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FromBoswelliato Vitamins:ArthritisSolutionsAreMany

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A rthritis is a prevalent anddebilitating disease thataffects articulating joints.

The joint is where bones connect witheach other, such as the knee, hip orelbow. The most common forms ofarthritis are rheumatoid (autoimmunedisease), and osteoarthritis (brittlebone disease, a type of arthritis thatoccurs as a result of wear and tear onthe joints as we age).

Osteoarthritis (OA) is the most com-mon form of arthritis and accounts formore than half of all arthritis cases inthe United States. An estimated 20million Americans, mostly womenover the age 45, suffer from thisdisabling disease in which thejoints become inflamed, enlargedand swollen.

OA develops when the liningsof joints degenerate, leading to painand decreased mobility. The onsetof OA is gradual and results fromprogressive loss of cartilage proteo-glycans (cartilage breakdown).Cartilage is a highly differentiatedtissue that cushions and protectsjoints against the friction caused bythe rubbing together of bones.

According to the ArthritisFoundation, Rheumatoid arthritis(RA) affects two million Americansand usually strikes in middle age (35 to50 years old). Women are three timesmore likely than men to developrheuma-toid arthritis, in which joints stiffen andswell with fluid. Symptoms may alsoinclude fatigue,weakness, and fever.

RA is an inflammatory autoimmunedisease that affects the whole body, pri-marily the joints. It is believed that RAoccurs when the body's immune systemturns against itself and starts to damagejoint tissues.RA causes inflammationanddeformity of the joints. Other problemsassociated with RA include inflammation

of blood vessels, development of bumps(rheumatoid nodules) in various parts ofthe body, and lung disease.

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CONVENTIONAL MEDICINEMost treatments of osteoarthritis

include a combination of medication,exercise, and rest, use of heat and cold,joint protection techniques and some-times surgery.

Most common prescriptions arenon-steroidal anti-inflammatory drugs(NSAIDs), which can alleviate arthri-tis pain, but also upset stomachs, evencausing ulcers and impaired kidneyfunction. NSAIDs include aspirin andaspirin-like drugs that help reducejoint pain, stiffness, and swelling, but

don't promote healing. Corticosteroiddrugs are also prescribed to reduceinflammation, but these also haveserious side effects. Surgical treat-ment of OA includes removing jointspurs, realigning the joint, and jointreplacement.

There is no cure available for RA.However, conventional NSAID drugtreatment, such as aspirin, ibuprofenand naproxen; corticosteroids; andcytotoxic agents that suppress theimmune system, can bring somerelief of pain, but often produce seri-ous side effects.

Alternativetherapies include a varietyof nutritionalsupplementsand herbs.

ByYousry Naguib, PhD

VITAMINS AND MINERALSVitamin B complex, which is often

lacking in people with arthritis, can behelpful. High-dose niacinamide (vitaminB-3) was shown in a double-blind studyto be beneficial in osteoarthitis andrheumatoid arthritis. In a double-blind,placebo-controlled study, 72 patientswith osteoarthritis were randomized fortreatment with niacinamide or placebofor 12 weeks. At the end of the study,those in the niacinamide group reducedtheir anti-inflammationmedications, andshowed improvement in joint flexibility

when compared to placebo.!Maintaining strong bones is

another part of the equation. Infact, many people with arthritishave severe calcium deficiencies.To prevent this, supplements thatare high in bone-building calciumand magnesium, which is neededfor proper absorption of calcium,are recommended. Recently, coralcalcium has been touted in someresearch as the best source of pro-viding calcium and magnesium inthe desired ratio of two to one.

Vitamin D is also required forthe body to utilize calcium, whichis manufactured in the body withthe help of a brief dose of sunshine.A prospective observational study,

known as the Framingham study, involv-ing 500 participantsfound that low intakeand low serum levelsof vitaminD appearto be associatedwith an increasedrisk for

progression of osteoarthritisof the knee.2Arthritis patients are often asked to

follow a regimen of antioxidant vita-mins and minerals to neutralize thetoxic buildup of free radicals. Leadingmost lists are vitamins A, C and E andminerals zinc and selenium.

A diet rich in vegetables and fruits,which are abundant in antioxidants, mayalso help slow arthritis progression. Avariety of berries and cherries containantioxidant compounds that protect car-tilage. Green tea contains the potent

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antioxidants polyphenols that fight oxi-dation in arthritic joints.

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FATTY ACIDSOils such as those derived from bor-

age, black currant, evening primrose, andwalnuts can decrease pain and swelling.Borage oil is rich in the essentialfatty acidgamma-linolenic acid (GLA), which isalso found in black currant, and eveningprimrose oils. GLA is converted by thebody to a hormone-like substance calledprostaglandinEl, which may account forits abilityto reduce inflammation.

A common dose is several grams ofborage oil per day, which provides morethan 400 mg of GLA. In a study conduct-ed at the University of MassachusettsMedical Center, GLA from borage seedsrelievedpain of arthritis.

In a double-blindtrial, 56 patientswithactive RA receivedeither a 2.8 g daily ofGLA or sunflower seed oil (placebo) forsix months. At the end of the trial, theGLA-group showedprogressiveimprove-ment in the symptomsof RA.3

Fish oil EPA and DHA in a dose of 3grams daily have been shown to reducejoint tenderness and morning stiffness,and to reduce the dose of NSAIDs inpatients with rheumatoid arthritis.4Another study reported that the use ofomega-3 supplements,360 mg per day ofEPA and 240 mg per day of DHA,appeared to decrease production of pro-inflammatory prostaglandin E2 in bone,and significantlystoppedbone loss.s

The pathway of arthritis involves acascade of catabolic events that ultimate-ly lead to loss of articularcartilage.Theseevents involve a complex network ofinflammatory mediators, including thecytokines interleukin-l (IL-I) and tumornecrosis factor-alpha(TNF-alpha), a cen-tral mediator of inflammatory processesin rheumatoid arthritis.6Fish oil was alsoshown to inhibit production of the pro-inflammatory cytokines TNF-alpha andinterleukin-Ibeta, which is the chemicaltargeted by cortico-steroids.

In a recent study,GLA administeredtopatients with arthritis was shown to sup-press the release of interleukin-Ibeta (IL-Ibeta) from human monocytes stimulatedwith lipopolysaccharides.7Research hasalso showed that GLA from borage oilsuppressedthe productionof TNF-alpha.8

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Flaxseed oil was also found toreduce the production of thesecytokines.9 Flaxseed oil contains alphalinolenic acid, which can be convertedafter ingestion to EPA.

In a most recent double-blind,place-bo-controlled study at the University ofNewcastle in Australia, 50 people withrheumatoid arthritis were randomlyassignedto take either40 mg per kg bodyweight of fish oil containing 60 percentomega-3 fatty acids, or placebo daily for15 weeks.At 15 weeks, the fish oil groupshowed modest improvement in RAsymptoms(joint stiffness,and soreness).10

ENZYMESSome enzymes have shown promise

in alleviating symptoms associated withosteoarthritis. Proteolytic enzymes, suchas bromelain and papain (protein-digest-ing enzymes from pineapple and papaya,respectively),have analgesic,anti-inflam-matory, and swelling-reducingproperties.

Phlogenzym is a mix of the enzymes90 mg bromelain, which comes from thestem of the pineapple plant (Ananascomosus Merr.), and 48 mg trypsin,which is usually taken from hog pan-creas, and 100 mg of the antioxidantrutin, derived from citrus fruits. The effi-cacy of an oral enzyme therapy withphlogenzym was compared to diclofenacin patients with osteoarthritis of kneejoints. Patients received either phlogen-zym or diclofenacfor three weeks. At theend of the study,reduction in joint tender-ness was greater in the phlogenzym ascompared to the diclofenac group. II

GLUCOSAMINE & CHONDROITINTwo of the more promising treat-

ments for OA cofue from animalsources: glucosamine sulfate, derivedfrom chitin, a tissue found in shellfish;and chondroitin, which comes fromrefined fish or animal cartilage.Cartilage in the diet may help to rebuildthe cartilage of humans. The body natu-rally produces glucosamine sulfate torepair joints, but people often don'tmake enough so consuming adequateamounts in the diet is essential.

Chondroitin sulfate (CS) alone or incombination with glucosamine is oftendescribed as a medical miracle that canhalt, reverse, and even cure OA. CS is an

important componentof the body's natur-al building blocks for the cartilage foundin joints. CS, a glycosaminoglycan, isfound in the proteoglycansof cartilage.

Glucosamine, conversely, acts as thebuilding block for the biosynthesis ofglycosaminoglycans needed for the for-mation of proteoglycans that are impor-tant constituents of the cartilage.Glucosamine sulfate cannot only relievearthritis symptoms, but also help thebody repair damaged joints.12

The first U.S. six-month trial on the

efficacy of chondroitin sulfate in thetreatment of knee osteoarthritis is

reported in the Journal of OsteoarthritisCartilage 2000, September issue. In arandomized, placebo-controlled study,93 patients with OA of the knee weregiven a combination of low molecularweight sodium chondroitin sulfate (800mg), glucosamine HCl (1,000 mg), andmanganese ascorbate (152 mg) twicedaily. After 6 months, a significantimprovement in the severity of the OAof the knee was observed in patientswith mild to moderate OA of the knee.13

A similar study was conductedby theU.S. Navy on 34 males with chronic painand radiographic degenerativedisease ofthe knee. After 16 weeks of treatment, thedouble-blind study found that patientswho took the therapeutic combination ofchondroitin sulfate (1,200 mg/day), glu-cosarnine HCl (1,500 mg/day), and man-ganese ascorbate (226 mg/day) experi-enced significant relief of knee pain, butno improvement in function. 14

MSMMSM (methylsulfonylmethane) has

been claimed to play an important rolein collagen synthesis, which helpsarthritis. In a double-blind study,Ronald Lawrence, MD, at UCLASchool of Medicine found that about 80percent of patients with arthritis whoingested 2,250 mg of MSM a day forsix weeks showed improvement in theirpain symptoms, while those on theplacebo experienced on average an 18percent improvement at six weeks(www.nutriteam.com/msm.htm).

Daily dosages of 2 to 4 grams arerecommended; excess MSM is said tobe flushed out of the body after about a12-hour period.

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S.ADENOSYLMETHIONINE(SAMe)

SAMe appars to act like glucosaminein the treatment of OAIS SAMe has beenshown in a double-blindstudy to increasecartilage formation in fourteen patientswith OA of the hands.16In another dou-ble-blind trial, SAMe (400 mg threetimes per day) was found to reducepain and symptoms of OA similar toNSAID, such as aspirin, ibuprofen,indomethacine,and naproxen.17

In a recent meta-analysis of random-ized controlled trials of SAMe versus

placebo or NSAID for the treatment ofOA, SAMe was found to be as effectiveas NSAID in reducing pain and improv-ing activity limitation in patients withOA without the adverse effects associat-ed with NSAID therapies.IS

CETYL MYRISTOLEATE (CMO)CMO is a fatty acid isolated from

albino mice that were immune to inducedarthritis. This compound or the syntheticCMO (synthesizedfrom cetyl alcohol andmyristoleic acid) afforded good protec-tion against adjuvant-induced arthritis inrats. A study published in TownsendLetter for doctors and patients (1997,Aug/Sep: 58-63) reported a randomizedclinical trial on the efficacyof CMO.

Patients with RA received placebo or90 grams of oil containing 18 grams ofCMO, with or without the addition ofglucosamine hydrochloride plus seacucumber and cartilage (18 grams eachof these ingredients) over the course ofone month. This means 600 mg of eachingredient per day. At the end of thestudy,CMO, and CMO plus glucosaminehydrochloride and sea cucumber andhydrolyzed cartilage were found to sig-nificantly reduce arthritis symptoms.

AVOCADO/SOYBEANAvocado/soybean un-saponifiables

(ASU) are extracted from a mixture ofavocado and soybean oil in a ratio ofeither one or two parts of avocado oil tothree parts of soybean. ASU, when useddaily for several months, might helpOA, especially of the hip and knee.

In a randomized, double-blind,place-bo-controlled trial, researchers in Franceexamined the effect of avocado/soybeanun-saponiofiables on OA symptoms ofthe hip in 163 patients. Patients wereassigned to either 300 mg capsules ofASU or placebo for two years. At the end

of the study, the joint space loss inpatients with advanced joint space nar-rowing was significantly greater in theplacebo group than in the ASU group.The study suggested that ASU could havea beneficial effect in people withadvanced joint space IOSS.19

BOTANICALSSome botanicals may also reduce

inflammation and boost the healingprocess of arthritis. Ginger inhibitspain-producing prostaglandins. A newextract of ginger, called Zinaxin, worksjust like NSAIDs, but without the toxic-ity, by interfering with the production ofa hormone called prostaglandin, whichplays a major role in inflammation.

Other anti-inflammatoryherbs includeboswellia, ashwagandha,nettle, turmeric,cayenne, white willow, cat's claw, and

Some enzymeshave shown promise

in alleviating

symptoms ofosteoarthritis.

devil's claw. Turmeric (Curcuma Zanga),

an orange-colored spice, reduces inflam-mation. Baswellia sermta, an Ayurvedicherb, has shown good results in reducinginflammation and improving blood supplyto the joint tissues. Boswellia containsboswellic acids, which was shown toreduce symptoms in both osteoarthritis andrheumatoid arthritis.

When applied topically, capsaicinmay initially cause the skin to becomered and inflamed and produce pain andburning. Over time, this initial reactionlessens and underlying pain and inflam-mation is reduced. Thus, capsaicin hasbecome accepted as the active ingredi-ent in over-the-counter creams used top-ically to treat not only arthritis but alsoother skin conditions.

TYPE.II COLLAGENThere are several types of collagen;

the main ones are designated Type-I,Type-II and Type-III.Type-II collagen is

found predominantly in articular cartilageand is sold as dietary supplements, suchas Biocell Collagen-II (hydrolyzed colla-gen type II protein), and DC-II (nothydrolyzed). In a recent study,researchers found that 39 percent of 54rheumatoid arthritis patients treated orallywith undenatured (not hydrolyzed) Type-II collagen demonstrated significantimprovement while only 19 percent of 57rheumatoid arthritis patients taking place-bo showed improvement. 20

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CONCLUSIONComplementary medicine holds

promising solutions for the treatment ofarthritis,withoutthe sideeffectsassociatedwithnon-steroidanti-inflammatorydrugs.

References

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2. McAlindon TE et al. Ann Intern Med 1996;125:353

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5. Requirand P, et al. Clin Nutr 2000; 19:271

6. Westacott CI, Sharif M. Semin. Arthr. Rheum.1996; 25:254-272

7. Furse RK et al. J Clin Immunol2002; 22:83

8. Kast RE. Int Immunopharmacol2001; 1:2197

9. James MJ et al. Am J Clin Nutr 2000; 71 (1

Suppl):343S

10. Volker D et al. J Rheumatol 2000; 27:2343

11. Tilwe GH et at.. J Assoc Physicians India2001; 49:617

12. Phoon S, Manolios N. Aust Fam Physician2002; 31 :539

13. Das et al. Osteoarthritis Cartilage 2000;8:343

14. Leffler et al. Mil Med 1999; 164:85

15. Harmand MF et. Am J Med 1987; 83 (Suppl5A):48

16. Konig H et al. Aktuelle Radio11995; 5:36

17. Muller-Fassbender. Am J Med 1987; 83

(SuppI5A):81

18. Soeken KL et al. J Fam Pract 2002; 51:425

19. Long L, Soeken K, Ernst E. Rheumatology2001; 7:779

20. Barnett et al. Arthritis Rheum 1998; 141:290

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