Efficacy of Chondroitin Sulfate in Patients with Knee Osteoarthritis: A Comprehensive Meta-Analysis Exploring Inconsistencies in Randomized, Placebo-Controlled Trials

Efficacy of the use of chondroitin sulphate and glucosamine for the treatment of temporomandibular joint dysfunction: A systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy of chondroitin sulfate (CS) and glucosamine (GS), the most relevant drugs of "Symptomatic Slow Acting Drug for Osteoarthritis" (SYSADOA), in the functional and symptomatic improvement of temporomandibular dysfunction. Although, controversy exists regarding their benefit.

METHODS

An electronic search was conducted to retrieve randomized controlled clinical trials (RCTs). The risk of bias assessment was evaluated using the Cochrane Collaboration's tool. Data were meta-analyzed with a random effect model whenever possible.

RESULTS

Three RCTs were included. Qualitative results showed a decrease in pain, joint noise, and inflammatory biomarkers in synovial fluid and an improvement in maximum mouth opening without significant adverse effects. Meta-analysis showed a significant increase in maximum mouth opening with the use of CS-GS (p = 0.19). No statistically significant differences were found in pain reduction compared to tramadol.

CONCLUSION

CS-GS is effective and safe in the symptomatic and functional improvement of patients with TMD.

The effect of combined hydrolyzed type 2 collagen, methylsulfonylmethane, glucosamine sulfate and chondroitin sulfate supplementation on knee osteoarthritis symptoms

Objectives

This study aimed to evaluate the effects of the combined hydrolyzed type 2 collagen, methylsulfonylmethane (MSM), glucosamine sulfate (GS), and chondroitin sulfate (CS) supplement on knee pain intensity in patients with knee osteoarthritis (OA).

Patients and methods

This multicenter, observational, noninterventional study included 98 patients (78 females, 20 males; mean age: 52.8±6.5 years; range, 40 to 64 years) who had Grade 1-3 knee OA between May 2022 and November 2022. The patients were prescribed the combination of hydrolyzed type 2 collagen, MSM, GS, and CS as a supplement for knee OA. The sachet form of the combined supplement containing 1250 mg hydrolyzed type 2 collagen, 750 mg MSM, 750 mg GS, and 400 mg CS was used once daily for two consecutive months. Patients were evaluated according to the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Visual Analog Scale (VAS)-pain, and Health Assessment Questionnaire (HAQ). Patients were scheduled to visit for follow-up four weeks (Visit 2) and eight weeks (Visit 3) after Visit 1 (baseline; day 0 of the study).

Results

For the VAS-pain, WOMAC, WOMAC-subscale, and HAQ scores, the differences in improvement between the three visits were significant (p<0.001 for all). The patient compliance with the supplement was a median of 96.77%, both for Visit 2 and Visit 3.

Conclusion

The combination of hydrolyzed type 2 collagen, MSM, GS, and CS for eight weeks in knee OA was considered an effective and safe nutritional supplement.

Molecular mechanisms and potential applications of chondroitin sulphate in managing post-traumatic osteoarthritis

Post-traumatic osteoarthritis (PTOA), a disorder of the synovium, subchondral bone, and cartilage that affects the entire joint, constitutes approximately 12% of all cases of symptomatic osteoarthritis. This review summarizes the pathogenetic mechanisms that underlie the positive influence of chondroitin sulphates (CSs) on PTOA as means of preventive and therapeutic treatment. Mechanisms of PTOA development involve chondrocytes undergoing various forms of cell death (apoptosis, pyroptosis, necroptosis, ferroptosis and/or necrosis). Chondroitin sulphates are a class of glycosaminoglycans that improve the structure and function of cartilage and subchondral bone, which is associated with their ability to decrease the activation of NF-κB and p38 MAPK, and up-regulate Nrf2. Standardized small fish extract (SSFE) is an example of the drugs that can attenuate NF-κB-mediated systemic inflammation, potentially helping to reduce joint inflammation and cartilage degradation, improve joint function, and alleviate pain and disability in patients with these conditions.

Current and Novel Therapeutics for Articular Cartilage Repair and Regeneration

Articular cartilage repair is a sophisticated process that has is being recently investigated. There are several different approaches that are currently reported to promote cartilage repair, like cell-based therapies, biologics, and physical therapy. Cell-based therapies involve the using stem cells or chondrocytes, which make up cartilage, to promote the growth of new cartilage. Biologics, like growth factors, are also being applied to enhance cartilage repair. Physical therapy, like exercise and weight-bearing activities, can also be used to promote cartilage repair by inducing new cartilage growth and improving joint function. Additionally, surgical options like osteochondral autograft, autologous chondrocyte implantation, microfracture, and others are also reported for cartilage regeneration. In the current literature review, we aim to provide an up-to-date discussion about these approaches and discuss the current research status.

Chondroitin Sulfate Supplements for Osteoarthritis: A Critical Review

Over the years, chondroitin sulfate (CS) has been used as a slow-acting drug for the treatment of osteoarthritis, for the reduction of pain and improvement of function, and for its disease-modifying properties by limiting cartilage volume loss and joint space narrowing progression. However, there have been inconsistencies in published trials regarding clinical efficacy, with reports of a lack of significant effects compared to placebo. The therapeutic effects of chondroitin sulfate may depend on many variables, such as the source of origin, purity, and contamination with by-products. Another source of confusion may be related to the fact that CS is commonly combined with glucosamine, which makes it challenging to isolate the specific contribution of chondroitin to the therapeutic outcome. This is aggravated by the fact that CS supplements, used in many countries, are not regulated, and labels wrongly claim high levels of purity. Many of these inferior CS products may have been used in clinical trials, which may have had limited but significant results. This has led to recent recommendations to opt for higher-purity pharmacologic-grade CS for the treatment of OA. This article aims to provide an up-to-date view of the current literature regarding the biological effects and efficacy of CS and discusses the quality of available chondroitin sulfate supplements and the current direction in CS investigation. This review concludes that pharmacologic-grade CS supplements may have clinically significant benefits when properly standardized; however, high-quality evidence from properly designed clinical trials is still needed to draw definitive conclusions about clinical efficacy in osteoarthritis.

Low-Molecular-Weight Chondroitin Sulfates Alleviate Simulated Microgravity-Induced Oxidative Stress and Bone Loss in Mice

(1) Background: Many studies have shown that microgravity experienced by astronauts or long-term bedridden patients results in increased oxidative stress and bone loss. Low-molecular-weight chondroitin sulfates (LMWCSs) prepared from intact chondroitin sulfate (CS) have been demonstrated to possess good antioxidant and osteogenic activities in vitro. This study aimed to assess the antioxidant activity of the LMWCSs in vivo and evaluate their potential in preventing microgravity-induced bone loss. (2) Methods: we used hind limb suspension (HLS) mice to simulate microgravity in vivo. We investigated the effects of LMWCSs against oxidative stress damage and bone loss in HLS mice and compared the findings with those of CS and a non-treatment group. (3) Results: LMWCSs reduced the HLS-induced oxidative stress level, prevented HLS-induced alterations in bone microstructure and mechanical strength, and reversed changes in bone metabolism indicators in HLS mice. Additionally, LMWCSs downregulated the mRNA expression levels of antioxidant enzyme- and osteogenic-related genes in HLS mice. The results showed that overall effect of LMWCSs was better than that of CS. (4) Conclusions: LMWCSs protect against the bone loss caused by simulated microgravity, which may be related to their ability to reduce oxidative stress. LMWCSs can be envisaged as potential antioxidants and bone loss protective agents in microgravity.

Molecular Basic of Pharmacotherapy of Cytokine Imbalance as a Component of Intervertebral Disc Degeneration Treatment

Intervertebral disc degeneration (IDD) and associated conditions are an important problem in modern medicine. The onset of IDD may be in childhood and adolescence in patients with a genetic predisposition. With age, IDD progresses, leading to spondylosis, spondylarthrosis, herniated disc, spinal canal stenosis. One of the leading mechanisms in the development of IDD and chronic back pain is an imbalance between pro-inflammatory and anti-inflammatory cytokines. However, classical therapeutic strategies for correcting cytokine imbalance in IDD do not give the expected response in more than half of the cases. The purpose of this review is to update knowledge about new and promising therapeutic strategies based on the correction of the molecular mechanisms of cytokine imbalance in patients with IDD. This review demonstrates that knowledge of the molecular mechanisms of the imbalance between pro-inflammatory and anti-inflammatory cytokines may be a new key to finding more effective drugs for the treatment of IDD in the setting of acute and chronic inflammation.

Development of a mobile application to monitor the effectiveness of a hydrolyzed cartilage matrix supplement on joint discomfort: a real-life study

BACKGROUND

Joint discomfort is a widespread and growing problem in active adults. The rising interest in preventative nutrition has increased the demand for supplements reducing joint discomfort. Protocols assessing the effect of a nutritional intervention on health commonly involve a series of face-to-face meetings between participants and study staff that can weigh on resources, participant availabilities and even increase drop-out rates. Digital tools are increasingly added to protocols to facilitate study conduct but fully digitally run studies are still scarce. With the increasing interest in real-life studies, the development of health applications for mobile devices to monitor study outcomes could be of great importance.

OBJECTIVE

The purpose of the current real-life study was to develop a specific mobile application, Ingredients for LifeTM, to conduct a 100% digital study testing the effectiveness of a hydrolyzed cartilage matrix (HCM) supplement on joint discomfort in a heterogeneous group of healthy, active consumers.

METHODS

The 'Ingredients for LifeTM ' mobile app using Visual Analog Scale (VAS) was specifically developed to monitor the variation in joint pain after exercise by the study participants. A total of 201 healthy and physically active, adult women and men (18 to 72 years old) with joint pain completed the study over a period of 16 weeks. Participants were randomly allocated to the study groups and did not receive any dietary or lifestyle advice. Each participant indicated one area of joint pain and logged the type and duration of their weekly activities. They received blinded study supplements and took a daily regimen of 1 g of hydrolyzed cartilage matrix (HCM-G) or 1g of maltodextrin (placebo group; P-G) for 12 weeks while weekly logging joint pain scores in the app. This was followed by a 4-week wash out period during which participants continued reporting their joint pain scores (until the end of week 16).

RESULTS

Joint pain was reduced within 3 weeks of taking a low dosage of HCM (1g/day), regardless of gender, age group and activity intensity when compared to the placebo-group. After stopping supplementation, joint pain scores gradually increased but still remained significantly lower than placebo after 4 weeks of washout. The low dropout rate (< 6% of participants, mainly in the P-G) demonstrates the digital study was well received by the study population.

CONCLUSIONS

The digital tool allowed to measure a heterogeneous group of active adults in a real-life setting (without any lifestyle intervention), thus promoting inclusivity and diversity. With low dropout rates, it demonstrates that mobile applications can generate qualitative, quantifiable, real-world data showcasing supplement effectiveness. The study confirmed that the oral intake of a low dose (1g/day) of HCM led to a significant reduction of joint pain from 3 weeks after starting supplementation.

CLINICALTRIAL

The Biota orientalis, oil extract Epiitalis®, is efficacious at reducing the symptoms of knee osteoarthritis: a pilot, multi-site, dose-ranging, randomized, blinded, placebo-controlled trial

Objective

To explore the safety, and efficacy of a proprietary hydrolyzed oil extract from seeds of Biota orientalis (hBO/Epiitalis^®, Interpath Pty Ltd) in patients with knee pain due to osteoarthritis (OA).

Methods

Patients aged 40–65 with X-ray diagnosed knee OA and knee pain ≥ 60 on a 100-point VAS (visual analog scale) were enrolled and randomized into four groups to receive daily hBO for 56 days as high (hBO-HD, 640 mg), mid (hBO-MD, 320 mg) or low (hBO-LD, 160 mg) doses, or a matched placebo oil. The primary outcome was change in VAS knee pain from baseline to 56 days in the mITT (modified intention to treat) population. Exploratory outcomes were the mWOMAC (modified Western Ontario and McMaster Universities Arthritis Index), and the SF-36 QoL (quality of life) questionnaire. The OMERACT-OARSI (Outcome Measures in Arthritis Clinical Trials–Osteoarthritis Research Society International) responder index was also calculated.

Results

223 patients were included in the mITT population. Reductions in VAS scores between baseline and day 56 [Least square mean (LS mean) and 95% confidence interval (CI) of LS mean] were 36.4 (31.7–41.0), 37.9 (33.2–42.7), 35.7 (31.2–40.1) and 9.8 (14.5–15.2) for the hBO-HD, hBO-MD, hBO-LD, and placebo groups respectively. The VAS changes in all hBO groups were significantly different (p < 0.0001) vs. changes in the placebo group. hBO treatment led to similar quantitative beneficial changes in mWOMAC, SF-36 and OMERACT-OARSI responder index. There were no SAEs and no adverse events ascribed to the intervention.

Conclusion

In a 56-day trial, hBO was safe, and was efficacious at reducing symptoms in patients with knee OA. Registration: NCT04117490; Oct 7, 2019.

Chondroitin sulfate in therapy osteoarthritis chronic pain patients according to actual clinical recommendations

Of undoubted interest is the search for new drugs comparable in effectiveness to nonsteroidal anti-inflammatory drugs (NSAIDs), but with a safer application profile. NSAIDs are characterized by a good analgesic effect due to the modulation of prostaglandin metabolism by inhibition of cyclooxygenase-2. One of the promising directions of pharmacotherapy of degenerative-dystrophic joint lesions is the use of symptom-modifying drugs of delayed action, which include chondroitin sulfate (CS). CS has antiresorptive activity, anti-inflammatory and anti-inflamaging effects. In addition to the direct effect on pain syndrome severity, he also have a modulating level effect of systemic inflammation of cartilage tissue. According to experts of international and Russian societies, pharmaceutical prescription-quality CS is a basic part of the treatment of osteoarthritis. One of the advantages of CS over NSAIDs is the preservation of the effect for 24 months after the treatment. Against the background of the use of CS, it is possible to reduce the dose or completely cancel NSAIDs, which helps to reduce the frequency of adverse events associated with their intake. CS has a favorable safety profile, which is important for elderly patients and those with comorbid diseases (cardioprotective effects). CS drugs can be administered per orally, intramuscularly, intra-articularly and in combination with different administration methods. Several clinical trials of CS (Chondrogard), including randomized, were conducted in Russia. The Russia Health Ministry approved the appointment of parenteral CS in clinical guidelines: Chronic pain in elderly and senile patients (2020), Falls in elderly and senile patients(2020), "Knee osteoarthritis" (2021), "Hip osteoarthritis" (2021).

Osteoarthritis complications and the recent therapeutic approaches

The accelerated prevalence of osteoarthritis (OA) disease worldwide and the lack of convenient management led to the frequent search for unprecedented and specific treatment approaches. OA patients usually suffer from many annoying complications that negatively influence their quality of life, especially in the elderly. Articular erosions may lead eventually to the loss of joint function as a whole which occurs over time according to the risk factors presented in each case and the grade of the disease. Conventional therapies are advancing, showing most appropriate results but still greatly associated with many adverse effects and have restricted curative actions as well. Hence, novel management tools are usually required. In this review, we summarized the recent approaches in OA treatment and the role of natural products, dietary supplements and nanogold application in OA treatment to provide new research tracks for more therapeutic opportunities to those who are in care in this field.

Drug Screening Implicates Chondroitin Sulfate as a Potential Longevity Pill

Discovering compounds that promote health during aging ("geroprotectors") is key to the retardation of age-related pathologies and the prevention of chronic age-related diseases. In in-silico and model organisms' lifespan screens, chondroitin sulfate has emerged as a geroprotective compound. Chondroitin sulfate is a glycosaminoglycan attached to extracellular matrix proteins and is naturally produced by our body. Oral supplementation of chondroitin sulfate shows a high tolerance in humans, preferable pharmacokinetics, a positive correlation with healthy human longevity, and efficacy in deceleration of age-related diseases in randomized clinical trials. We have recently shown that chondroitin sulfate supplementation increases the lifespan of C. elegans. Thus, chondroitin sulfate holds the potential to become a geroprotective strategy to promote health during human aging. This review discusses the two major potential mechanisms of action, extracellular matrix homeostasis and inhibition of inflammation, that counteract age-related pathologies upon chondroitin sulfate supplementation.

Locomotive syndrome: from paradigms to clinical reality

Locomotive syndrome is an unsatisfactory condition of patients over 60 years of age who need or may require outside help in the near future due to functional deterioration of the musculoskeletal system, including pathology of bone tissue, joints, muscles and nervous tissue. In real clinical practice, one often has to deal with the following manifestations of locomotive syndrome: osteoarthritis, sarcopenia, balance disorders, chronic musculoskeletal pain. Today, there is a clear understanding that drug therapy should be long-term, include comprehensive support for muscle tissue, balance training, and mandatory cognitive-behavioral therapy. Maximum safety of long-term drug therapy can be ensured by the use of vital micronutrients, which include highly purified forms of chondroitin sulfate and glucosamine sulfate, which have a wide range of anti-inflammatory and regenerative effects.

Comprehensive Review of Knee Osteoarthritis Pharmacological Treatment and the Latest Professional Societies' Guidelines

Osteoarthritis is the most common musculoskeletal progressive disease, with the knee as the most commonly affected joint in the human body. While several new medications are still under research, many symptomatic therapy options, such as analgesics (opioid and non-opioid), nonsteroid anti-inflammatory drugs, symptomatic slow-acting drugs in osteoarthritis, and preparations for topical administration, are being used, with a diverse clinical response and inconsistent conclusions across various professional societies guidelines. The concept of pharmacogenomic-guided therapy, which lies on principles of the right medication for the right patient in the right dose at the right time, can significantly increase the patient's response to symptom relief therapy in knee osteoarthritis. Corticosteroid intra-articular injections and hyaluronic acid injections provoke numerous discussions and disagreements among different guidelines, even though they are currently used in daily clinical practice. Biological options, such as platelet-rich plasma and mesenchymal stem cell injections, have shown good results in the treatment of osteoarthritis symptoms, greatly increasing the patient's quality of life, especially when combined with other therapeutic options. Non-inclusion of the latter therapies in the guidelines, and their inconsistent stance on numerous therapy options, requires larger and well-designed studies to examine the true effects of these therapies and update the existing guidelines.

[Chondroitin sulfate role in the complex rehabilitation of elderly people with chronic pain syndrome]

The article presents the data of the latest domestic and foreign original studies, the results of a number of meta-analyses, conclusions of randomized clinical trials (RCTs), and other scientific studies that prove the effectiveness and necessity of mandatory inclusion in the treatment of chronic pain syndrome of the stage of non-invasive non-pharmacological therapy. One of the promising areas of pharmacotherapy for degenerative-dystrophic joint lesions is the use of chondroprotectors (CP), in particular chondroitin sulfate (CS). According to new Clinical Recommendations of Ministry Health (MH) of the Russian Federation (RF) «Chronic pain in patients of elderly and senile age» (2020), according to which the purpose of CS is recommended for patients older than 60 years with joint pain and contraindications to non-steroidal anti-inflammatory drugs (NSAIDs) or senile asthenia for the purpose of pain relief and the prevention of exacerbations of pain. A high level of reliability and persuasiveness of the recommendations was noted (1A) of CS use. Most of the CS is available in the form of forms for oral use, the bioavailability of which, according to clinical studies, is 13-38% due to the destruction of the CS molecules in the gastrointestinal tract. Intramuscular (i/m) administration of the drug can increase the bioavailability of CS, which can not only increase the effectiveness of therapy, but also lead to a more rapid development of the symptomatic effect. In Russia available parenteral forms of CS (Chondroguard) pharmaceutical quality, efficacy has been proven in randomized clinical trial (RCT) MH RF. To relieve pain in the joints, it is recommended to use parenteral forms of CS (Chondroguard) at a dose of 100-200 mg per day, every other day, the total duration of the course of treatment is 25-30 injections.

Structural analysis of glycosaminoglycans from Oviductus ranae

Oviductus ranae (O.ran.) has been widely used as a tonic and a traditional animal-based Chinese medicine. O.ran. extracts have been reported to have numerous biological activities, including activities that are often associated with mammalian glycosaminoglycans such as anti-inflammatory, antiosteoperotic, and anti-asthmatic. Glycosaminoglycans are complex linear polysaccharides ubiquitous in mammals that possess a wide range of biological activities. However, their presence and possible structural characteristics within O.ran. were previously unknown. In this study, glycosaminoglycans were isolated from O.ran. and their disaccharide compositions were analyzed by liquid chromatography-ion trap/time-of-flight mass spectrometry (LC-MS-ITTOF). Heparan sulfate (HS)/heparin (HP), chondroitin sulfate (CS)/dermatan sulfate (DS) and hyaluronic acid (HA) were detected in O.ran. with varied disaccharide compositions. HS species contain highly acetylated disaccharides, and have various structures in their constituent chains. CS/DS chains also possess a heterogeneous structure with different sulfation patterns and densities. This novel structural information could help clarify the possible involvement of these polysaccharides in the biological activities of O.ran..

Highly purified chondroitin sulfate: a literature review on clinical efficacy and pharmacoeconomic aspects in osteoarthritis treatment

Osteoarthritis (OA) is the most prevalent musculoskeletal disease and a major cause of negative relevant outcomes, associated with an ever-increasing societal burden. Pharmaceutical-grade chondroitin sulfate (CS) was repeatedly reported to reduce pain and improve function in patients with OA. This article aims to review the evidence for the role of highly purified (hp) CS (Condrosulf^®, IBSA) in the treatment of OA. We collected and reported evidence concerning (1) efficacy of hpCS 800 mg/day in the treatment of OA affecting the knee, hand and hip; (2) efficacy and safety of hpCS 1200 mg/day also in the oral gel formulation; (3) the safety profile of hpCS; (4) the difference of hpCS and pharmaceutical-grade formulations versus food supplements; (5) pharmacoeconomic added value of hpCS. The data support that hpCS is an effective and safe treatment of OA, with its effect already evident at 30 days; in addition, its beneficial action is prolonged, being maintained for at least 3 months after the drug is discontinued. Full safety reports’ analyses confirm that CS is safe to use and has almost no side effects, in particular, it showed better gastrointestinal tolerance if compared with non-steroidal anti-inflammatory drugs (NSAIDs). Moreover, the therapeutic strategy has proved to be cost-effective: treatment with CS reduced the use of NSAIDs and their side effects.

[Antiresorptive activity of pharmacological chondroitin sulfate in the older age group]

The prevalence of osteoarthritis (OA) increases in proportion to age, so in the population of people over 65 years of age. The pathogenesis of OA is based on inflammation of the cartilage tissue of the joint, which leads to damage to the cartilage, activation of signaling pathways and increased levels of cytokines.

AIM

To study the literature data on bone and cartilage remodeling with the development of resorptive processes and discuss possible algorithms and recommendations for the management of patients with OA on the background of chondroprotective therapy.

MATERIALS AND METHODS

A comprehensive analysis of data presented in open sources, published and available on such resources as PubMed, EMBASE, Cochrane, and Library.

RESULTS

According to the available recommendations and the opinion of experts, among the methods of OA therapy, drugs containing pharmaceutical chondroitin sulfate are currently being discussed, which in a number of studies has demonstrated high antiresorptive effectiveness.

CONCLUSION

The use of drugs based on pharmaceutical chondroitin sulfate (Chondroguard) contributes not only to the reduction of pain in OA, but also has a positive effect on the processes of inflammation, including those associated with age-related changes in the body.

A new look at back pain treatment in light of the latest ESCEO guidelines

Chronic pain (CP) is still one of the urgent problems of modern medicine. The paper provides a review of the main pharmacotherapeutic approaches from the standpoint of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) guidelines. When preparing this material, the authors have analyzed the publications available in the resources: PubMed, EMBASE, Cochrane, and еLIBRARY. The paper presents the main pathogenetic mechanisms of pain syndrome development in osteoarthritis (OA), including synovial inflammation and associated immune disorders. It considers the types of development of pain syndrome and the main prognostic outcomes according the mechanism of pain, providing a rationale for the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and/or chondroprotectors (CPs). In accordance with the ESCEO guidelines, it is noted that when starting OA therapy, CPs should be considered as the first step (in their long-term prescription and pharmaceutical quality), then NSAIDs should be added (topically), then (if ineffective) orally, by excluding patients with hip OA. It is known that the intramuscular administration of CPs (chondroitin sulfate (CS) in particular) can increase their bioavailability. The use of glucosamine sulfate (GS) is recommended for patients over 60 years of age. According to the recommendations of the 2019 ESCEO experts, CS and GS should be used as a disease-modifying OA drug from the first step and at all subsequent stages.

Symptomatic Efficacy of Pharmacological Treatments for Knee Osteoarthritis: A Systematic Review and a Network Meta-Analysis with a 6-Month Time Horizon

INTRODUCTION

Several pharmacological treatments aiming at a better symptomatic control of osteoarthritis (OA) are used in daily practice but their efficacy is often disputed. The purpose of this network meta-analysis (NMA) is to assess the efficacy on pain and function of the drugs that are most widely prescribed against knee OA.

METHODS

Medline, Scopus, and Cochrane database of systematic reviews were searched for randomized controlled trials published up to August 2019 and assessing the efficacy of knee OA treatments using a 6-month time horizon. Pain and function changes from baseline were the primary outcomes. A Bayesian network meta-analysis was run and standardized mean differences (SMDs) with 95% credibility intervals (95% CrIs) were calculated.

RESULTS

9697 references were identified and 80 RCTs were concordant with our inclusion criteria (79 studies involving 15,609 individuals reported pain outcomes and 55 studies involving 13,655 individuals reported function outcomes). A significant decrease in pain was observed for the intra-articular (IA) combination of hyaluronic acid (HA) and triamcinolone (SMD - 0.49, 95% CrI - 0.78; - 0.19), vitamin D (SMD - 0.31, 95% CrI - 0.56; - 0.06), IA HA (SMD - 0.29, 95% CrI - 0.40; - 0.17), prescription-grade crystalline glucosamine sulfate (pCGS) (SMD - 0.29, 95% CrI - 0.58; - 0.004), and prescription-grade chondroitin sulfate (pCS) (SMD - 0.26, 95% CrI - 0.44; - 0.08). Significant improvements in physical function were found with pCGS (SMD - 0.44, 95% CrI - 0.66; - 0.21), vitamin D (SMD - 0.30, 95% CrIs - 0.49; - 0.11) and IA HA (SMD - 0.21, 95% CrIs - 0.31; - 0.11).

CONCLUSION

Six months of treatment with IA HA, pCGS, pCS, vitamin D and the combination of IA HA and triamcinolone improve pain and/or physical function in patients suffering from knee OA.

Role of Collagen Derivatives in Osteoarthritis and Cartilage Repair: A Systematic Scoping Review With Evidence Mapping

INTRODUCTION

There is currently no disease-modifying drug for osteoarthritis (OA), and some safety concerns have been identified about the leading traditional drugs. Therefore, research efforts have focused on alternatives such as supplementation with collagen derivatives. The objective of this scoping review is to examine the extent, range, and nature of research, and to summarize and disseminate research findings on the effects of collagen derivatives in OA and cartilage repair. The purpose is to identify gaps in the current body of evidence in order to further help progress research in this setting.

METHODS

The databases Medline, Scopus, CENTRAL, TOXLINE, and CDSR were comprehensively searched from inception to search date. After studies selection against eligibility criteria, following recommended methods, data were charted from the retrieved articles and these were subsequently synthesized. Numerical and graphical descriptive statistical methods were used to show trends in publications and geographical distribution of studies.

RESULTS

The systematic literature search identified a total of 10,834 records. Forty-one published studies were ultimately included in the review, 16 of which were preclinical studies and 25 were clinical studies (including four systematic reviews/meta-analyses). Collagen hydrolysate (CH) and undenatured collagen (UC) were the two types of collagen derivatives studied, with a total of 28 individual studies on CH and nine on UC. More than a third of studies originated from Asia, and most of them have been published after 2008. Oral forms of collagen derivatives were mainly studied; three in vivo preclinical studies and three clinical trials investigated intra-articularly injected CH. In most of the clinical trials, treatment durations varied between 3 and 6 months, with the shortest being 1.4 months and the longest 11 months. All in vivo preclinical studies and clinical trials, regardless of their quality, concluded on beneficial effects of collagen derivatives in OA and cartilage repair, whether used as nutritional supplement or delivered intra-articularly, and whatever the manufacturers of the products, the doses and the outcomes considered in each study.

CONCLUSIONS

Although current evidence shows some potential for the use of CH and UC as an option for management of patients with OA, there is still room for progress in terms of laboratory and clinical research before any definitive conclusion can be made. Harmonization of outcomes in preclinical studies and longer randomized placebo-controlled trials in larger populations with the use of recommended and validated endpoints are warranted before collagen derivatives can be recommended by large scientific societies.

Responder Profile to Pharmaceutical-Grade Chondroitin Sulfate: An Analysis of the CONCEPT Trial

Introduction

The recent CONCEPT study showed that 800 mg/day of pharmaceutical-grade chondroitin sulfate (CS) was superior to placebo and similar to celecoxib in reducing pain and improving function over 6 months in patients with symptomatic knee osteoarthritis (OA). We investigate, in the present study, whether a responder profile to CS could be defined (i.e., to determine a patient’s profile with the best response to treatment).

Methods

Subjects from the CS group of the CONCEPT study were included in the present analysis. Within the CS group, various subgroups were created on the basis of different categories of age, sex, body mass index, Kellgren and Lawrence grade, age since the beginning of OA, and baseline level of pain (i.e., VAS) or function (i.e., Lequesne index). The nonparametric Kruskal–Wallis (KW) test was applied to compare the VAS pain/Lequesne index evolutions between the subgroups, and the Dwass, Steel, Critchlow, Fligner (DSCF) procedure was used to compute multiple comparisons. The impact of various covariates on the VAS pain/Lequesne index evolution was assessed by means of multiple regression.

Results

Across all analyses, the probability of response to CS treatment was significantly associated with the duration between the date of diagnosis and the initiation of treatment. In other words, the shorter the interval between the diagnosis and the beginning of the treatment, the higher the response for both pain and function, particularly for patients with a duration of less than 5 years compared to patients with a duration of 10 years or more. No other criteria were found to be consistently associated with the response to CS treatment.

Conclusion

The treatment of OA with CS has the highest chance of success if administered in the early stage of the disease. Further research with other clinical outcomes should be carried out prior to widespread application of these findings.

Trial Registration

ClinicalTrials.gov identifier, NCT03200288.

Nutraceuticals and Pharmaceuticals

Aim. To provide a definition and classification of nutraceutical products and to show their significane in modern integrative medicine.

Background. Nutraceuticals are foodstuffs and their components, which have a positive effect on human health, including preventive maintenance and treatment of diseases. Nutraceuticals include healthy and functional foods, as well as biologically active food additives (BAFA). Healthy foods are nutritional foodstuffs without any artificial modification. These include organic, whole, and natural foods. Alongside a high nutritional value, functional food products have a positive effect on the human body due to functional food ingredients. BAFAs are food additives that contains one or several food ingredients (vitamins, mineral substances, plant components, amino acids and others). Specialists express conflicting viewpoints concerning nutraceuticals. Some nutraceuticals, such as probiotics, have confirmed their effectiveness in clinical trials, while the beneficial properties of others require further elucidation.

Conclusions. The application of nutraceuticals, as well as their combined use with pharmaceuticals, in accordance with recommendations by scientific professional associations formulated on the basis of valid research studies can lead to an improvement in the quality of the life and longevity of the population. This position forms a basis for the development of integrative medicine — a contemporary approach to the treatment of diseases.

[The place of chondroitin sulfate and glucosamine sulfate in osteoarthritis pain therapy: a practical view from evidence-based medicine]

Osteoarthritis is one of the leading causes of a chronic pain in elderly people. Old and very old age in itself is a risk factor of a comorbidity, which often limits the therapy specified in clinical recommendations. First of all, it concerns NSAID. In such situations, priority is given to chondroitin sulfate (CS) and glucosamine sulfate (GS) having the anti-inflammatory properties comparable with effects of NSAID. CS and GS also promote the delay in progression of degenerative processes and restoration of the structure of cartilaginous tissue. The drugs of CS and GS groups are Chondroguard and Sustaguard Artro having the considerable evidence-based efficacy and safety and also a polymodality of effects in patients with a combination of osteoarthritis and socially important diseases (atherosclerosis, diabetes mellitus type 2, oncological diseases) and also geriatric syndromes (sarcopenia) and aging in general.

[Osteoarthritis and geriatric syndromes]

AIM

To study the geriatric status of patients with osteoarthritis (OA) older than 60 years depending on the severity of frailty.

MATERIAL AND METHODS

The study included 201 patients with OA (mean age 75.84±8.09 years). The patients were divided into 3 groups: patients without frailty, patients with prefrailty and patients with frailty. Along with clinical examination, the risk of falls, pain intensity, the Charlson comorbidity index and the number of geriatric syndromes were calculated.

RESULTS AND CONCLUSION

With the increase of frailty, the number of patients experiencing difficulties in movement increases. The physical activity of the patients gradually reduces with the appearance of prefrailty and significantly reduces in OA. At the same time, there is the increase in dependence on outside help, the decrease in IADL and walking speed. The most common geriatric syndromes in patients with OA are sensory deficits, chronic pain syndrome and falls. The neuropathic component of pain is diagnosed in every tenth patient with OA without frailty and in every third patient with OA and frailty. In light of results obtained in the study, the authors suggest detailed recommendations for treatment of patients.

An updated algorithm recommendation for the management of knee osteoarthritis from the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO)

OBJECTIVES

The European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) sought to revisit the 2014 algorithm recommendations for knee osteoarthritis (OA), in light of recent efficacy and safety evidence, in order to develop an updated stepwise algorithm that provides practical guidance for the prescribing physician that is applicable in Europe and internationally.

METHODS

Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process, a summary of evidence document for each intervention in OA was provided to all members of an ESCEO working group, who were required to evaluate and vote on the strength of recommendation for each intervention. Based on the evidence collected, and on the strength of recommendations afforded by consensus of the working group, the final algorithm was constructed.

RESULTS

An algorithm for management of knee OA comprising a stepwise approach and incorporating consensus on 15 treatment recommendations was prepared by the ESCEO working group. Both "strong" and "weak" recommendations were afforded to different interventions. The algorithm highlights the continued importance of non-pharmacological interventions throughout the management of OA. Benefits and limitations of different pharmacological treatments are explored in this article, with particular emphasis on safety issues highlighted by recent literature analyses.

CONCLUSIONS

The updated ESCEO stepwise algorithm, developed by consensus from clinical experts in OA and informed by available evidence for the benefits and harms of various treatments, provides practical, current guidance that will enable clinicians to deliver patient-centric care in OA practice.

Comparative Analyses of Pharmaceuticals or Food Supplements Containing Chondroitin Sulfate: Are Their Bioactivities Equivalent?

Introduction

Oral supplementation of chondroitin sulfate (CS) and glucosamine (GlcN), symptomatic slow-acting molecules, is recommended by European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis and Musculoskeletal Diseases (ESCEO) and other European Union (EU) guidelines for the restoration of the articular cartilage surface in patients affected by osteoarthritis (OA). They are commercialized as pharmaceutical grade products and as food supplements in combination with plant extracts hyaluronic acid, methylsulfonylmethane, and other components. Food supplements do not need to undergo the strict regulatory controls of pharmaceutical grade products; thus, composition and contaminants that could be present may not be evidenced before commercialization and these uncertainties may give rise to concerns about the bioactivity of these formulations.

Methods

In this paper 10 different food supplements (FS) from diverse European countries were analyzed in comparison with two pharmaceutical grade products (Ph) using updated analytical approaches and biochemical cell-based assays. The purity, the titer, and the origin of CS in Ph and FS samples were initially assessed in order to successively compare the biological function. Both food supplements and pharmaceutical formulations were tested in vitro, using the same final CS concentration, on primary chondrocytes and synoviocytes in terms of (i) cell viability, (ii) activation of the NF-κB-mediated inflammation pathway, (iii) cartilage oligomeric matrix protein (COMP-2), IL-6, and IL-8 production.

Results

All the FS presented a certain insoluble fraction; the CS and the GlcN contents were lower than the declared ones in 9/10 and 8/10 samples, respectively. All FS contained keratan sulfate (KS) at up to 50% of the total glycosaminoglycan amount declared on the label. Primary cells treated with the samples diluted to present the same CS concentration in the medium showed cytotoxicity in 7/10 FS while Ph preserved viability and reduced NF-κB, COMP-2, and secreted inflammatory cytokines.

Conclusion

Among all samples tested, the pharmaceutical grade products demonstrated effective modulation of biomarkers counteracting the inflammation status and improving viability and the physiological condition of OA human primary chondrocyte and synoviocyte cells. In contrast to that, most FS were cytotoxic at the tested concentrations, and only 3/10 of them showed similarities to Ph sample behavior in vitro.

Funding

This work was partially supported by PON01_1226 NUTRAFAST, MIUR Ministero dell’Università e della Ricerca Scientifica. Bioteknet financed two short-term grants for graduate technicians. The journal’s Rapid Service and Open Access fees were funded by IBSA CH.

Effectiveness of Non-Animal Chondroitin Sulfate Supplementation in the Treatment of Moderate Knee Osteoarthritis in a Group of Overweight Subjects: A Randomized, Double-Blind, Placebo-Controlled Pilot Study

Osteoarthritis (OA) is the most common form of arthritis in the world and is characterized by pain, various disabilities and loss of quality of life. Chondroitin sulfate (CS) is recommended as first-line therapy. CS of non-animal origin is of great interest for safety and sustainability reasons. This study aims to investigate the anti-inflammatory effects, anti-pain and ability-enhancement of a short-term supplementation with non-animal CS in overweight subjects with OA. In a randomized, double-blind, placebo-controlled pilot study, 60 overweight adults with symptomatic OA were allocated to consume 600 mg of non-animal CS (n = 30) or a placebo (n = 30) daily for 12 consecutive weeks. The assessment of knee-pain, quality of life, related inflammation markers and body composition was performed at 0, 4 and 12 weeks. The Tegner Lysholm Knee Scoring (TLKS) scale of the experimental group showed a statistically significant increase (+10.64 points; confidence interval (95% confidence interval (CI) 5.57; 15.70; p < 0.01), while the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score decreased (−12.24 points; CI 95% −16.01; −8.38; p < 0.01). The results also showed a decrease in the C-reactive protein (CRP) level (−0.14 mg/dL, CI 95% −0.26; −0.04; p < 0.01) and erythrocyte sedimentation rate (ESR) level (−5.01 mm/h, CI 95% −9.18; −0.84, p < 0.01) as well as the visual analogue scale (VAS) score in both knees. In conclusion, this pilot study demonstrates the effectiveness of non-animal CS supplementation in overweight subjects with knee OA in improving knee function, pain and inflammation markers.

[Chronic pain in patients older than 60 years: a view of the geriatrics]

AIM

To analyze the geriatric status of patients with chronic pain.

MATERIAL AND METHODS

One hundred and sixteen patients of a geriatric unit, aged 75.66±7.98 years (110 women, 94.8%), were studied. All patients underwent general clinical examination and complex geriatric assessment, on the results of which geriatric syndromes were identified. Characteristics of pain syndrome (cause, intensity, localization) are described.

RESULTS

Chronic pain syndrome is identified in 85 (73.3%) patients. Most often pain is localized in large joints (n=44 (51.76%)) and back (n=50 (58.8%)). The intensity of pain was higher in patients with moderate dependence in daily activities compared to those with mild dependence (p<0.05). Pain intensity is associated with the degree of impairment of physical functioning (p<0.05). Patients with chronic pain have more geriatric symptoms (6.8±2.8). More syndromes (9.11±2.37) are identified in patients with marked impairment of physical functioning. The reduction of muscle strength is observed in 45.9% patients with- and 9.7% patients without chronic pain syndrome. The velocity of pace is 0.59 m/s and 0.71 m/s, respectively.

CONCLUSION

The high prevalence of chronic pain in patients of a geriatric unit is shown. The intensity of pain iss higher in patients with moderate dependence in daily activities compared to those with mild dependence. Pain intensity increases with the reduction of patient's physical functioning. Patients with chronic pain more often have dynapenia and significantly lower velocity of pace that indicates the poor outcome in elderly patients.

Update on the role of pharmaceutical-grade chondroitin sulfate in the symptomatic management of knee osteoarthritis

Osteoarthritis (OA) is the most prevalent musculoskeletal disease and a major cause of negative relevant outcomes, associated with an ever-increasing societal burden. Pharmaceutical-grade chondroitin sulfate (CS) was repeatedly reported to reduce pain and improve function in patients with knee OA. This treatment was also shown to be cost-effective, compared to placebo, up to 24 months. However, controversies still persist regarding the usefulness of CS for patients with knee OA, mainly due to inconsistent reports from various clinical trials. In this literature review, we aimed to summarize the main most recent findings on the efficacy and safety of CS in OA. Based on the results of studies presenting a low risk of bias, the most recent meta-analysis shows that only the pharmaceutical-grade CS may be considered as an appropriate background treatment for the management of knee OA. Evidence from another recent meta-analysis, using data from full safety reports, confirms the good safety profile of CS in OA. This new evidence on efficacy and safety suggests that recommendations for the use of CS in patients with knee OA cannot be extrapolated to other low-grade preparations as generics, nutraceutical-grade or over-the-counter preparations.