucosamine (sulfate and HCl)?
- more evidence for sulfate salt
- significantly ↓ joint space narrowing
- may be effective when combined with omega-3 or IBU
What is the onset of glucosamine?
2-4 weeks to show any effect
What are the safety points for glucosamine?
- allergy to shellfish is due to antigen in flesh (not shell) – many cases of hypersensitivity (use synthetic source to be cautious)
- avoid combination with warfarin
What are the sources of chondroitin?
- synthesized in body
- bovine, pork, avian, or shark cartilage
- produced synthetically
- available as sulfate salt
What is the MOA of chondroitin?
- most abundant glycosaminoglycan (GAG) → substrate for cartilage
- stimulates chondrocytes (increase cartilage production)
- needed for maintenance of healthy joints
- inhibits inflammatory mediators
What is the evidence for chondroitin (sulfate)?
↓ in pain intensity and improved physical function
What is the onset of chondroitin?
slow – maximum clinical benefit seen between 3-6 months
What are the safety points for chondroitin?
part of heparin molecule, theoretical risk of bleeding – avoid warfarin
Evidence for Glucosamine and Chondroitin
only chondroitin sulfate significantly reduced pain intensity and improved physical function
- only glucosamine sulfate significantly decreased joint space narrowing
- combination of GS + CS showed no decrease in pain nor increase in physical function
omega-3 has anti-inflammatory effects
- combination of GS + CS not shown to be effective at reducing pain
- addition of omega-3 was shown to decrease side effects of glucosamine
Chondroitin vs. Celecoxib (Knee OA)
- both CS and celecoxib had improvement in pain from placebo by 3 months, at 6 months
- no difference between chondroitin and celecoxib – both very slow-acting
What are the limitations to research?
- concerns over study bias (especially positive findings with GS – Dona®)
- small numbers, heterogeneity of studies
- different salts used
- different quality of products
- conflicting data regarding efficacy has led to some guidelines supporting positive statements in use, and others recommending against use in osteoarthritis
Summary of Glucosamine and Chondroitin
- despite conflicting data, there is continued interest from experts and patients due to lack of options (and safety of NSAIDs in aging population)
- most research shows modest reduction in knee pain (in patients with moderate to severe knee pain), but benefits may not occur for several months – latest review puts CS as more effective
- does not appear to help back pain or hip pain caused by OA (although CS did improve hand pain)
- may help build cartilage
- tell patients it will take longer to achieve pain relief
- reasonable trial: 3-6 months (mostly safe)
What is eggshell membrane?
- What is it used for?
- Is it recommended?
naturally contain type I collagen, elastin, and small amounts of glucosamine and chondroitin
- shown to modestly improve joint pain and flexibility – people with most difficulty walking had improved knee stiffness + walking distance, modest improvement in knee function + reduced pain + stiffness
- popular, but insufficient evidence to recommend
- seems well tolerated
What is boswellia (frankincense)?
- What is it used for?
gum resin yielded from bark
- used to treat pain and inflammation in OA
- often used in combination products
What is the evidence for boswellia (frankincense)?
significant improvement in pain, stiffness, and joint function
- results as soon as 4 weeks
- limitations of study: heterogeneity (different dosages/preps), low to medium quality
- many positive studies where combined with other products (ie. turmeric, ginger, MSM, glucosamine sulfate)
What are the safety points for boswellia (frankincense)?
generally safe, with no significant adverse effects or drug interactions reported
What is the MOA of boswellia (frankincense)?
anti-inflammatory, analgesic, and ‘anti-arthritic effects’
What is turmeric (curcumin)?
- curcumin is compound found in turmeric, which gives it its yellow-orange colour
- source is root of Curcuma longa
- used as an extract
What is the evidence for turmeric (curcumin)?
- curcumin alone significantly decreased function, pain, and stiffness – efficacy comparable to NSAID use, optimal use is > 8 weeks (reported more significant improvement), may be a safer alternative to NSAIDs
- curcumin + NSAIDs was most effective intervention for reducing use of rescue medication – curcumin had few adverse events compared to NSAIDs
What are the safety points for turmeric (curcumin)?
- generally safe to take
- stomach upset, nausea/diarrhea
- may decrease blood glucose – caution in diabetes
- anti-coagulants – may increase INR
What is the MOA of turmeric (curcumin)?
- possibly reduces inflammation through blocking COX-2, prostaglandins, and other cytokines
- anti-oxidant properties
What are the sources of methylsulfonylmethane (MSM)?
- naturally occurring organosulfur compound
- naturally in grains, eggs, fish, green plants, fruits
- NHPs are synthetic
What is the evidence for methylsulfonylmethane (MSM)?
- combination therapy with MSM (500 mg TID) and GS (500 mg TID) was significantly more effective in reducing pain, and swelling and improving functional ability of joints than individual agents alone – clinical effectiveness seen at 4 weeks
- GS + CS + MSM showed significant clinical improvement compared to GS + CS alone (at 12 weeks only)
What are the safety points for methylsulfonylmethane (MSM)?
- well-tolerated, mild GI symptoms
- no known drug interactions
What is the MOA of methylsulfonylmethane (MSM)?
- essential compound in formation of keratin and collagen
- anti-inflammatory
- may inhibit degenerative changes in joints
What are the sources of S-Adenosyl-Methionine (SAMe)?
- synthetic (as NHP)
- made in liver from methionine
What is the evidence for S-Adenosyl-Methionine (SAMe)?
- SAMe was equal to NSAID and better than placebo for pain and function – slower onset than celecoxib
- NSAID and NSAID + SAMe groups had similar decrease in pain/stiffness (equals NSAID) – SAMe well-tolerated (significantly greater improvement in activities of daily living, quality of life (also has anti-depressant properties))
What is the onset of S-Adenosyl-Methionine (SAMe)?
slow – may take up to 30 days to see any improvement
What are the safety points for S-Adenosyl-Methionine (SAMe)?
NHP-condition interaction – avoid use in bipolar disorder (may cause mania or hypomania)
What is the MOA of S-Adenosyl-Methionine (SAMe)?
stimulates cartilage growth and repair (increase chondrocytes)
What are some other considerations for S-Adenosyl-Methionine (SAMe)
- use enteric-coated – unstable at room temperature when exposed to air
- very costly – depending on dose
Boswellia
Efficacy
- recent MA/SR shows significant improvement in reducing pain/stiffness and increasing function (note shortcomings of studies)
- NatMed: possibly effective
Boswellia
Safety
generally safe
Turmeric/Curcumin
Efficacy
- superior to placebo at reducing pain and function
- seems to be as effective as NSAIDs with less adverse events
- one MA suggests > 8 weeks of treatment for bes
effect - NatMed: possibly effective
Turmeric/Curcumin
Safety
CI: may decrease blood glucose (monitor if diabetic)
Methylsulfonylmethane (MSM)
Efficacy
- may be beneficial to combine with GS and CS
- clinical significance uncertain
- not well studied alone
- NatMed: possibly effective
Methylsulfonylmethane (MSM)
Safety
very well tolerated
S-Adenosyl-Methionine (SAMe)
Efficacy
- evidence indicates that it may be as effective as NSAIDS and better than placebo
- slower onset than NSAIDs
- positive evidence for improving mood
- NatMed: likely effective
S-Adenosyl-Methionine (SAMe)
Safety
- CI: bipolar disorder
- well tolerated
Deciding to Recommend or Not
What therapies may be recommended?
evidence supports safety for patient AND evidence supports efficacy is equal to or better than alternatives
Deciding to Recommend or Not
What therapies may be accepted?
evidence supports safety for patient BUT evidence for efficacy is inconclusive
Deciding to Recommend or Not
What therapies should be discouraged?
evidence indicates serious risk for patient OR evidence indicates inefficacy
