Osteoarthritis Treatment by Gretchen A. Reis, MD

What is it?

Osteoarthritis (OA) is the most common form of arthritis, one of the leading causes of disability, and affects over 30 million Americans. It is also called degenerative joint disease or DJD. Unlike inflammatory arthritis types like rheumatoid arthritis, it is felt to be mostly aging and wear-and-tear. However, we now have discovered that some inflammatory pathways are increased in OA, also, so inflammation likely is a factor in addition to the wearing away of cartilage,

Osteoarthritis is a joint disease caused by progressive destruction of the joint cartilage. It mostly affects knees, hips, fingers and the spine. Although it mostly occurs with aging, traumatic injuries can also lead to OA. The cartilage slowly wears away and the ends of the bones also become ragged. The result is pain and stiffness.

 

How does it happen?

While OA has typically been thought to be just mechanical from a lack of cushioning, recent studies have shown that the innate immune system is stimulated in OA, which creates an inflammatory effect. This can worsen cartilage damage and the symptoms. We also now have found a possible link to gut health. A change in the microbiome of the intestine, called “dysbiosis”, is well known to increase gut lining inflammation. This leads to “leaky gut” where food substances and bacteria that are supposed to stay in the gut are absorbed through the intestinal lining. Once inside, they strongly trigger the immune system, which increases inflammation. In fact, certain substances called lipopolysaccharides “LPS” are made by bacteria in your gut. They are not supposed to be absorbed. When they sneak in through a leaky gut wall, they can actually go to certain immune cells right in the joint, where they stimulate inflammation. So, controlling overall inflammation and gut health is important.

 

Exercise:

A sedentary lifestyle increases the risk of OA. Moderate physical activity is recommended for everyone with mild to severe OA. Exercise causes mild mechanical stress, which stimulates the creation of more cartilage. It also reduces stiffness, which increases physical ability. Mild to moderate activity such as walking, cycling, swimming or gardening are all a good way to improve joint function. Not exercising is a sure way to make arthritis worse.

 

Nutrition:

A healthy diet that is patterned after the Mediterranean diet is well known to be anti-inflammatory. Eating more fruits and vegetables, fish, chicken, legumes, nuts and healthy oils is a great nutrition plan. Avoid processed foods, white flour, sugar, and commercial red meat. A healthy diet will help you with weight, provides antioxidants, and includes healthy fatty acids. There are some studies on the Mediterranean diet and OA, and they do show a benefit. A well-balanced diet that includes a wide variety of fruits and vegetables will also provide many vitamins and minerals that are important for healthy metabolism and cellular function.

 

Pharmacologic Treatments:

Physicians often inject joints with steroids, but these give only temporary relief. Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are often prescribed as well. These do provide symptomatic relief quickly, but their benefits stop as soon as the medication stops, so they are not reversing the disease. They also have side effects such as ulcers and kidney impairment, so they are not without risk.

 

Glucosamine

The past several decades have been filled with many studies on glucosamine, and it is widely used as a dietary supplement. The research is generally positive on glucosamine as a treatment for OA. It does have a slow onset of action, meaning that it has to be taken for weeks to several months to have its effect, but in contrast to NSAIDs, it has effect for some time after it is discontinued, and it has fewer side effects. A typical dose is 1500 mg divided into several doses per day.

 

Chondroitin

Glucosamine is often used with chondroitin. Chondroitin sulfate works by drawing water into the cartilage. Studies done in the past 30 years have shown that it can reduce pain. It, too, takes longer to work than NSAIDs, but one study showed residual benefit for months after it was discontinued. A typical dose is 800-1200 mg divided into several doses per day.

 

Hyaluronates

Hyaluronic acid (HA) is a structural component of the synovial fluid in the joints that chondroitin attaches to. It has been used for years in joint injections to provide cushioning for the joint, which does work, albeit temporarily. Oral use of HA has been studied with overall positive results. HA is usually used in combination with other ingredients such as collagen.

 

Collagen

Commercial collagen products vary widely in their quality and the type of collagen. The most important quality of the collagen, though, is whether is it undenatured or hydrolyzed. Undenatured collagen is a very large protein molecule, which has very low bioavailability. Partially or fully hydrolyzed collagen products are much smaller molecules, and thus are better absorbed. Hydrolyzed collagen has been shown to improve OA pain in some studies but not in others. At this time, the research is not conclusive, most likely due to the high variability and composition in products studied. There also is not enough data to determine if there is any benefit to certain types of collagen in the products (type 1, type 2, etc) or not. Collagen that is hydrolyzed is very safe and many people do find benefit, so it may be worth a try.

 

Sulfur Molecules

S-adenosylmethionine (SAMe) is a source of sulfur, which is a crucial component of chondroitin. SAMe studies have shown some promise for OA, but the studies were small so no firm conclusions could be drawn. Dimethyl sulfoxide (DMSO) is used as a topical analgesic but it probably works by blocking pain fibers, not directly on the joint.

 

Curcumin

The turmeric root and rhizome contain a number of curcuminoids, which are typically referred to as “curcumin”. Studies and clinical experience have shown definite anti-inflammatory activity of curcumin. In OA, data usually shows that curcumin is either equal or better than NSAIDs. Products that include a range of curcuminoids, in particular using extracts from the turmeric root and rhizome, are likely better than a single isolated curcuminoid product.

 

Omega-3 Fatty Acids

EPA and DHA are the two essential fatty acids found in most fish oil products. They have been studied for decades for heart disease and are well known to have a powerful anti-inflammatory effect. They have not been extensively studied for OA, however, so no recommendations can be given. In general for overall health, omega-3 fatty acids should be consumed either in the diet or by supplementation. The best guide to the dose needed is a blood test called the “omega-3 index”, which should be 8% or higher.

 

Which product should I buy?

With all dietary supplements, especially some of these used for OA, the quality of the product makes a big difference. Many companies manufacture joint health supplements with poor quality ingredients or in a way that the product is poorly absorbed. They spend more money in their marketing than they do in the quality of their ingredients. Buying a pharmaceutical grade product (generally only available through a health care provider) is always worth it for OA supplements. The less expensive products at a super store are more likely to be a waste of money.

 

Conclusion:

Aging cartilage cells are a leading driver of osteoarthritis. While there is not a lot we can do about aging, the other cause of osteoarthritis such as lack of cartilage precursors and inflammation are definite opportunities for intervention. Recommendations include maintaining a healthy weight, staying well hydrated, eating a Mediterranean diet and staying physically active. Supplements should include cartilage precursors as a foundation, which is two or three of the following: glucosamine, chondroitin, and hyaluronic acid. Adding botanical anti-inflammatories such as turmeric and omega-3 fatty acids will improve the overall effect.