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ASK THE DOCTOR - Naturopathic physician, Dr. Michael T Murray, addresses concerns and answers questions often asked by his patients about a specific health issue.

In the last few years, more Americans than ever have discovered the benefits of nutritional and herbal supplements. Despite the fact that there is tremendous scientific evidence to support the use of nutritional supplementation, some medical experts have not overwhelmingly endorsed nutritional supplementation. Some say diet alone can provide all the essential nutrition necessary, while many others tout the health benefits of vitamins and minerals. The consumer is left in the middle trying to sort things out. Hopefully, my answers to common questions on this subject will provide some clarity.

Q What is arthritis? A Arthritis refers to inflammation of the joints. The most common form of arthritis is osteoarthritis, which is also known as degenerative joint disease because it is characterized by joint degeneration and loss of cartilage - the shock absorbing gel like material between joints.

The percentage of people with osteoarthritis increases dramatically with age. Surveys have indicated that over 40 million Americans have osteoarthritis, including 80% of persons over the age of 50. Under the age of 45, it is much more common in women.

Q What joints are affected in osteoarthritis?
A The weight bearing joints such as the knees, hips, and spine, as well as the hands, are the joints most often affected with the degenerative changes of osteoarthritis. These joints are under greater stress because of weight and use.

Q How does a person know if he or she has osteoarthritis?
A The onset of osteoarthritis can be subtle. Morning joint stiffness is often the first symptom. As the disease progresses, there is pain during motion of the involved joint, which is made worse by prolonged activity and relieved by rest

Osteoarthritis is usually quite easily distinguished from other types of arthritis. In more inflammatory forms of arthritis like rheumatoid arthritis and gout, the joints will appear red, spongy and warm. In osteoarthritis, however, the joint will generally be cooler and bony hard. If you think you have arthritis consult a physician for an accurate diagnosis.Diagnostic summary of osteoarthritis.
Symptoms: mild early morning stiffness, following periods of rest, pain that worsens on joint use, and loss of joint function.
Signs: local tenderness, soft tissue swelling, joint crepitus, bony swelling, restricted mobility, Heberedn’s nodes, and other sign of degenerative loss of articular cartilage.

Q What causes osteoarthritis?
A Osteoarthritis is divided into two categories, primary and secondary. In primary osteoarthritis, the degenerative “ wear and tear” process occurs after a person turns 40 years of age. The cumulative effects of decades of use leads to the degenerative changes by stressing the collagen matrix of the cartilage. Damage to the cartilage results in the release of enzymes that destroy cartilage components. With aging, the ability to restore and manufacture normal cartilage structures decreases. So, what i am saying is that aging is the primary cause of osteoarthritis. But, just because you may be getting older doesn’t mean that you have to suffer from the pain of osteoarthritis.

Secondary osteoarthritis is associated with some predisposing factor which is responsible for the degenerative changes. These predisposing factors include: inherited abnormalities in joint structure or function; trauma (fractures along joint surfaces, surgery, etc.); presence of abnormal cartilage; and previous inflammatory disease of the joint (rheumatoid arthritis, gout, etc.).

Q What is the conventional medical treatment for osteoarthritis?
A The primary drugs used in the treatment of osteoarthritis are the so-called “nonsteroidal anti-inflammatory drugs or NSAIDs” which includes aspirin. Although these drugs are extensively used in the united states, research indicates that they may actually accelerate the progression of joint destruction and cause more problems down the road. These drugs are also associated with side effects including gastrointestinal upset, headaches, and dizziness, and are therefore recommended for only short periods of time.

Q How do they accelerate joint destruction?
A NSAIDs work by inhibiting enzymes involved in the production of inflammatory compounds. Enzymes are molecules that speed up chemical reactions. They either join molecules or split them by making or breaking the chemical bonds that keep molecules together. NSAIDs not only suppress the enzymes that produce inflammatory compounds, but they also inhibit enzymes that manufacture cartilage components.

So, you see why the use of NSAIDs in the treatment of osteoarthritis is a classic example of a drug suppressing the symptom while promoting the progression of the disease process. A person may feel free from pain while on the NSAID, but his or her arthritis is silently getting worse as noted in several clinical studies that have shown that NSAID use is associated with acceleration or osteoarthritis and increased joint destruction.

Q What can be used instead of NSAIDs in the treatment of osteoarthritis?
A Glucosamine sulfate! Glucosamine is a simple molecule that can be naturally produced in the body. The main function of glucosamine on joints is to stimulate the manufacture of molecules known as glycosaminoglycans (GAGs) key structural components of cartilage. It Appears that as some people age, they lose the ability to manufacture sufficient levels of glucosamine. The result is that cartilage loses its ability to act as a shock absorber. The body’s inability to manufacture glucosamine has been suggested to be the major factor leading to osteoarthritis. That’s why supplementing your diet with stabilized glucosamine sulfate the proven form of glucosamine is so vitally important.

Q Are there scientific studies that show glucosamine sulfate is effective?
A Yes. Glucosamine sulfate has been the subject of more than 300 scientific investigations and over 20 double blind clinical studies.

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The benefits of glucosamine sulfate in the treatment of osteoarthritis are impressive. In one of the more recent studies comparing glucosamine sulfate to a placebo, 252 patients with osteoarthritis of the knee were given either a placebo or 500mg of glucosamine sulfate three times daily for four weeks. Glucosamine sulfate was significantly effective in improving pain and movement after only four weeks of use. Previous studies have shown that the longer glucosamine sulfate is used the more obvious the therapeutic benefit. These results are consistent with other double blind studies versus a placebo.

Q Have there been studies comparing glucosamine sulfate to NSAIDS?
A Yes. In these head to head double blind studies glucosamine sulfate was shown to produce better results than NSAIDs in relieving the pain and inflammation of osteoarthritis despite the fact that glucosamine sulfate exhibits very little direct anti inflammatory effect and no direct analgesic or pain relieving effects. While NSAIDs offer purely symptomatic relief and may actually promote the disease process, glucosamine sulfate appears to address the cause of osteoarthritis. By treating the root of the problem through actually building joint cartilage, glucosamine sulfate not only improves the symptoms, including pain, it also helps the body repair damaged joints. The clinical effect is impressive, especially when glucosamine sulfate’s safety and lack of side effects is considered.

Q How long before results are seen with glucosamine sulfate?
A With glucosamine sulfate supplementation, most people will experience significant improvement within two to eight weeks. However, the longer it is used the more obvious the results. The effects are cumulative and long lasting.

Q Are other forms of glucosamine as effective as glucosamine sulfate?
A No. All of the research has been done with glucosamine sulfate. It is the only form of glucosamine with proven effectiveness. Only glucosamine sulfate is approved as a treatment for osteoarthritis in over 70 countries of the world and has been used by millions of people safely and effectively.

Consumers should be aware that many companies marketing other forms of glucosamine, such as N-acetyl-glucosamine (NAG) and glucosamine hydrochloride (HCL) try to mislead people into believing that these forms are better absorbed, more stable, and better used than glucosamine sulfate. These contentions are without support in the scientific literature. Glucosamine sulfate is clearly the preferred form. From a scientific perspective this statement is irrefutable.

Q Is the sulfate portion of glucosamine sulfate important?
A Sulfur is an essential nutrient for joint tissue where it functions in the stabilization of the connective tissue matrix of cartilage, tendons, and ligaments. The sulfur levels in the blood and joint fluid are very low in people with osteoarthritis. As far back as the 1930s, researchers demonstrated that individuals with arthritis are commonly deficient n this essential nutrient. Restoring sulfur levels brought about significant benefit to these patients.

In addition to sulfur playing a critical role in the manufacture of GAGs like chondroitin sulfate, researchers discovered that sulfur inhibits the various enzymes which lead to cartilage destruction in osteoarthritis (e.g., collagenase, elastases, and hyaluronidase). Because one of the primary effects of glucosamine sulfate is to promote the manufacture of chondroitin sulfate and other poly sulfated compounds in cartilage, a lack of the sulfur molecule may mean less cartilage synthesis when other forms of glucosamine are used.

Q Do I need to take glucosamine sulfate and chondroitin sulfate together?
A No, there is no additional benefit provided by a combination of glucosamine sulfate and chondroitin sulfate over glucosamine sulfate alone. Chondroitin sulfate is composed of repeating units of derivatives of glucosamine sulfate with attached sugar molecules. While the absorption rate of glucosamine sulfate is 90-97%, the absorption of intact chondroitin sulfate is estimated to be less than 12%. The difference in absorption os largely due to the difference in size. Chondroitin sulfate is at least 50 to 300 times larger than glucosamine sulfate, too large to pass through the normal intact intestinal barrier. If chondroitin sulfate molecules were absorbed intact or partially digested they are still unlikely to produce any significant benefit as the chondroitin sulfate molecules are too large to be delivered to cartilage cells.

One of the key reasons glucosamine sulfate is so effective is that its small molecular size allows it to penetrate the joint cartilage and be delivered to the chondrocyte and stimulate cartilage and be delivered to the chondrocyte and stimulate GAG synthesis. It would be nearly impossible for large chondroitin sulfate molecules to produce this effect.

Any clinical benefit from chondroitin sulfate is most likely due to the absorption of sulfur or smaller GAG molecules broken down by the digestive tract. But, even this is controversial as in one human study, 1 tram of chondroitin sulfate failed to increase serum GAG concentration at all based on a highly sensitive measure of intact or depolymerized GAG absorption. These results prompted the researchers to conclude that, “chondroprotection by orally administered chondroitin sulfate is a biologically and pharmacologically unfounded theory.” In a further analysis, these experts on chondroitin sulfate also concluded that, “Pooled literature on chondroitin sulfate biochemistry offers enough information to assert that neither intact, nor polymerized chondroitin sulfate is absorbed by the mammalian gastrointestinal tract. Therefore, any direct action of orally administered chondroitin sulfate on cartilage and chondrocytes is not possible.”

Q Does glucosamine sulfate interact with any drugs?
A There have been no reports of any adverse drug interactions with glucosamine sulfate. The only caveat is that individuals taking diuretics may need to take higher dosages

Q I am allergic to sulfur. Can i take glucosamine sulfate?
A When people say they are allergic to sulfur, what they really mean is that they are allergic to the so called sulfa drugs or sulfite containing food additives. It is impossible to be allergic to sulfur as sulfur is an essential mineral. The sulfate form of sulfur is present in relatively high concentrations in human blood. In short, glucosamine sulfate is extremely well tolerated and no allergic reaction have been reported.

Q I am a diabetic. Can I Take Glucosamine Sulfate?
A Yes 98% of glucosamine is absorbed intact and has absolutely no effect on blood sugar levels.

Q What is the effective dosage of glucosamine sulfate?
A I recommend 500mg of stabilized glucosamine sulfate three times a day. Individuals over 200 pounds may need higher dosages based on body weight.

Michael T Murray, N.D. is widely regarded as one of the world’s leading authorities on natural medicine. He is a graduate, faculty member, and serves on the board of Trustees of Bastyr University in Seattle, Washington. In addition to maintaining a private medical practice, Dr. Murray is an accomplished writer educator and lecturer. He is the author of over 20 books, including the co author of the best seller Encyclopedia of Natural Medicine, and is medical editor of the Natural Medicine Journal.
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12.17.03