Efficacy and safety of the combination of glucosamine and chondroitin for knee osteoarthritis: a systematic review and meta-analysis

Evaluation of efficacy and safety of glucosamine sulfate, chondroitin sulfate, and their combination regimen in the management of knee osteoarthritis: a systematic review and meta-analysis

AIM

This study was aimed to assess the efficacy and safety of two oral Symptomatic Slow Acting Drugs for Osteoarthritis (SYSADOAs)-Glucosamine Sulfate, Chondroitin Sulfate, and their combination regimen in the management of knee osteoarthritis (KOA).

METHODS

This systematic review was conducted according to PRISMA 2020 guidelines. A detailed literature search was performed from 03/1994 to 31/12/2022 using various electronic databases including PubMed, Embase, Cochrane Library, and Google Scholar, using the search terms-Glucosamine sulfate (GS), Chondroitin sulfate (CS), Knee osteoarthritis, Joint pain, Joint disease, and Joint structure, for literature concerning glucosamine, chondroitin, and their combination in knee osteoarthritis treatment. Cochrane Collaboration's Risk assessment tool (version 5.4.1) was used for assessing the risk of bias and the quality of the literature. The data was extracted from the included studies and subjected to statistical analysis to determine the beneficial effect of Glucosamine Sulfate, Chondroitin Sulfate, and their combination.

RESULTS

Twenty-five randomized controlled trials (RCTs) were included in this systematic review. In short, exclusively 9 RCTs for GS, 13 RCTs for CS, and 3 RCTs for the combination of GS and CS. All these studies had their treatment groups compared with placebo. In the meta-analysis, CS showed a significant reduction in pain intensity, and improved physical function compared to the placebo; GS showed a significant reduction in tibiofemoral joint space narrowing. While the combination of GS and CS showed neither a reduction in pain intensity, nor any improvement in the physical function. However, the combination exhibited a non-significant reduction in joint space narrowing. In the safety evaluation, both CS and GS have shown good safety profile and were well tolerated.

CONCLUSION

This meta-analysis revealed that the CS (with decreased pain intensity and improvement in the physical function), and GS (with significant reduction in the joint space narrowing) have significant therapeutic benefits. However, their combination did not significantly improve the symptoms or modify the disease. This may be due to the limited trials that are available on the combination of the sulfate forms of the intervention. Hence, there is a scope for conducting multicentric randomised controlled trials to evaluate and conclude the therapeutic role of CS and GS combination in the management of KOA.

Glucosamine Enhancement of Learning and Memory Functions by Promoting Fibroblast Growth Factor 21 Production

Fibroblast growth factor 21 (FGF21) plays a crucial role in metabolism and brain function. Glucosamine (GLN) has been recognized for its diverse beneficial effects. This study aimed to elucidate the modulation of FGF21 production by GLN and its impact on learning and memory functions. Using both in vivo and in vitro models, we investigated the effects of GLN on mice fed with a normal diet or high-fat diet and on mouse HT22 hippocampal cells, STHdhQ7/Q7 striatal cells, and rat primary cortical neurons challenged with GLN. Our results indicated that GLN promotes learning and memory functions in mice and upregulates FGF21 expression in the hippocampus, cortex, and striatum, as well as in HT22 cells, STHdhQ7/Q7 cells, and cortical neurons. In animals receiving GLN together with an FGF21 receptor FGFR1 inhibitor (PD173074), the GLN-enhanced learning and memory functions and induction of FGF21 production in the hippocampus were significantly attenuated. While exploring the underlying molecular mechanisms, the potential involvement of NF-κB, Akt, p38, JNK, PKA, and PPARα in HT22 and NF-κB, Akt, p38, and PPARα in STHdhQ7/Q7 were noted; GLN was able to mediate the activation of p65, Akt, p38, and CREB in HT22 and p65, Akt, and p38 in STHdhQ7/Q7 cells. Our accumulated findings suggest that GLN may increase learning and memory functions by inducing FGF21 production in the brain. This induction appears to be mediated, at least in part, through GLN's activation of the NF-κB, Akt, p38, and PKA/CREB pathways.

Combining various acupuncture therapies with multimodal analgesia to enhance postoperative pain management following total knee arthroplasty: a network meta-analysis of randomized controlled trials

Objective

This study aims to evaluate the efficacy and safety of various acupuncture treatments in conjunction with multimodal analgesia (MA) for managing postoperative pain and improving knee function in patients undergoing total knee arthroplasty (TKA), based on the findings from clinical research indicating the potential benefits of acupuncture-related therapies in this context.

Methods

We searched Web of Science, PubMed, SCI-hub, Embase, Cochrane Library, China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), Wanfang Data, and Chinese Scientific Journal Database (VIP) to collect randomized controlled trials of acupuncture-related therapies for post-TKA pain. After independent screening and data extraction, the quality of the included literature was evaluated. The potential for bias in the studies incorporated in the analysis was assessed according to the guidelines outlined in the Cochrane Handbook 5.1. Network meta-analysis (NMA) was conducted using RevMan 5.4 and Stata 16.0 software, with primary outcome measures including visual analog scale (VAS), pain pressure threshold (PPT), hospital for special surgery knee score (HSS), and knee joint range of motion (ROM). Furthermore, the interventions were ranked based on the SUCRA value.

Results

We conducted an analysis of 41 qualifying studies encompassing 3,003 patients, examining the efficacy of four acupuncture therapies (acupuncture ACU, electroacupuncture EA, transcutaneous electrical acupoint stimulation TEAS, and auricular acupoint therapy AAT) in conjunction with multimodal analgesia (MA) and MA alone. The VAS results showed no significant difference in efficacy among the five interventions for VAS-3 score. However, TEAS+MA (SMD: 0.67; 95%CI: 0.01, 1.32) was more effective than MA alone for VAS-7 score. There was no significant difference in PPT score among the three interventions. ACU + MA (SMD: 6.45; 95%CI: 3.30, 9.60), EA + MA (SMD: 4.89; 95%CI: 1.46, 8.32), and TEAS+MA (SMD: 5.31; 95%CI: 0.85, 9.78) were found to be more effective than MA alone for HSS score. For ROM score, ACU + MA was more efficacious than EA + MA, TEAS+MA, and AAT + MA, MA. Regarding the incidence of postoperative adverse reactions, nausea and vomiting were more prevalent after using only MA. Additionally, the incidence of postoperative dizziness and drowsiness following ACU + MA (OR = 4.98; 95%CI: 1.01, 24.42) was observed to be higher compared to that after AAT + MA intervention. Similarly, the occurrence of dizziness and drowsiness after MA was found to be significantly higher compared to the following interventions: TEAS+MA (OR = 0.36; 95%CI: 0.18, 0.70) and AAT + MA (OR = 0.20; 95%CI: 0.08, 0.50). The SUCRA ranking indicated that ACU + MA, EA + MA, TEAS+MA, and AAT + MA displayed superior SUCRA scores for each outcome index, respectively.

Conclusion

For the clinical treatment of post-TKA pain, acupuncture-related therapies can be selected as a complementary and alternative therapy. EA + MA and TEAS+MA demonstrate superior efficacy in alleviating postoperative pain among TKA patients. ACU + MA is the optimal choice for promoting postoperative knee joint function recovery in TKA patients. AAT + MA is recommended for preventing postoperative adverse reactions.

Systematic review registration

https://www.crd.york.ac.uk/, identifier (CRD42023492859).

The effect of MSM in the treatment of ankle arthrosis: Is MSM as effective as methylprednisolone or hyaluronic acid?

Posttraumatic ankle osteoarthritis (PTAO) causes severe ankle and adjacent joint morbidity. We aimed to compare the treatment efficacy of previously tried and still applied intra-articular injections and oral methylsulfonylmethane (MSM) at functional and histopathological level in PTAO animal model. Thirty-two adult female Sprague-Dawley rats were divided into four groups (Group 1: Control, Group 2: 0.06 g/kg/day MSM, Group 3: 0.04 mg/µL methylprednisolone [MP], Group 4: 0.04 mg/µL hyaluronic acid [HA]). MSM was started orally between Day 0 to the end of 8 weeks. Intra-articular injections were applied to the right ankles of the subjects after surgery. All subjects were killed after radiological evaluation at the 8th week. Subsequently, functional (range of motion) and histopathological evaluation was performed. Radiological evaluation showed better results of the MP (p < 0.001) and MSM (p < 0.001) groups than the control group. Severity of osteoarthritis (OA) in the MP group was significantly less than in the HA group (p = 0.032). When the total Osteoarthritis Research Society International score was compared, the severity of OA was higher in the KS and HA groups than in the control group (p < 0.001). No significant statistical difference was found in the histopathological comparison of MSM and control group (p = 0.466). There was no difference between the groups in range of motion measurement according to the contralateral ankle joint. The radiological progression of OA was slowed in the MSM and MP groups, but significant histopathological worsening was found in the MP and HA applied groups. We suggest that the treatment methods used in daily practice need to be reviewed.

Structural Insights into the Catalytic Activity of Cyclobacterium marinum N-Acetylglucosamine Deacetylase

N-Acetylglucosamine deacetylase from Cyclobacterium marinum (CmCBDA) is a highly effective and selective biocatalyst for the production of d-glucosamine (GlcN) from N-acetylglucosamine (GlcNAc). However, the underlying catalytic mechanism remains elusive. Here, we show that CmCBDA is a metalloenzyme with a preference for Ni2+ over Mn2+. Crystal structures of CmCBDA in complex with Ni2+ and Mn2+ revealed slight remodeling of the CmCBDA active site by the metal ions. We also demonstrate that CmCBDA exists as a mixture of homodimers and monomers in solution, and dimerization is indispensable for catalytic activity. A mutagenesis analysis also indicated that the active site residues Asp22, His72, and His143 as well as the residues involved in dimerization, Pro52, Trp53, and Tyr55, are essential for catalytic activity. Furthermore, a mutation on the protein surface, Lys219Glu, resulted in a 2.3-fold improvement in the deacetylation activity toward GlcNAc. Mechanistic insights obtained here may facilitate the development of CmCBDA variants with higher activities.

Pathogenic Mechanisms and Therapeutic Approaches in Obesity-Related Knee Osteoarthritis

The knee is the joint most frequently involved in osteoarthritis, a common joint disorder in the adult population that is associated with significant chronic joint pain, reduced mobility and quality of life. Recent studies have established an association between obesity and the development of knee osteoarthritis that goes beyond the increased mechanical load on the knees as weight-bearing joints. This link is based on the maintenance of a chronic low-grade inflammation, altered secretion of adipokines by the adipose tissue and development of sarcopenia. Major adipokines involved in the pathogenesis of obesity-related knee osteoarthritis include adiponectin, which appears to have a protective effect, as well as leptin, resistin and visfatin, which are associated with higher pain scores and more severe structural damage. Joint pain in knee osteoarthritis may be both nociceptive and neuropathic and is the result of complex mechanisms driven by nerve growth factor, calcitonin gene-related peptide and pro-inflammatory cytokines. The role of endogenous cannabinoids and gut microbiota in common mechanisms between obesity and knee pain has recently been studied. The aim of the present review is to highlight major pathogenic mechanisms in obesity-related knee osteoarthritis with special attention on pain and to comment on possible therapeutic approaches.

Effects of adding glucosamine or glucosamine combined with chondroitin to exercise on pain and physical function in adults with knee osteoarthritis: a systematic review and meta-analysis

It is well known that different types of exercise significantly improve physical function and relieve pain in knee osteoarthritis (KOA) patients. The aim of this study was to investigate the added effects of glucosamine or glucosamine and chondroitin supplementation in combination with an exercise program in the management of KOA. The randomized controlled trials on adding glucosamine (G) or G combined with chondroitin (C) to an exercise program in the treatment of KOA were searched in the PubMed, Cochrane Central Register of Controlled Trials, PEDro, and Web of Science online databases. The Pedro scale tool was used to assess quality of literature. A meta-analysis was performed using the Review Manager 5.4 software. In total, 6 studies (including 297 participants) were included for the final meta-analysis. According to the PEDro scale, the average quality of the studies was rated as good (mean = 8.2 (2)). The results showed that the effect of G, or G and C, in combination with exercise is not significant, as indicated by the assessed knee pain (WOMAC pain: SMD -0.18, 95% CI -0.47 to 0.11, p = 0.23; and VAS pain: SMD -0.34, 95% CI -0.85 to 0.17, p = 0.20) and physical function (SMD -0.13, 95% CI -0.95 to 0.69, p = 0.76). Adding glucosamine alone or a combination of glucosamine and chondroitin to exercise, has no effect on knee pain and physical function compared with exercise alone in KOA patients. Keywords: treatment, dietary supplement, physical activity, older adults.

Guidelines for the diagnosis and treatment of knee osteoarthritis with integrative medicine based on traditional Chinese medicine

Knee osteoarthritis (KOA) is a common geriatric disease in middle-aged and elderly people. Its main pathological characteristics are articular cartilage degeneration, changes in subchondral bone reactivity, osteophyte formation at joint edges, synovial disease, ligament relaxation or contracture, and joint capsular contracture. The prevalence rate of symptomatic KOA in middle-aged and elderly people in China is 8.1%, and this is increasing. The main clinical manifestations of this disease are pain and limited activity of the knee joint, which seriously affect the quality of life of patients and may cause disability, posing a huge burden on society and the economy. Although the pathogenesis of KOA is not clear, the treatment of KOA is diverse, and Chinese medicine, which mainly relies on plant-based natural products, has a relatively stable and reliable curative effect. This guideline aims to emphasize the evidence-based staging and stepped treatment of KOA and the therapeutic effect of integrative medicine based on traditional Chinese medicine on KOA. We make recommendations that include the adoption of manual therapy, acupuncture, external application of herbs, herbal plasters, exercise therapy, and other integrative medicine based on traditional Chinese medicine. Users of the above guidelines are most likely to include clinicians and health managers in healthcare settings.

A Review of Chondroitin Sulfate's Preparation, Properties, Functions, and Applications

Chondroitin sulfate (CS) is a natural macromolecule polysaccharide that is extensively distributed in a wide variety of organisms. CS is of great interest to researchers due to its many in vitro and in vivo functions. CS production derives from a diverse number of sources, including but not limited to extraction from various animals or fish, bio-synthesis, and fermentation, and its purity and homogeneity can vary greatly. The structural diversity of CS with respect to sulfation and saccharide content endows this molecule with distinct complexity, allowing for functional modification. These multiple functions contribute to the application of CS in medicines, biomaterials, and functional foods. In this article, we discuss the preparation of CS from different sources, the structure of various forms of CS, and its binding to other relevant molecules. Moreover, for the creation of this article, the functions and applications of CS were reviewed, with an emphasis on drug discovery, hydrogel formation, delivery systems, and food supplements. We conclude that analyzing some perspectives on structural modifications and preparation methods could potentially influence future applications of CS in medical and biomaterial research.

Concurrent Imaging and Clinical Study of the Efficacy of Hyaluronic Acid Injection for Knee Osteoarthritis: A Synovial Membrane Investigation with Ultrasound Imaging

We investigated whether hyaluronic acid (HA) injections can ameliorate ultrasound-detected synovitis in knee osteoarthritis (OA). We recruited 103 patients with symptomatic knee OA and ultrasound-detected synovitis and performed two ultrasound-guided fluid drainage procedures, followed by the administration of a low-molecular-weight HA injection (2.5 mL) in the subpatellar bursa, at a 2-week interval. Knee ultrasound imaging evaluations were performed before injection (baseline) and at 1 and 6 months after the second injection and included the measurements of synovial vascularity by using color Doppler ultrasound, synovial fluid depth over the suprapatellar bursa (SF), and synovial hypertrophy (SH). Initial clinical assessments included a visual analog scale (VAS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). VAS scores decreased significantly at both 1-month and 6-month evaluations (p < 0.001). WOMAC scores also significantly decreased at 1 month (p < 0.001), but not at 6 months (p = 0.23). The ultrasound parameters did not significantly change, except color Doppler grading, which tended to decrease at the 6-month evaluation (p = 0.059). Our findings revealed that two ultrasound-guided HA injections following fluid drainage improved pain and knee function but did not considerably influence imaging-detected synovitis in patients with knee OA.

Acupuncture and related therapies for the anxiety and depression in irritable bowel syndrome with diarrhea (IBS-D): A network meta-analysis of randomized controlled trials

Objective

A growing number of clinical studies have suggested the value of acupuncture-related therapies for patients with irritable bowel syndrome with diarrhea (IBS-D), and the patient's mental state plays an important role, but there are many types of acupuncture-related therapies involved. This study aimed to evaluate the mental status, efficacy and safety of the different acupuncture-related therapies for IBS-D patients.

Methods

We searched seven databases to collect randomized controlled trials of acupuncture-related therapies for IBS-D. After independent literature screening and data extraction, the quality of the final included literature was evaluated. Hamilton anxiety rating scale (HAMA), hamilton depression rating scale (HAMD), self-rating anxiety scale (SAS), and self-rating depression scale (SDS) was used as the primary outcome indicator. And the network meta-analysis (NMA) was performed by using Revman 5.4, Stata 15.0 and WinBUGS 1.4.3 software, and the surface under the cumulative ranking curve was conducted to rank the included interventions.

Results

We analyzed 24 eligible studies with 1,885 patients, involving eight types of acupuncture and related therapies along with comprehensive therapies. The NMA result shows that: for SAS scores, combined therapies were more efficacious than anti-diarrheal or antispasmodic (western medicine, WM) (SMD: -8.92; 95% CI: -15.30, -2.47); for SDS scores, combined therapies were more efficacious than WM (SMD: -8.45; 95% CI: -15.50, -1.41). For HAMA scores, moxibustion (MOX) was more efficacious than placebo (SMD: -8.66; 95% CI: -16.64, -0.38). For HAMD scores, MOX was more efficacious than all other included interventions. For response rate, MOX was more efficacious than the following interventions: acupuncture (ACU) (SMD:0.29; 95% CI:0.08,0.93), Chinese herb medicine (CH) (SMD:0.09; 95% CI:0.02,0.36), combined therapies (SMD:0.23; 95% CI:0.06, 0.85), electroacupuncture (EA) (SMD:0.06; 95% CI:0.01,0.33), warm acupuncture (WA) (SMD:22.16; 95% CI:3.53,148.10), WM (SMD:15.59; 95% CI:4.68,61.21), and placebo (SMD:9.80; 95% CI:2.90,45.51). Combined therapies were more efficacious than the following interventions: CH (SMD:0.39; 95% CI:0.19,0.80), WA (SMD:4.96; 95% CI:1.30,21.62), and WM (SMD:3.62; 95% CI:2.35,5.66). The comprehensive ranking results show that MOX, ACU, combined therapies, and EA had high SUCRA rankings involving different outcome indicators.

Conclusion

MOX, ACU, combined therapies, and EA better alleviate anxiety and depression among IBS-D patients, and with a higher safety level, may be the optimal therapies. In addition, combining acupuncture-related treatments and other therapies also delivers a higher global benefit level.

Systematic review registration

[https://www.crd.york.ac.uk/], identifier [CRD42022364560].

Is intraarticular enjections effective on pain management in patients with late stage primer gonarthrosis during COVID-19 pandemic? A single centre experience

Background: Primary gonarthrosis is a progressive disease that increases with age and leads to limitations in activities of daily living. Until surgery is performed, nonsteroidal anti-inflammatory drugs, intraarticular injections, and physical therapy methods are used. Purpose: This study aims to compare the clinical outcomes of intra- articular corticosteroid (CCS) and hyaluro nic acid (HA) injections for pain relief in primary gonartrhosis in COVID -19 pandemic period. Study Design: Retrospective Cohort Study. Methods: In this study, 88 patients who underwent intra-articular CCS and HA injection between August 2020 and March 2021 due to Kellgren-Lawrence stage 2 and higher gonarthrosis were investigated. Patients were divided into two groups. Group I represents the patients who received HA injections, and group II represents the patients who received CCS injection. Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Knee Society Score (KSS) scores were used for the preoperative and postoperative functional evaluations of the patients. Results: Group I included 40 patients and group II included 48 patients. The mean age was 59.4 ± 7.3 years, and the average follow-up period was 12 ± 2,6 months. The pre-intervention WOMAC scores were 13,5 in Group I and 13.6 in Group II, KSS scores were 26,5 in Group I and 25,2 in Group II. While there was a significant change in the control at month 1 in both groups, no difference was found between the groups. At the 6th month control, the improvement in group 1 continued at a significant level compared to the pre-injection period, while group 2 returned to the pre-injection level. (p

Connection between Mesenchymal Stem Cells Therapy and Osteoclasts in Osteoarthritis

The use of mesenchymal stem cells constitutes a promising therapeutic approach, as it has shown beneficial effects in different pathologies. Numerous in vitro, pre-clinical, and, to a lesser extent, clinical trials have been published for osteoarthritis. Osteoarthritis is a type of arthritis that affects diarthritic joints in which the most common and studied effect is cartilage degradation. Nowadays, it is known that osteoarthritis is a disease with a very powerful inflammatory component that affects the subchondral bone and the rest of the tissues that make up the joint. This inflammatory component may induce the differentiation of osteoclasts, the bone-resorbing cells. Subchondral bone degradation has been suggested as a key process in the pathogenesis of osteoarthritis. However, very few published studies directly focus on the activity of mesenchymal stem cells on osteoclasts, contrary to what happens with other cell types of the joint, such as chondrocytes, synoviocytes, and osteoblasts. In this review, we try to gather the published bibliography in relation to the effects of mesenchymal stem cells on osteoclastogenesis. Although we find promising results, we point out the need for further studies that can support mesenchymal stem cells as a therapeutic tool for osteoclasts and their consequences on the osteoarthritic joint.