Intra-articular hyaluronic acid increases cartilage breakdown biomarker in patients with knee osteoarthritis

Association between current medication use and progression of radiographic knee osteoarthritis: data from the Osteoarthritis Initiative

Objective

Use of specific medications may accelerate the progression of radiographic knee OA (RKOA). Our aim was to examine the effect of medication use on the progression of RKOA.

Methods

We used longitudinal data from the Osteoarthritis Initiative (OAI), an observational study of risk factors for knee OA. At baseline, we selected participants with RKOA (Kellgren–Lawrence grade ≥2) and excluded those with a history of knee-related injury/surgery and other musculoskeletal disorders. Current medication use (use/non-use in the previous 30 days) and radiographic medial minimum joint space width (mJSW) data were available at baseline and annually up to 96 months follow-up. We used random effects, panel regression to assess the association between current medication use (non-users as reference group) and change in mJSW.

Results

Of 2054 eligible participants, 2003 participants with baseline mJSW data were included [55.7% female, mean age 63.3 (s.d. 8.98) years]. Of seven medication classes, at baseline NSAIDs were the most frequently used analgesia (14.7%), anti-histamine (10.4%) use was frequent and the following comorbidity medications were used most frequently: statins (27.4%), anti-hypertensives (up to 15.0%), anti-depressant/anxiolytics/psychotropics (14.0%), osteoporosis-related medication (10.9%) and diabetes-related medication (6.9%). Compared with current non-users, current use of NSAIDs was associated with a loss of mJSW (b = −0.042, 95% CI −0.08, −0.0004). No other associations were observed.

Conclusions

In current users of NSAIDs, mJSW loss was increased compared with current non-users in participants with RKOA. Clinical trials are required to assess the potential disease-modifying effects of these medications.

Topical Application of Wogonin Provides a Novel Treatment of Knee Osteoarthritis

Osteoarthritis (OA) is a degenerative joint disease characterized by inflammatory degradation of articular cartilage and subchondral bone. Wogonin, a compound extracted from the plant Scutellaria baicalensis (colloquially known as skullcap), has previously been shown to have direct anti-inflammatory and antioxidative properties. We examined the pain-reducing, anti-inflammatory, and chondroprotective effects of wogonin when applied as a topical cream. We validated the efficacy of delivering wogonin transdermally in a cream using pig ear skin in a Franz diffusion system. Using a surgical mouse model, we examined the severity and progression of OA with and without the topical application of wogonin. Using a running wheel to track activity, we found that mice with wogonin treatment were statistically more active than mice receiving vehicle treatment. OA progression was analyzed using modified Mankin and OARSI scoring and direct quantification of cyst-like lesions at the chondro-osseus junction; in each instance we observed a statistically significant attenuation of OA severity among mice treated with wogonin compared to the vehicle treatment. Immunohistochemistry revealed a significant decrease in protein expression of transforming growth factor β1 (TGF-β1), high temperature receptor A1 (HTRA1), matrix metalloprotease 13 (MMP-13) and NF-κB in wogonin-treated mice, further bolstering the cartilage morphology assessments in the form of a decrease in inflammatory and OA biomarkers.

Epicatechin and scopoletin rich Morinda citrifolia (Noni) leaf extract supplementation, mitigated Osteoarthritis via anti-inflammatory, anti-oxidative, and anti-protease pathways

The scopoletin (coumarin) and epicatechin (flavonoid) rich Morinda citrifolia L. (MC) Noni leaves are non-toxic (unlike the fruits) and consumed as vegetables. The anti-osteoarthritis effects of the MC leaf extract against joint cartilage degradation and inflammation were investigated through cartilage explant cultures and pre-clinical animal study. Osteoarthritis were induced by intra-articular monosodium iodoacetate injection into the right knee. The extract, scopoletin and epicatechin, suppressed glycosaminoglycan and nitric oxide release from the cartilage explant in the presence of Interleukin-1β. After 28 days, the extract treatment reduced the in vivo serum levels and joint tissues mRNA expressions for joint cartilage degradation, aggrecanase, and collagenase biomarkers. The extract increased the bone formation marker PINP levels, besides improving the articular cartilage structure and chondrocytes cellularity. The extract improved bone formation/repair, subchondral bone structure, strength and integrity, as well as cartilage synthesis by suppressing inflammation, nitric oxide production, joint catabolism by proteases, and oxidative stress. PRACTICAL APPLICATIONS: The scopoletin (coumarin) and epicatechin (flavonoid) rich Morinda citrifolia (Noni) leaves may be used as vegetables, functional food ingredient, or dietary supplements to suppress osteoarthritis progression against joint cartilage degradation and inflammation. The extract, scopoletin, or epicatechin, suppressed glycosaminoglycan, and nitric oxide release from the cartilage. The Morinda citrifolia leaf extract suppressed inflammation, nitric oxide production, tissues catabolism by proteases and oxidative stress to help reduce joint cartilage degradation, besides improving the articular cartilage structure, chondrocytes health, subchondral bone structure, bone formation/repair, and cartilage synthesis.

Hyaluronic Acid Suppresses the Expression of Metalloproteinases in Osteoarthritic Cartilage Stimulated Simultaneously by Interleukin 1β and Mechanical Load

Purpose

In patients with osteoarthritis (OA), intraarticular injection of hyaluronic acid (HA) frequently results in reduced pain and improved function for prolonged periods of time, i.e. more than 6 months. However, the mechanisms underlying these effects are not fully understood. Our underlying hypothesis is that HA modifies the enzymatic breakdown of joint tissues.

Methods

To test this hypothesis, we examined osteochondral cylinders from 12 OA patients. In a bioreactor, these samples were stimulated by interleukin 1β (Il1ß) (2 ng/ml) plus mechanical load (2.0 Mpa at 0.5 Hz horizontal and 0.1 Hz vertical rotation), thus the experimental setup recapitulated both catabolic and anabolic clues of the OA joint.

Results

Upon addition of HA at either 1 or 3 mg/ml, we observed a significant suppression of expression of metalloproteinase (MMP)-13. A more detailed analysis based on the Kellgren and Lawrence (K&L) OA grade, showed a much greater degree of suppression of MMP-13 expression in grade IV as compared to grade II OA. In contrast to the observed MMP-13 suppression, treatment with HA resulted in a suppression of MMP-1 expression only at 1 mg/ml HA, while MMP-2 expression was not significantly affected by either HA concentration.

Conclusion

Together, these data suggest that under concurrent catabolic and anabolic stimulation, HA exhibits a pronounced suppressive effect on MMP-13. In the long-run these findings may benefit the development of treatment strategies aimed at blocking tissue degradation in OA patients.

The mechanism of action for hyaluronic acid treatment in the osteoarthritic knee: a systematic review

BACKGROUND

Knee osteoarthritis (OA) is one of the leading causes of disability within the adult population. Current treatment options for OA of the knee include intra-articular (IA) hyaluronic acid (HA), a molecule found intrinsically within the knee joint that provides viscoelastic properties to the synovial fluid. A variety of mechanisms in which HA is thought to combat knee OA are reported in the current basic literature.

METHODS

We conducted a comprehensive literature search to identify currently available primary non-clinical basic science articles focussing on the mechanism of action of IA-HA treatment. Included articles were assessed and categorized based on the mechanism of action described within them. The key findings and conclusions from each included article were obtained and analyzed in aggregate with studies of the same categorical assignment.

RESULTS

Chondroprotection was the most frequent mechanism reported within the included articles, followed by proteoglycan and glycosaminoglycan synthesis, anti-inflammatory, mechanical, subchondral, and analgesic actions. HA-cluster of differentiation 44 (CD44) receptor binding was the most frequently reported biological cause of the mechanisms presented. High molecular weight HA was seen to be superior to lower molecular weight HA products. HA derived through a biological fermentation process is also described as having favorable safety outcomes over avian-derived HA products.

CONCLUSIONS

The non-clinical basic science literature provides evidence for numerous mechanisms in which HA acts on joint structures and function. These actions provide support for the purported clinical benefit of IA-HA in OA of the knee. Future research should not only focus on the pain relief provided by IA-HA treatment, but the disease modification properties that this treatment modality possesses as well.

Detection of urine C2C and trace element level in patients with knee osteoarthritis

The objective is to determine the relation between severity of knee osteoarthritis (KOA) and levels of Collagen type II metabolite (C2C) and trace elements in the urine. The urine sample and knee joint films (anteroposterior and lateral) from the KOA patients and control subjects were collected. The KOA patients were divided into five groups (controls and grades I-IV) according to the Kellgren-Lawrence radiographic grading standards. Urine levels of C2C and trace elements were detected by enzyme-linked immunosorbent assay and inductively coupled plasma atomic emission spectrometry, respectively. Urine C2C levels in the KOA subjects (261.235 ± 39.944 pg/ml) were higher than those of the control group (218.341 ± 22.270 pg/ml). The Fe content in KOA groups was significantly lower than that of control group (group IV > group III > group II > group I or controls). The contents of Cu and Zn were also significantly higher in the KOA patients than in the control group (p < 0.05). However, Cr, Al, Cd, Ni, and Se levels of KOA patients were not significantly different from those of the controls (p > 0.05). Determination of the urine levels of C2C and trace elements may prove to be informative for an early diagnosis of KOA. It can also assist in the prognosis judgment of the disease and selecting an appropriate therapeutic regimen.

Osteoarthritis year 2013 in review: biomarkers; reflecting before moving forward, one step at a time

In 2010, in Osteoarthritis and Cartilage, we published a comprehensive systematic review applying the consensus BIPED criteria (Burden of Disease, Investigative, Prognostic, Efficacy of Intervention and Diagnostic) criteria on serum and urinary biochemical markers for knee and hip osteoarthritis (OA) using publications that were available at that time. It appeared that none of the biochemical markers at that time were sufficiently discriminating to allow diagnosis and prognosis of OA in individual or limited numbers of patients, nor performed so consistently that they could function as primary outcome parameters in clinical trials. Also at present, almost 3 years later, this ultimate goal has not been reached (yet). Frankly, it might be questioned whether we are making the most adequate steps ahead and maybe we have to take a step back to reconsider our approaches. Some reflections are made and discussed: A critical review of molecular metabolism in OA and validation of currently investigated marker molecules in this may be vital and may lead to new and better markers. Creating cohorts in which synovial fluid (SF) is obtained in a systematic way, together with serum and urine, may also bring the field a further step ahead. Thirdly, better understanding of different phenotypes (subtypes) of OA may facilitate identification and validation of biochemical markers. Finally, the systems biology approach as discussed in the last years OA in review on biomarkers, although very complex, might provide steps forward. Looking ahead, we are optimistic but realistic in our expectations, we believe that the field can be brought forward by critically and cautiously reconsidering our approaches, and making changes forward, one step at a time.

End-stage osteoarthritis of the great toe/hallux rigidus: a review of the alternatives to arthrodesis: implant versus osteotomies and arthroplasty techniques

Hallux rigidus is defined as end-staged arthrosis of the first metatarsophalangeal joint. Although the literature supports arthrodesis as being the gold standard for the treatment of end-staged hallux rigidus, there are several other treatments available that can either prolong the life of the remaining joint or artificially mimic the original biomechanics by replacing a portion of or the entire joint with the added advantage of preserving joint mobility. There are several new and emerging joint preservative techniques that may delay or prevent the need for a joint-destructive procedure, such as arthrodesis or arthroplasty.

Current nutraceuticals in the management of osteoarthritis: a review

Osteoarthritis (OA) is a progressive degenerative joint disease that has a major impact on joint function and quality of life. Nutraceuticals and dietary supplements derived from herbs have long been used in traditional medicine and there is considerable evidence that nutraceuticals may play an important role in inflammation and joint destruction in OA. We review the biological effects of some medicinal fruits and herbs - pomegranate, green tea, cat's claw, devil's claw, ginger, Indian olibaum, turmeric and ananas - in an attempt to understand the pivotal molecular targets involved in inflammation and the joint destruction process and to summarize their toxicities and efficacy for OA management. So far there is insufficient reliable evidence on the effectiveness of ginger, turmeric and ananas. Pomegranate and green tea only have preclinical evidence of efficacy due to the lack of clinical data. In vivo and clinical studies are required to understand their targets and efficacy in OA. Limited in vitro and in vivo evidence is available for cat's claw and Indian olibaum. More extensive studies are required before long-term controlled trials of whole cat's claw and Indian olibaum extracts, or isolated active compounds, are carried out in patients with OA to determine their long-term efficacy and safety. Devil's claw has not been rigorously tested to determine its antiarthritic potential in in vitro and in vivo models. There is strong clinical evidence of the effectiveness of devil's claw in pain reduction. However, high-quality clinical trials are needed to determine its effectiveness. No serious side effects have been reported for any fruits and herbs. Overall, these studies identify and support the use of nutraceuticals to provide symptomatic relief to patients with OA and to be used as adjunct therapy for OA management. More high-quality trials are needed to provide definitive answers to questions related to their efficacy and safety for OA prevention and/or treatment.

Analgesic control and functional outcome after knee arthroscopy: results of a randomized double-blinded trial comparing a hyaluronic acid supplement with bupivacaine

OBJECTIVE

Hyaluronic acid (HA) is a naturally occurring substance within normal synovial joints. Although its efficacy in treating osteoarthritis has been evaluated, it has not been established whether it is of benefit after routine arthroscopic procedures. We hypothesized that immediate supplementation with HA after completion of arthroscopy would result in improved short-term analgesic and functional outcomes after knee arthroscopy.

DESIGN

Double-blinded randomized controlled trial.

SETTING

Tertiary referral center.

PATIENTS

One hundred ten patients presenting for routine arthroscopic procedures were invited to participate in the study. After exclusion criteria were applied, 98 patients were randomized to receive either 10 mL of 0.5% bupivacaine or 3 mL of HA into the joint immediately after completion of surgery.

INTERVENTIONS

After completion of surgery, all patients were randomized to receive either 10 mL of 0.5% bupivacaine or 3 mL of HA into the knee joint.

MAIN OUTCOME MEASURES

Visual analogue scale (VAS) pain scores were obtained at baseline; 1, 2, and 24 hours; and 1, 2, and 6 weeks after surgery. Western Ontario and McMaster Universities (WOMAC) and Tegner-Lysholm scores were obtained at baseline and then at 1, 2, and 6 weeks after surgery.

RESULTS

Forty-nine patients received intra-articular bupivacaine and 49 received HA. There was no statistical difference in any of the outcome measures (VAS pain scores, WOMAC, and Tegner-Lysholm) at any time point between the groups overall.

CONCLUSIONS

There was no benefit of HA injection immediately at the end of knee arthroscopy in the first 6 weeks after surgery.

CLINICAL RELEVANCE

Routine use of HA at the time of knee arthroscopy cannot be recommended.

Green tea polyphenol epigallocatechin-3-gallate: inflammation and arthritis. [corrected]

A number of factors including inflammation and oxidative stress are believed to play a role in the development of chronic joint diseases. Green tea has become a popular drink and is consumed throughout the world. Extracts of green tea and polyphenols present therein have been shown to inhibit the inflammatory responses in vitro in different cell types and the development of arthritis in animal model studies. There is considerable evidence that (-)-epigallocatechin-3-gallate (EGCG), the predominant green tea polyphenol which mimic its effects, inhibits enzyme activities and signal transduction pathways that play important roles in inflammation and joint destruction in arthritis. After oral consumption EGCG become bioavailable and proteomic studies suggest that EGCG may directly interact with a large set of protein targets and alter the physiological response of the cells. Taken together these and other studies identify and support the use of EGCG as a possible chemopreventive agent with a potential to inhibit the development of arthritis. Here we review the biological effects of EGCG in an attempt to understand its pivotal molecular targets that directly affect the inflammation and joint destruction process for prevention and/or for the development of new therapeutics for arthritis in humans.