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Joint Therapies. Compliance and Effectiveness

Osteoarthritis is a disease affecting all species and can affect almost any joint in the body.  The condition affects up to 70% of the humans, upwards of 60% of pets dependent on breed and approximately 70% of horses dependent on age and use.  It is a debilitating problem, causing not only pain and discomfort, but decreased range of motion, loss of use and decreased quality of life, not to mention decreased performance for the athlete.  The question comes as to how to best manage this condition with our eyes set on prevention.

 There are many causative factors involved with development of osteoarthritis including:

  • Genetics/conformation
  • Lifestyle (which includes joint overuse due to training or even career)
  • Diet
  • Body weight and condition

A person whose particular job is more physically active or have higher demands on the body, will likely experience earlier joint deterioration than one who is more sedentary, due to increased joint usage.  That being said, those that are sedentary tend to be more predisposed to joint deterioration mainly due to excessive loading of the joints due to heavy body weight.  This holds true for horses and pets as well, with those that are overweight being more likely to have joint problems. Putting lifestyle and genetics aside,we also have to take into consideration diet and its impact on overall joint health.  We just mentioned that those that tend to be heavier or overweight tend to have more joint deterioration, which is likely connected to diet and lifestyle.  However, we need to remember the impact diet can have in terms of contributing to inflammation or helping to control it.  Diets higher in various omega fatty acids and antioxidants, tend to favor healthier joints in the long term.

Considering that osteoarthritis plagues so many people, pets and horses, inflicting high levels of pain and restricting activity…what options do we have to help manage it more effectively?  Personally, I feel that the ultimate question is regarding what stage of degeneration are we at upon presentation?  Why? Because this ultimately dictates what our options are in terms of therapy options and realistic outcomes.

Prevention and Management

One thing that I have noted, as a veterinarian, is that preventing disease is by far easier than treating or managing one. That holds true for almost everything.  The reality is that with osteoarthritis, we should be taking preventative measures instead of waiting for deterioration to occur.  The irony is that despite the logic in this approach, prevention is the least desirable by people for themselves, their pets and their horses.  Research makes the connections and shows the path for deterioration, but yet, we fail to heed these warnings and make changes that could make all of the difference.  When at horse shows, I inevitably encounter individuals seeking solutions for their equine athletes and inquire about our stronger formulas.  We discuss that particular patient but I always raise the issue regarding prevention for their younger, up and coming athletes.  My input is often overlooked and the need to ‘supplement’ a young horse in training with no apparent problems doesn’t make sense. More so, the average owner will wait for problems to develop, then try to manage, which I believe is the wrong course of action, especially if there are negative conformational contributors.

In order to understand or determine the best route to management or prevention, one has to grasp the underlying problems taht are occuring.  The fact is that osteoarthritis is a degenerative condition, involving many inflammatory pathways and multiple inflammatory proteins and enzymes.  For discussion sake, lets’ estimate that there are over 30 proinflammatory proteins or cytokines involved, not only in the production and perception of pain, but also deterioration of the joint capsule, cartilage and underlying bone.  As a part of this process of inflammation, certain nutrients are lost including collagen and proteoglycans, which make up large part of the cartilage.  If we are going to help to prevent or slow the degenerative process, it is important to try to intervene at the highest level, which will then trickle down and impact many pathways below.

Typical Therapies:

  1. Glucosamine/ Chondroitin Sulfate  (oral or injectable)
  2. Hyaluronic acid (oral or injectable)
  3. MSM
  4. Corticosteroids
  5. Non-steroidal anti-inflammatories

Let’s look at typical joint supplements utilized in humans, companion pets and horses.  The top three components utilized in supplements include glucosamine, chondroitin sulfate and hyaluronic acid.  These are potentially effective ingredients, but there is more that you need to know.  First, all three of these ingredients are more so seen as chondroprotective or cartilage restoring, meaning that they provide the base components found in either the joint cartilage or the synovial fluid which bathes the joint. The general idea is that with degenerating cartilage, there is a loss of these components, not to mention a degradation in the quality of joint fluid.  Thus, if we provide these nutrients, then ideally the cartilage can repair or become healthier.  The theory is sound and supported by research, however, I think that it is important to mention stage of deterioration, compliance, dosage and time to results.

Personally, I have had mixed results when using the oral form of any of these ingredients in our patients.  The injectable forms seem to have more efficacy but come with not only increased expense but more risk to the patient.  Once the joint becomes progressive, joint space is lost and remodeling has occurred, to me, we have outlived their resourcefulness. That is not to say that there are not benefits to be gained, but I feel that they are lesser than when if in an early stage of disease. The other issue that comes up is compliance in the usage of these nutrients.  Horse owners are by far the most compliant in terms of administering or supplementing daily while humans are probably the worst, no disrespect meant.  If we have a supplement that may help and aid in recovery, it needs to be administered routinely not only due to half lives of the ingredients or elimination from the body, but due to ongoing deterioration on a daily basis.  One dose or two doses a week will not provide results.  This holds true for all medications and supplements…not just glucosamine type formulas.  The final issue regarding these nutrients is adequate dosing,which is not often achieved with typical supplements. In human clinical studies, results were seen with glucosamine supplementation at a daily dose of 1500 mg.  The majority of human OTC glucosamine supplements provide 500-750 mg per dose, which is about one half of the research proven levels.  In horses, if we extrapolate the dose from human studies, we are talking about 5000-10,000 mg daily.  Thankfully, most equine glucosamine supplements do provide this level or close to it initially, but then the recommendation is to drop down to a maintenance dose, which is less than 5000 mg.  Why is the adequate dose not provided?  Likely it is due to cost and profit margins.  The final variable worthy of mentioning with glucosamine,chondroitin or hyaluronic acids supplements is that results were most notable up to 6 months post initiation and in only a small portion of research candidates, which means that results are not immediate but could take time. Could this be due to overall potential of the ingredients or more due to stage of joint deterioration? Probably a combination of both.

So, given what we have discussed, why do people continue to use these ingredients for themselves, their pets and their horses?  First, they do have some research viability and justification for usage, but as mentioned, not everyone responded in studies and it often takes many months to see results.  Second, because this is all ‘we’ know as individuals, horse owners and pet owners.  It is marketed to us, drilled into our heads and often our doctors will recommend the same.  Again, I believe they have merit but are best used for prevention or early stage joint deterioration, but even then, the dose needs to be increased as dictated by research.  Does this raise the cost?  Yes, but one has to look at long term potential benefits.

In regards to corticosteroids, these medications can be very effective at diminishing pain but usually are injected directly into the joint, which comes with risk and cost.  There is much debate regarding the long term usage of corticosteroids for management of osteoartritis as there is some indication that their use could actually worsen the cartilage deterioration.  Non-steroidal anti-inflammatories, of which there are several, are designed to just reduce pain for the most part and have not demonstrated any negative impact on the joint, but do come with the side effects of possible stomach or colon irriation, not to mention kidney compromise in the long term.

Again, we have to understand that we have several inflammatory pathways and cytokines that are contributing to joint deterioration and discomfort.  Assuming we have 30 pathways or inflammatory proteins involved, as an estimate, we have to realize that corticosteroids and NSAIDs are only tackling a very small percentage of those proteins, usually just one or two inactuality, which leaves much to be desired.  Usage of glucosamine, chondroitin, MSM and even hyaluronic acid really only replaces what is being lost as a result of the process and impacts the inflammatory process in a very minor way.

This leaves much to be desired for these patients, but leaves many opportunities for therapy options!

A Different Perspective

What if we looked at the disease for what it is?  Take the research that has been done and connect the dots both for prevention and potential management of clinical joint disease?  There is no denying that chronic inflammation is to blame for the majority of the joint deterioration.  After all, if we over exert ourselves, overwork our horses or our pets….we (and they) are sore.  Right?  That is the hallmark sign that inflammation is present, so why are we not managing that aspect?  Yes, it is true that glucosamine, chondroitin sulfate and hyaluronic acid do demonstrate some anti-inflammatory properties, but it is not what they are known for.  Do they help to manage the joint inflammation?  Yes, but we can do much better.

Osteoarthritis cannot be cured or reversed in most instances, but it can be better managed with potential slowing of the degenerative process.

The reality is that ongoing inflammation, due to a variety of factors, contributes to joint deterioration through loss or breakdown of cartilage components including glucosamine, PGAG’s and deterioration of joint fluid resulting in lowered hyaluronic acid levels.  Considering this, would it not be better to manage the cause of the ingredient loss rather than just supplementing what is being lost as a result of the inflammation?  Prevention is the ideal stage to step in and combat ongoing inflammation, but even after joint deterioration has occurred, the inflammation can still be managed to improve overall quality of life and potentially slow further degradation.  The chondroprotective agents only go to a certain point with inflammation, but we can do more.

Let’s look at some options to impact the process of inflammation.  There are many herbs in nature that have demonstrated the ability to effectively modulate the inflammatory process, with some examples being Curcumin, Boswellia and Green Tea for starters.  They impact the inflammatory process at a cellular level, reducing the production of many inflammatory proteins which not only trigger pain, but contribute to swelling, cartilage loss and cell turnover.  In many cases, research has shown that some herbs, such as curcumin, can actually impact the rate of bone resorption and remodeling, which could be huge in many clinical conditions.  The impact of these particular herbs on the process of inflammation appears to be of a wider scope than that provided by glucosamine or the other chondroprotective agents.  If we can modulate or control that inflammatory process, then we can slow joint deterioration and even minimize the potential use of the ‘chondroprotective’ supplements so commonly used while getting better results.  We also have to keep in mind the impact of antioxidants on joint deterioration which have shown some benefit in human trials.  Ascorbic acid or vitamin C is one that is note worthy, implying that once again inflammation and oxidative stress play a role.  Through the use of some of these herbs, we can impact or reduce a higher percentage of inflammatory proteins potentially than through the use of traditional therapies.

For comparison sakes, human studies have evaluated Curcumin up to 8 grams or 8000 mg per day for 90 days with no noted side effects.  Equine studies are not readily available regarding Curcumin, aside from our published research, but extrapolating from human studies, this would equate to 24 grams or 24,000 mg on the high end.  If one is using Turmeric, the levels required would be even higher as Turmeric only contains 2-4% curcumin on average.  Of course, these are high end doses and likely results can be achieved with lower levels.  In most human arthritic trials, the average dose is between 1500 -3000 mg daily.  Horses average between 5000-10,000 mg. 

The bottom line is that joint deterioration is a progressive condition, the question comes as to when you intervene, as this dictates the results.  We need to keep in mind that being a progressive condition, it has to start somewhere and that is the point in which we need to act preventatively.  The question is if you do this for yourself, your pet or your horse and the next question comes as to which route you take in terms of supplementation?  Do you provide nutrients that are being lost with the hope of rebuilding OR do you try to control the inflammatory response which is governing the deterioration?

I’ve seen the results first hand in my patients both as a protective measure in our personal horses and pets as well as in patients with active joint disease.  The process can be controlled in the early stages and modified in the later stages, often with slowing of progression.  Of course, there is no reversing the damage inflicted over time and the more severe the deterioration, often the more difficult it is to control or manage.  I don’t claim to have all of the answers, but I do think we need to get back to the roots of the problem.  We need to keep in mind that prevention is always the best option if at all possible and in doing that, we need to keep in mind the ingredients that are being utilized as well as dose.  I do also believe that if using a particular ingredient for prevention, their dose can likely be lowered, especially if combined with others due to synergism type effects.  I will also say that in my experience, glucosamine type products do tend to demonstrate synergism when utilized with anti-inflammatory herbs, likely due to the two tiered approach, which may allow us to further reduce dose and associated cost. 

Joint degeneration is a complex condition involving many different factors as listed above.  Repetitive motion and stressors upon the joint, as seen in competition, are major players in the process, which are hard to eliminate outside of retirement.  Poor conformation adds to the problem, creating more stress on the joints and supporting structures.  I find that through the use of various herbs, including Curcumin and Boswellia, we can control the process more effectively, making the patient more comfortable and creating better results in the end.  In some cases, results are evident through use of the herbs as monotherapies, but in other cases of progressive joint problems, better results are seen when combined with traditional therapeutic options, including oral medications and joint therapies.  Often the combination approach yields better results in the severe cases, than through the use of either therapy alone.

So, what is my approach in my patients, my self and my personal horses?  I tend to focus more on the inflammation management and reduction of free radicals through the use of many anti-inflammatory herbs such as curcumin, boswellia, ashwaghanda and antioxidants.  Does that mean I do not use the glucosamine type products?  Yes and no to be honest.  I believe that by combating inflammation directly, we can impact many health conditions and not just the joints, but if I have a patient with severe joint pathology that is not responding, I will add in some chondroprotective agents to help get synergism.  In some cases it helps, in others not so much.  Again, we have to keep in mind the level of deterioration present and given this, often there is not one simple answer.

Keep in mind that just because you are using a ‘joint supplement’ doesn’t mean that you are necessarily providing the best avenue for success.  We need to go deeper and see the problem for what it is.

All our best,

Tom Schell, D.V.M.

Nouvelle Research, Inc.

tschelldvm@nouvelleresearch.com

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