THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 12 - December 97
Can supplements reduce arthritis symptoms?
When patients ask if taking a pair of dietary supplements—glucosamine sulfate and chondroitin sulfate—can reduce their osteoarthritis symptoms, how should physicians respond? Although there is some evidence that glucosamine helps, many physicians familiar with the supplements advise caution until well-designed studies are done to gauge treatment efficacy.
Interest in the treatment combination was spurred by the book The Arthritis Cure (1), published earlier this year. Its author, Jason Theodosakis, MD, assistant clinical professor of preventive medicine at the University of Arizona College of Medicine in Tucson, claims that the treatment rebuilds damaged cartilage and halts the progression of the disease. He describes how he successfully treated himself, his dog, and hundreds of patients with the nutrients.
Both glucosamine and chondroitin occur naturally in cartilage. In vitro, glucosamine stimulates cartilage growth, and oral glucosamine has been shown in animal studies to decrease inflammation and arthritis symptoms. Chondroitin may inhibit cartilage-degrading enzymes.
Glucosamine, a mucopolysaccharide, is absorbed through the gastric mucosa. Radioactive tagging studies are needed to evaluate uptake at cartilage sites. Clinical studies of glucosamine's benefits were mostly short-term (4 to 12 weeks) and involved small numbers of patients in Europe and Asia in the 120210s. Their findings (2-6) indicated that glucosamine was superior to placebo in relieving pain and improving function, and it equaled ibuprofen in pain control with fewer side effects, largely mild gastrointestinal upsets.
Orthopedic surgeon Amal Das, MD, who wrote the introduction to Theodosakis' book, stumbled on the European and Asian studies while searching for biological alternatives to joint replacement, his specialty. He found that the only relevant medical article written in the United States dealt with why American physicians ignore glucosamine (7). The author speculated that glucosamine treatment has been ignored because it is an unpatentable natural substance and because physicians are wary of treatments that are not approved by the FDA. Das is financing his own double-blind, randomized, controlled study at Hendersonville Orthopedic Associates in Hendersonville, North Carolina, where he practices. (A supplement maker, Nutramax Inc of Baltimore, is funding half of the study.)
An Osteoporosis Parallel?
Osteoarthritis may parallel osteoporosis, says Das. In both cartilage and bone, cell synthesis and degradation occur continuously. With age, synthesis slows more than degradation, leading to thinner bones or cartilage. Osteoporosis is treated with the building blocks of bone—calcium and vitamin D. Therefore, Das asks, why not treat osteoarthritis with the building blocks of cartilage—glucosamine and chondroitin? "It seems like a simple idea that could work," he says.
Before counseling patients, physicians should familiarize themselves with the Asian and European studies, says Marc C. Hochberg, MD, head of the division of rheumatology and clinical immunology at the University of Maryland School of Medicine in Baltimore. But the final decision lies with patients, who don't need a prescription for supplements. "There's no quality control of the manufacturing process by the FDA," says Hochberg, and no guarantee a tablet contains the dose claimed. The monthly cost of the supplements is $40 to $60.
A critically reviewed report in The Medical Letter (8) concluded that glucosamine appears to be safe and might be effective for treating osteoarthritis; however, most published trials lasted only 4 to 8 weeks. The Medical Letter consultants found the trials unconvincing.
Warren Scott, MD, a family practice and sports medicine physician at Permanente Medical Group in Santa Clara, California, helps patients conduct individual experiments. First, he advises patients to stabilize their arthritis symptoms with anti-inflammatory drugs, therapeutic rehabilitation and exercise. Then they add glucosamine for 4 months. Those who improve discontinue glucosamine temporarily to see if symptoms worsen. If so, they resume glucosamine to check for improvement again. Glucosamine seems to help patients with less advanced disease, notes Scott.
Until US studies confirm the supplements' effectiveness, Das does not recommend that physicians endorse them. For patients who can't wait, a typical regimen is 1,500 mg of glucosamine and 1,200 mg of chondroitin daily. "At worst, [patients are] wasting their money; at best, it may control pain," Das says.
Meanwhile, an injectable intra-articular analgesic treatment for osteoarthritis of the knee was approved by the FDA in August. Synvisc (Biomatrix, Inc, Ridgefield, New Jersey) is made from natural hyaluronan, which, according to a company press release, is similar to human synovial fluid. Patients receive three injections in a 2-week period. The product became available to physicians in November.
College athletes using steroids less, marijuana more
Marijuana use by college athletes has increased since 1993, while anabolic steroid, alcohol, and smokeless tobacco use has dropped, according to a National Collegiate Athletic Association (NCAA) survey of nearly 14,000 athletes at more than 600 institutions (table 1: not shown).
Twenty-eight percent of the athletes reported using marijuana, up from 21.4% in a similar NCAA survey in 1993. Anabolic steroid use was only 1.1%—down from 2.5% in 1993 and 4.9% in 120219. Alcohol and smokeless tobacco use decreased by about 9% and 16%, respectively. A small minority—3.5%—of the athletes reported using ephedrine as an ergogenic aid. Because of a change in data collection practices, researchers were not able to run tests of statistical significance among the years.
Nearly a quarter of the student-athletes who used marijuana said they used it 40 or more times during the past year, mostly for recreational or social reasons. Though amphetamine use rose slightly, those who used them as appetite suppressants were more than four times as numerous (13.5% vs 2.9%) as in 1993.
The increases in marijuana usage "mirror a general increase among students," says Frank D. Uryasz, NCAA director of sport sciences. "College student -athletes' recreational drug use is less than that of all college students," he adds.
Of the steroid users, more respondents said they use steroids to rehabilitate injuries (51.6%) than to enhance athletic performance (46.7%). Theoretically, steroids may help an athlete regain muscle strength after an injury, but there are no controlled trials to prove this, says Gregory A. Landry, MD, professor of pediatrics and head team physician at the University of Wisconsin-Madison. Ironically, long-time steroid users seem more prone to injury, he says. Landry is an editorial board member of The Physician and Sportsmedicine.
Perhaps more disturbing is that about one third of the steroid users said their main source is a physician. "I worry that physicians are telling athletes to use anabolic steroids for rehabilitation knowing that the athletes are using them for performance enhancement. I think that's unethical," says Landry, who is also president of the American Medical Society for Sports Medicine.
Part of the reason steroid use among athletes is down, Landry says, is that "we are showing athletes other ways to help build muscle. The increase in use of creatine has reduced anabolic steroid use, and so has an increased emphasis on proper nutrition. Some of the things we're doing are working."
Some of the decreased use is also due to NCAA drug testing, says Uryasz. Currently, athletes get 24 hours' notice for steroid testing. "Steroid use is changing, with athletes moving more toward using steroids that are quickly eliminated from the body," he says. "We may be looking at no-notice testing in the near future, requiring a specimen on demand."
Group indoor cycling at health clubs, commonly known as "spinning," may be too intense for beginning or occasional exercisers, according a study published in the November/December issue of FitnessMatters, a publication of the American Council on Exercise in San Diego. Researchers put five participants of various fitness levels through a standardized 30-minute indoor cycling workout on stationary cycles specially made for group indoor cycling. Pressure to keep up with more fit classmates and keeping pace with the instructor may push beginners beyond their limit, the researchers say. Novice or occasional exercisers who want to participate in group indoor cycling should be advised to seek out an instructor who will modify the class to accommodate beginners.
Slam-dunking a basketball can cause tooth avulsion because the teeth may strike the rim or become entangled in the net, particularly when recreational players lower the net or jump from a raised platform, according to a report in the September issue of the Journal of the American Dental Association.