Glucosamine, where's the proof?

Millions of Americans are plagued with arthritis. Arthritis is synonymous with old age. However, I am diagnosing younger and younger patients with arthritic changes in the joints of their spine, hips, shoulders and knees.

So what can you do? Well, the answer is not that simple. There is little you can do to reverse the bony spurs that occur with osteoarthritis (OA). You can however address the muscles, joints and cartilage of the affected areas.

Clinically, chiropractic manipulation of the spine has mixed results. Some patients respond very well to manipulation where as others respond less favorably. My approach consists of addressing tight muscles and joint capsules. I find that stretching is very effective in reducing "tightness" associated with OA. Of course the location of the arthritis may limit these treatments. Once the joints are moving more freely, there is much less pressure in the joints and thereby providing a lot of relief. The next step is dietary modifications. Remove all inflammatory foods from your diet, such as dairy and wheat. The next step is supplementation. There is strong scientific support for the use of Glucosamine to promote healthy joints and reduce the pain associated with OA. Although results vary from study to study, the literature does support its use.

All human studies of glucosamine have been done using glucosamine sulphate. However, there is new evidence suggesting that glucosamine HCL is more readily absorbed, cheaper to manufacture and provides more glucosamine by weight. Therefore, you are getting more for your money. For the purposes of literature review and for this blog, consider these products as equals.

Glucosamine is a natural compound that is found in healthy cartilage. Glucosamine sulfate is a normal constituent of glycoaminoglycans in cartilage matrix and synovial fluid.

Dosage:

*** the most common mistake patients make when taking glucosamine is that they do not take enough of the active ingredient and they do not take it long enough. Remember cartilaginous tissue builds slowly, subjective changes can take 2-3 months, be patient.

Adults (18 years and older)

In most available studies, 500 milligrams of glucosamine sulfate has been used, taken by mouth as tablets or capsules three times daily, for 30 to 90 days. Once daily dosing as 1.5 grams (1,500 milligrams) has also been used.

Glucosamine hydrochloride provides more glucosamine than glucosamine sulfate , although this difference may not matter when products are prepared to provide a total of 500 milligrams of glucosamine per tablet. Glucosamine HCL will provide about 20% more than glucosamine sulphates by weight.

Children (younger than 18 years)

There is not enough scientific evidence to recommend the use of glucosamine in children.

Research in children has shown that there could be a relationship between the ingestion of MSM (methylsulfonylmethane) and autism; whether it is beneficial or harmful is unclear. MSM is often marketed with glucosamine as a dietary supplement and at this time should be avoided in children.

Allergies

Since glucosamine can be made from the shells of shrimp, crab, and other shellfish, people with shellfish allergy or iodine hypersensitivity may have an allergic reaction to glucosamine products. A serious hypersensitivity reaction including throat swelling has been reported with glucosamine sulfate.

Side Effects and Warnings

In most human studies, glucosamine sulfate has been well tolerated for 30 to 90 days.

Side effects may include upset stomach, drowsiness, insomnia, headache, skin reactions, sun sensitivity, and nail toughening. There are rare reports of abdominal pain, loss of appetite, vomiting, nausea, flatulence (gas), constipation, heartburn, and diarrhea. Look for a product that contains other GI soothing elements such as Ginger, this should help reduce these symptoms.

It remains unclear if glucosamine alters blood sugar levels. Several human studies suggest no effects on blood sugar, while other research reports effects on insulin. Caution is advised in patients with diabetes or hypoglycemia, and in those taking drugs, herbs, or supplements that affect blood sugar. Serum glucose levels may need to be monitored by a health care provider, and medication adjustments may be necessary.

In theory glucosamine may increase the risk of bleeding. Caution is advised in patients with bleeding disorders or taking drugs that may increase the risk of bleeding. Dosing adjustments may be necessary.

In several human cases, abnormal increased amounts of protein were found in the urine of patients receiving glucosamine/chondroitin products. The clinical meaning of this is unclear. Glucosamine is removed from the body mainly in the urine, and elimination of glucosamine from the body is delayed in people with reduced kidney function. Increased blood levels of creatine phosphokinase may occur with glucosamine/chondroitin, which may be due to impurities in some products. This may alter certain laboratory tests measured by healthcare providers.

Preliminary data suggest that glucosamine may modulate the immune system, although the clinical relevance of this is not clear.

Pregnancy & Breastfeeding

Glucosamine is not recommended during pregnancy or breastfeeding due to lack of scientific evidence.

Interactions with Drugs

In theory, glucosamine may decrease the effectiveness of insulin or other drugs used to control blood sugar levels. However, there is limited human research to suggest that glucosamine may not have significant effects on blood sugar. Nonetheless, caution is advised when using insulin or drugs for diabetes by mouth. Patients with diabetes should be monitored closely by a qualified health care provider, and medication adjustments may be necessary. Based on limited evidence, the combination of glucosamine with diuretics (water pills) such as furosemide (Lasix®) may cause an increased risk of glucosamine side effects.

In theory, glucosamine may increase the risk of bleeding when taken with drugs that increase the risk of bleeding. Some examples include aspirin, anticoagulants ("blood thinners") such as warfarin (Coumadin®) or heparin, anti-platelet drugs such as clopidogrel (Plavix®), and non-steroidal anti-inflammatory drugs such as ibuprofen (Motrin®, Advil®) or naproxen (Naprosyn®, Aleve®). Please consult your physician if you are taking any medications.

Interactions with Herbs and Dietary Supplements

In theory, glucosamine may decrease the effectiveness of herbs or supplements that lower blood sugar levels, also glucosamine may increase the risk of bleeding when taken with herbs and supplements that are believed to increase the risk of bleeding.

There are preliminary reports that use of glucosamine with vitamin C, bromelain, chondroitin sulfate, bioflavonoids or manganese may lead to increased beneficial glucosamine effects on osteoarthritis. Simultaneous use with fish oil may have additive beneficial effects in the treatment of psoriasis, based on preliminary research.

Bromelain is a natural protein-digesting enzyme from the pineapple plant. It has been used therapeutically for reducing acute and chronic inflammation in joints and muscle tissue. The literature supports the use of proteolytic enzymes such as Bromelain along with glucosamine to reduce swelling in the affected joints.

When choosing a good glucosamine supplement you should consider several factors. Glucosamine HCl contains more glucosamine by weight and is the most absorbable form. Look for a supplement that also contains a proteolytic enzyme (bromelain, papain) and a strong anti-oxidant such as green tea extract.

Be patient, appreciable changes and improvements may take several months to achieve. Be sure to make dietary modifications, exercise regularly and take a good multi-vitamin.

Stay healthy!

Sachin

References:

1. Reginster JY, Deroisy R, Rovati LC, et al: Long-term effects of glucosamine sulphate on osteoarthritis progression: a randomised, placebo-controlled clinical trial. Lancet 2001c; 357(9252):251-256.

2. Pavelka K, Gatterova J, Olejarova M, et al: Glucosamine sulfate use and delay of progression of knee osteoarthritis: a 3-year, randomized, placebo-controlled, double-blind study. Arch Intern Med 2002; 162(18):2113-2123.

3. Houpt JB, McMillan R, Wein C, et al: Effect of glucosamine hydrochloride in the treatment of pain of osteoarthritis of the knee. J Rheumatol 1999; 26(11):2423-2430.

4. D'Ambrosio E, Casa B, Bompani R, et al: Glucosamine sulphate: a controlled clinical investigation in arthrosis. Pharmatherapeutica 1981; 2:504-508.