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Zhao J, Liang G, Zhou G, Hong K, Yang W, Liu J, Zeng L. Efficacy and safety of curcumin therapy for knee osteoarthritis: A Bayesian network meta-analysis. JOURNAL OF ETHNOPHARMACOLOGY 2024; 321:117493. [PMID: 38036015 DOI: 10.1016/j.jep.2023.117493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 08/15/2023] [Accepted: 11/21/2023] [Indexed: 12/02/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Curcumin, a polyphenolic compound extracted from turmeric (Curcuma longa L.), is widely used in traditional Chinese medicine to treat osteoarthritis and rheumatoid arthritis. Clinical and experimental studies show that curcuminoid formulations have considerable clinical application value in the treatment of knee osteoarthritis (KOA). AIM OF THE STUDY To evaluate the efficacy and safety of curcumin, both alone and in combination with other drugs, in KOA treatment through a Bayesian network meta-analysis (NMA). METHODS We searched PubMed, Embase and Cochrane Library for randomized controlled trials of curcumin for KOA treatment. The time range of the search was from the establishment of each database to April 26, 2023. The NMAs of outcome indicators were all performed using a random-effects model. NMAs were calculated and graphed in R using MetaInsight and Stata 140 software. Measurement data were represented by the mean difference (MD), while count data were represented by the odds ratio (OR); the 95% confidence interval (CI) of each effect size was also calculated. RESULTS This study included 23 studies from 7 countries, including 2175 KOA patients and 6 interventions. The NMA results showed that compared with placebo, curcumin significantly reduced the visual analogue scale pain score (MD = -1.63, 95% CI: -2.91 to -0.45) and total WOMAC score (MD = -18.85, 95% CI: -29.53 to -8.76). Compared with placebo, curcumin (OR = 0.17, 95% CI: 0.08 to 0.36), curcumin + NSAIDs (OR = 0.01, 95% CI: 0.00 to 0.13) and NSAIDs (OR = 0.11, 95% CI: 0.02 to 0.47) reduced the use of rescue medication. Compared with NSAIDs, curcumin (OR = 0.51, 95% CI: 0.25 to 0.94) and curcumin + NSAIDs (OR = 0.23, 95% CI: 0.06 to 0.9) had a reduced incidence of adverse reactions. The surface under the cumulative ranking curve results indicated that curcumin monotherapy, curcumin + chondroprotective agents, and curcumin + NSAIDs have good clinical value in KOA treatment. CONCLUSIONS Curcumin, either alone or in combination with other treatments, is considered to have good clinical efficacy and safety in KOA treatment. Drug combinations containing curcumin may have the dual effect of enhancing efficacy and reducing adverse reactions, but this possibility still needs to be confirmed by further clinical and basic research.
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Affiliation(s)
- Jinlong Zhao
- State Key Laboratory of Traditional Chinese Medicine Syndrome/The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China; The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, 510120, China; The Research Team on Bone and Joint Degeneration and Injury of Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, 510120, China.
| | - Guihong Liang
- State Key Laboratory of Traditional Chinese Medicine Syndrome/The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China; The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, 510120, China; The Research Team on Bone and Joint Degeneration and Injury of Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, 510120, China.
| | - Guanghui Zhou
- State Key Laboratory of Traditional Chinese Medicine Syndrome/The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.
| | - Kunhao Hong
- The Fifth Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.
| | - Weiyi Yang
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, 510120, China.
| | - Jun Liu
- The Research Team on Bone and Joint Degeneration and Injury of Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, 510120, China; The Fifth Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China; Guangdong Second Chinese Medicine Hospital (Guangdong Province Enginering Technology Research Institute of Traditional Chinese Medicine), Guangzhou, 510095, China.
| | - Lingfeng Zeng
- State Key Laboratory of Traditional Chinese Medicine Syndrome/The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China; The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, 510120, China; The Research Team on Bone and Joint Degeneration and Injury of Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, 510120, China.
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Kunnumakkara AB, Hegde M, Parama D, Girisa S, Kumar A, Daimary UD, Garodia P, Yenisetti SC, Oommen OV, Aggarwal BB. Role of Turmeric and Curcumin in Prevention and Treatment of Chronic Diseases: Lessons Learned from Clinical Trials. ACS Pharmacol Transl Sci 2023; 6:447-518. [PMID: 37082752 PMCID: PMC10111629 DOI: 10.1021/acsptsci.2c00012] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Indexed: 03/08/2023]
Abstract
Turmeric (Curcuma longa) has been used for thousands of years for the prevention and treatment of various chronic diseases. Curcumin is just one of >200 ingredients in turmeric. Almost 7000 scientific papers on turmeric and almost 20,000 on curcumin have been published in PubMed. Scientific reports based on cell culture or animal studies are often not reproducible in humans. Therefore, human clinical trials are the best indicators for the prevention and treatment of a disease using a given agent/drug. Herein, we conducted an extensive literature survey on PubMed and Scopus following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The keywords "turmeric and clinical trials" and "curcumin and clinical trials" were considered for data mining. A total of 148 references were found to be relevant for the key term "turmeric and clinical trials", of which 70 were common in both PubMed and Scopus, 44 were unique to PubMed, and 34 were unique to Scopus. Similarly, for the search term "curcumin and clinical trials", 440 references were found to be relevant, of which 70 were unique to PubMed, 110 were unique to Scopus, and 260 were common to both databases. These studies show that the golden spice has enormous health and medicinal benefits for humans. This Review will extract and summarize the lessons learned about turmeric and curcumin in the prevention and treatment of chronic diseases based on clinical trials.
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Affiliation(s)
- Ajaikumar B. Kunnumakkara
- Department
of Biosciences and Bioengineering, Indian
Institute of Technology Guwahati, Assam-781039, India
| | - Mangala Hegde
- Department
of Biosciences and Bioengineering, Indian
Institute of Technology Guwahati, Assam-781039, India
| | - Dey Parama
- Department
of Biosciences and Bioengineering, Indian
Institute of Technology Guwahati, Assam-781039, India
| | - Sosmitha Girisa
- Department
of Biosciences and Bioengineering, Indian
Institute of Technology Guwahati, Assam-781039, India
| | - Aviral Kumar
- Department
of Biosciences and Bioengineering, Indian
Institute of Technology Guwahati, Assam-781039, India
| | - Uzini Devi Daimary
- Department
of Biosciences and Bioengineering, Indian
Institute of Technology Guwahati, Assam-781039, India
| | - Prachi Garodia
- Integrative
Research Center, Miami, Florida 33125, United States
| | - Sarat Chandra Yenisetti
- Department
of Zoology, Drosophila Neurobiology Laboratory, Nagaland University (Central), Lumami, Nagaland-798627, India
| | - Oommen V. Oommen
- Department
of Computational Biology and Bioinformatics, University of Kerala, Kariavattom, Thiruvananthapuram, Kerala-695581, India
| | - Bharat B. Aggarwal
- Inflammation
Research Center, San Diego, California 92109, United States
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Panknin TM, Howe CL, Hauer M, Bucchireddigari B, Rossi AM, Funk JL. Curcumin Supplementation and Human Disease: A Scoping Review of Clinical Trials. Int J Mol Sci 2023; 24:4476. [PMID: 36901908 PMCID: PMC10003109 DOI: 10.3390/ijms24054476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/12/2023] [Accepted: 02/21/2023] [Indexed: 02/26/2023] Open
Abstract
Medicinal properties of turmeric (Curcuma longa L.), a plant used for centuries as an anti-inflammatory, are attributed to its polyphenolic curcuminoids, where curcumin predominates. Although "curcumin" supplements are a top-selling botanical with promising pre-clinical effects, questions remain regarding biological activity in humans. To address this, a scoping review was conducted to assess human clinical trials reporting oral curcumin effects on disease outcomes. Eight databases were searched using established guidelines, yielding 389 citations (from 9528 initial) that met inclusion criteria. Half focused on obesity-associated metabolic disorders (29%) or musculoskeletal disorders (17%), where inflammation is a key driver, and beneficial effects on clinical outcomes and/or biomarkers were reported for most citations (75%) in studies that were primarily double-blind, randomized, and placebo-controlled trials (77%, D-RCT). Citations for the next most studied disease categories (neurocognitive [11%] or gastrointestinal disorders [10%], or cancer [9%]), were far fewer in number and yielded mixed results depending on study quality and condition studied. Although additional research is needed, including systematic evaluation of diverse curcumin formulations and doses in larger D-RCT studies, the preponderance of current evidence for several highly studied diseases (e.g., metabolic syndrome, osteoarthritis), which are also clinically common, are suggestive of clinical benefits.
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Affiliation(s)
| | - Carol L. Howe
- The University of Arizona Health Science Library, Tucson, AZ 85724, USA
| | - Meg Hauer
- College of Medicine, University of Arizona, Tucson, AZ 85724, USA
| | | | - Anthony M. Rossi
- Department of Physiology, Honors College, University of Arizona, Tucson, AZ 85724, USA
| | - Janet L. Funk
- Department of Medicine and School of Nutritional Sciences and Wellness, University of Arizona, Tucson, AZ 85724, USA
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Sadeghian M, Rahmani S, Jafarieh A, Jamialahmadi T, Sahebkar A. The effect of curcumin supplementation on renal function: A systematic and meta-analysis of randomized controlled trials. J Funct Foods 2023. [DOI: 10.1016/j.jff.2022.105396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Nejadhosseinian M, Djalalinia S, Haerian H, Alikhani M, Mansour A, Mousavian AH, Mardani-Fard HA, Kasaeian A, Faezi ST. The effects of antioxidants on knee osteoarthritis: A systematic review and meta-analysis. Front Nutr 2022; 9:1026450. [PMID: 36601076 PMCID: PMC9806224 DOI: 10.3389/fnut.2022.1026450] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/10/2022] [Indexed: 12/23/2022] Open
Abstract
Objective Knee osteoarthritis (KOA) is one of the growing health problems with a considerable burden. With recent research on the possible effectiveness of antioxidants in the remission of KOA symptoms, a systematic review and meta-analysis was required to confirm this hypothesis. Design Literature studies were searched on the most comprehensive databases such as PubMed, International Scientific Indexing, and Scopus, with no language and time restrictions. On 17 July 2021, a search strategy was developed based on the roots of "osteoarthritis (OA)" and "antioxidants," with no time or language limitations. As the primary outcome, pain was evaluated based on all indicators for evaluating pain [e.g., Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scores, the visual analog scale (VAS), and the numerical rating scale (NRS)]. The symptoms and functions of KOA and quality of life (QOL) were also considered as secondary outcomes, each of which was measured and reported by the corresponding instrument in the studies. To measure the changes in pain, symptoms, and functions of participants, we included randomized controlled trials with a placebo control or other medical therapeutic interventions. Publication bias was assessed using Begg's funnel plot and Egger's regression test, which was deemed to be statistically significant at 0.1, and the results were checked by the trim-and-fill test. Results After refinement, data were extracted from 31 documents from 7,698 primary searched papers. Using the VAS as a reliable psychometric measuring instrument, the present study revealed that a significant difference in the characteristics of disease-related symptoms of patients with KOA was reached after antioxidant therapy (standardized mean difference (SMD): 0.467, 95% confidence interval (CI): 0.303-0.632, p < 0.0001). The results reported by WOMAC confirmed no significant difference in the combined score, difficulty score, pain score, and stiffness score. Conclusion As the first comprehensive systematic review of the association between antioxidant supplementation and KOA, this study showed that antioxidants can decrease disease-related symptoms in patients with KOA. The results can be useful for health policy decisions and future related studies. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022351060, identifier: CRD42022351060.
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Affiliation(s)
- Mohammad Nejadhosseinian
- Joint Reconstruction Research Center, Tehran University of Medical Science, Tehran, Iran,Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Shirin Djalalinia
- Development of Research and Technology Center, Deputy of Research and Technology, Ministry of Health and Medical Education, Tehran, Iran,Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hoda Haerian
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Majid Alikhani
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Asieh Mansour
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir-Hossein Mousavian
- Hematology, Oncology and Stem Cell Transplantation Research Center, Research Institute for Oncology, Hematology and Cell Therapy, Tehran University of Medical Sciences, Tehran, Iran,Digestive Diseases Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Amir Kasaeian
- Hematology, Oncology and Stem Cell Transplantation Research Center, Research Institute for Oncology, Hematology and Cell Therapy, Tehran University of Medical Sciences, Tehran, Iran,Digestive Diseases Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran,Inflammation Research Center, Tehran University of Medical Sciences, Tehran, Iran,*Correspondence: Amir Kasaeian
| | - Seyedeh Tahereh Faezi
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran,Seyedeh Tahereh Faezi
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Feng J, Li Z, Tian L, Mu P, Hu Y, Xiong F, Ma X. Efficacy and safety of curcuminoids alone in alleviating pain and dysfunction for knee osteoarthritis: a systematic review and meta-analysis of randomized controlled trials. BMC Complement Med Ther 2022; 22:276. [PMID: 36261810 PMCID: PMC9580113 DOI: 10.1186/s12906-022-03740-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 09/27/2022] [Indexed: 11/29/2022] Open
Abstract
Background Curcuminoids (CURs) are the principal ingredients of Curcuma longa L. [Zingiberaceae] (CL)—an herbal plant used in east Asia to alleviate pain and inflammation. Thus far, the therapeutic effects of CURs for knee osteoarthritis (OA) uncovered by multiple reviews remained uncertain due to broadly involving trials with different agents-combined or CURs-free interventions. Therefore, we formed stringent selection criteria and assessment methods to summarize current evidence on the efficacy and safety of CURs alone in the treatment of knee OA. Methods A series of databases were searched for randomized controlled trials (RCTs) evaluating the efficacy and safety of CURs for knee OA. Clinical outcomes were evaluated using meta-analysis and the minimum clinically important difference (MCID) for both statistical and clinical significance. Results Fifteen studies with 1670 patients were included. CURs were significantly more effective than placebo in the improvements of VAS for pain ( WMD: − 1.77, 95% CI: − 2.44 to − 1.09), WOMAC total score ( WMD: − 7.06, 95% CI: − 12.27 to − 1.84), WOMAC pain score ( WMD: − 1.42, 95% CI: − 2.41 to − 0.43), WOMAC function score ( WMD: − 5.04, 95% CI: − 7.65 to − 2.43), and WOMAC stiffness score ( WMD: − 0.54, 95% CI: − 1.03 to − 0.05). Meanwhile, CURs were not inferior to NSAIDs in the improvements of pain- and function-related outcomes. Additionally, CURs did not significantly increase the incidence of adverse events (AEs) compared with placebo ( RR: 1.03, 95% CI: 0.69 to 1.53, P = 0.899, I2 = 23.7%) and NSAIDs (RR: 0.71 0.65, 95% CI: 0.57 0.41 to 0.90 1.03). Conclusions CURs alone can be expected to achieve considerable analgesic and functional promotion effects for patients with symptomatic knee OA in short term, without inducing an increase of adverse events. However, considering the low quality and substantial heterogeneity of present studies, a cautious and conservative recommendation for broader clinical use of CURs should still be made. Further high-quality studies are necessary to investigate the impact of different dosages, optimization techniques and administration approaches on long-term safety and efficacy of CURs, so as to strengthen clinical decision making for patients with symptomatic knee OA. Supplementary Information The online version contains supplementary material available at 10.1186/s12906-022-03740-9.
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Affiliation(s)
- Jie Feng
- grid.411304.30000 0001 0376 205XDepartment of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province China
| | - Zhao Li
- grid.411304.30000 0001 0376 205XDepartment of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province China
| | - Linling Tian
- grid.411304.30000 0001 0376 205XDepartment of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province China
| | - Panyun Mu
- grid.411304.30000 0001 0376 205XDepartment of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province China
| | - Yimei Hu
- grid.415440.0Department of Orthopedics, Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province China
| | - Feng Xiong
- grid.411304.30000 0001 0376 205XDepartment of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province China
| | - Xu Ma
- grid.411304.30000 0001 0376 205XDepartment of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province China
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Sivani BM, Azzeh M, Patnaik R, Pantea Stoian A, Rizzo M, Banerjee Y. Reconnoitering the Therapeutic Role of Curcumin in Disease Prevention and Treatment: Lessons Learnt and Future Directions. Metabolites 2022; 12:metabo12070639. [PMID: 35888763 PMCID: PMC9320502 DOI: 10.3390/metabo12070639] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/30/2022] [Accepted: 07/08/2022] [Indexed: 02/04/2023] Open
Abstract
Turmeric is a plant with a very long history of medicinal use across different cultures. Curcumin is the active part of turmeric, which has exhibited various beneficial physiological and pharmacological effects. This review aims to critically appraise the corpus of literature associated with the above pharmacological properties of curcumin, with a specific focus on antioxidant, anti-inflammatory, anticancer and antimicrobial properties. We have also reviewed the different extraction strategies currently in practice, highlighting the strengths and drawbacks of each technique. Further, our review also summarizes the clinical trials that have been conducted with curcumin, which will allow the reader to get a quick insight into the disease/patient population of interest with the outcome that was investigated. Lastly, we have also highlighted the research areas that need to be further scrutinized to better grasp curcumin’s beneficial physiological and medicinal properties, which can then be translated to facilitate the design of better bioactive therapeutic leads.
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Affiliation(s)
- Bala Mohan Sivani
- Banerjee Research Group, College of Medicine and Health Sciences, Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai 505055, United Arab Emirates; (B.M.S.); (M.A.); (R.P.)
| | - Mahmoud Azzeh
- Banerjee Research Group, College of Medicine and Health Sciences, Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai 505055, United Arab Emirates; (B.M.S.); (M.A.); (R.P.)
| | - Rajashree Patnaik
- Banerjee Research Group, College of Medicine and Health Sciences, Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai 505055, United Arab Emirates; (B.M.S.); (M.A.); (R.P.)
| | - Anca Pantea Stoian
- Department of Diabetes, Nutrition and Metabolic Diseases, Carol Davila University of Medicine and Pharmacy, 020022 Bucharest, Romania;
| | - Manfredi Rizzo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (Promise), University of Palermo, 90128 Palermo, Italy;
| | - Yajnavalka Banerjee
- Banerjee Research Group, College of Medicine and Health Sciences, Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai 505055, United Arab Emirates; (B.M.S.); (M.A.); (R.P.)
- Centre for Medical Education, University of Dundee, Dundee DD1 4HN, UK
- Correspondence: or ; Tel.: +971-527-873-636
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Mathieu S, Soubrier M, Peirs C, Monfoulet LE, Boirie Y, Tournadre A. A Meta-Analysis of the Impact of Nutritional Supplementation on Osteoarthritis Symptoms. Nutrients 2022; 14:1607. [PMID: 35458170 PMCID: PMC9025331 DOI: 10.3390/nu14081607] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/05/2022] [Accepted: 04/08/2022] [Indexed: 02/06/2023] Open
Abstract
Conflicting evidence exists concerning the effects of nutrient intake in osteoarthritis (OA). A systematic literature review and meta-analysis were performed using PubMed, EMBASE, and Cochrane Library up to November 2021 to assess the effects of nutrients on pain, stiffness, function, quality of life, and inflammation markers. We obtained 52 references including 50 on knee OA. Twelve studies compared 724 curcumin patients and 714 controls. Using the standardized mean difference, improvement was significant with regard to pain and function in the curcumin group compared to placebo, but not with active treatment (i.e., nonsteroidal anti-inflammatory drugs, chondroitin, or paracetamol). Three studies assessed the effects of ginger on OA symptoms in 166 patients compared to 164 placebo controls. Pain was the only clinical parameter that significantly decreased. Vitamin D supplementation caused a significant decrease in pain and function. Omega-3 and vitamin E caused no changes in OA parameters. Herbal formulations effects were significant only for stiffness compared to placebo, but not with active treatment. A significant decrease in inflammatory markers was found, especially with ginger. Thus, curcumin and ginger supplementation can have a favorable impact on knee OA symptoms. Other studies are needed to better assess the effects of omega-3 and vitamin D.
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Affiliation(s)
- Sylvain Mathieu
- Service de Rhumatologie, Centre Hospitalier Universitaire Gabriel Montpied, F-63000 Clermont-Ferrand, France; (M.S.); (A.T.)
- Neuro-Dol, Inserm, CHU Clermont-Ferrand, Université Clermont Auvergne, F-63000 Clermont-Ferrand, France;
| | - Martin Soubrier
- Service de Rhumatologie, Centre Hospitalier Universitaire Gabriel Montpied, F-63000 Clermont-Ferrand, France; (M.S.); (A.T.)
| | - Cedric Peirs
- Neuro-Dol, Inserm, CHU Clermont-Ferrand, Université Clermont Auvergne, F-63000 Clermont-Ferrand, France;
| | - Laurent-Emmanuel Monfoulet
- CRNH Auvergne, Unité de Nutrition Humaine, INRAE, Université Clermont Auvergne, F-63000 Clermont-Ferrand, France; (L.-E.M.); (Y.B.)
| | - Yves Boirie
- CRNH Auvergne, Unité de Nutrition Humaine, INRAE, Université Clermont Auvergne, F-63000 Clermont-Ferrand, France; (L.-E.M.); (Y.B.)
- Service de Nutrition Clinique, CHU Gabriel Montpied, F-63000 Clermont-Ferrand, France
| | - Anne Tournadre
- Service de Rhumatologie, Centre Hospitalier Universitaire Gabriel Montpied, F-63000 Clermont-Ferrand, France; (M.S.); (A.T.)
- CRNH Auvergne, Unité de Nutrition Humaine, INRAE, Université Clermont Auvergne, F-63000 Clermont-Ferrand, France; (L.-E.M.); (Y.B.)
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Wan Y, Sun W, Yang J, Ren J, Kou Q. The comparison of curcuminoid formulations or its combination with conventional therapies versus conventional therapies alone for knee osteoarthritis. Clin Rheumatol 2022; 41:2153-2169. [PMID: 35294665 DOI: 10.1007/s10067-022-06105-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/11/2022] [Accepted: 02/15/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Presently, curcuminoid formulations or its combination with conventional therapies has been used for the treatment of knee osteoarthritis (KOA). Nevertheless, evidence is limited due to small-sized clinical trials. This study aims to evaluate the efficacy of curcuminoid formulations or its combination with conventional therapies for KOA. METHODS Randomized controlled trials comparing curcuminoid formulations or its combination with conventional therapies versus conventional therapies, such as non-steroidal antiinflammatory drugs (NSAIDs) and chondroitin sulfate/glucosamine, were searched from databases. RESULTS In total, 14 studies involving 1533 patients were included. Curcuminoid formulations were comparative to NSAIDs in reducing Visual Analogue Scale (VAS), total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and WOMAC score for pain/stiffness/physical function. No significant difference was seen between the two groups in terms of patients' satisfaction index, patients' global assessment, reduction of several inflammatory factor, rate of drug compliance, and rescue medication. Notably, curcuminoid formulations combined with NSAIDs significantly reduced VAS and WOMAC/Knee injury and OA Outcome Score (KOOS) pain score more than NSAIDs did. In addition, the curcuminoid formulations were superior to chondroitin sulfate/glucosamine in reducing VAS, total WOMAC score, and WOMAC score for stiffness/difficulty in physical function, while no significant difference was seen in reducing WOMAC pain score and Karnofsky Performance Scale score. CONCLUSIONS Curcuminoid formulations may be considered a promising alternative for treating KOA. Key points • Curcuminoid formulations are comparative to NSAIDs for KOA. • Curcuminoid formulations are superior to chondroitin sulfate/glucosamine for KOA. • Curcuminoid formulations could provide additional benefits in alleviating pain and some adverse events caused by NSAIDs.
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Affiliation(s)
- Yingying Wan
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, No. 1 Xiyuan Playground, Haidian District, Beijing, 100091, China
| | - Wenting Sun
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, No. 1 Xiyuan Playground, Haidian District, Beijing, 100091, China
| | - Jiaxi Yang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, No. 1 Xiyuan Playground, Haidian District, Beijing, 100091, China
| | - Jianxun Ren
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, No. 1 Xiyuan Playground, Haidian District, Beijing, 100091, China.
| | - Qiuai Kou
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, No. 1 Xiyuan Playground, Haidian District, Beijing, 100091, China.
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Hsiao AF, Lien YC, Tzeng IS, Liu CT, Chou SH, Horng YS. The efficacy of high- and low-dose curcumin in knee osteoarthritis: A systematic review and meta-analysis. Complement Ther Med 2021; 63:102775. [PMID: 34537344 DOI: 10.1016/j.ctim.2021.102775] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 08/11/2021] [Accepted: 09/14/2021] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVES The aim of this study was to critically appraise and evaluate effects of low- and high-dose curcuminoids on pain and functional improvement in patients with knee osteoarthritis (OA) and to compare adverse events (AEs) between curcuminoids and non-steroid anti-inflammatory drugs (NSAIDs). METHODS We systematically reviewed all randomized controlled trials (RCTs) on curcuminoids in knee osteoarthritis from the PubMed, Embase, Cochrane Library, AMED, Cinahl, ISI Web of Science, Chinese medical database, and Indian Scientific databases from inception to June 21, 2021. RESULTS We included eleven studies with a total of 1258 participants with primary knee OA. The meta-analysis results showed that curcuminoids were significantly more effective than comparators regarding visual analogue scale (VAS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain scores. However, no significant difference in pain relief or AEs between the high-dose (daily dose ≥1000 mg or total dose ≥42 gm) and low-dose (daily dose <1000 mg or total dose <42 gm) curcuminoid treatments was observed. When comparing curcumininoids versus NSAIDs, a significant difference in VAS pain was found. For AE analysis, three of our included studies used NSAIDs as comparators, with all reporting higher AE rates in the NSAID group, though significance was reached in only one study. CONCLUSIONS The results of our meta-analysis suggest that low- and high-dose curcuminoids have similar pain relief effects and AEs in knee OA. Curcuminoids are also associated with better pain relief than NSAIDs; therefore, using curcuminoids as an adjunctive treatment in knee OA is recommended.
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Affiliation(s)
- An-Fang Hsiao
- Department of Physical Medicine and Rehabilitation, Cheng Ching Hospital Chung Kang Branch, Taichung City, Taiwan, ROC
| | - Yi-Chieh Lien
- Department of Physical Medicine and Rehabilitation, Cardinal Tien Hospital An Kang Branch, New Taipei City, Taiwan, ROC
| | - I-Shiang Tzeng
- Department of Research, Taipei Tzu chi Hospital, Buddhist Tzu chi Medical Foundation, New Taipei City, Taiwan, ROC
| | - Chien-Ting Liu
- Department of Physical Medicine and Rehabilitation, Taipei Tzu chi Hospital, Buddhist Tzu chi Medical Foundation, New Taipei City, Taiwan, ROC; Department of Medicine, Tzu Chi University, Hualien, Taiwan, ROC
| | - Sheng-Hsun Chou
- Department of Physical Medicine and Rehabilitation, Taipei Tzu chi Hospital, Buddhist Tzu chi Medical Foundation, New Taipei City, Taiwan, ROC
| | - Yi-Shiung Horng
- Department of Physical Medicine and Rehabilitation, Taipei Tzu chi Hospital, Buddhist Tzu chi Medical Foundation, New Taipei City, Taiwan, ROC; Department of Medicine, Tzu Chi University, Hualien, Taiwan, ROC.
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11
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Dai W, Yan W, Leng X, Chen J, Hu X, Ao Y. Effectiveness of Curcuma longa extract versus placebo for the treatment of knee osteoarthritis: A systematic review and meta-analysis of randomized controlled trials. Phytother Res 2021; 35:5921-5935. [PMID: 34216044 DOI: 10.1002/ptr.7204] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 05/08/2021] [Accepted: 06/17/2021] [Indexed: 12/23/2022]
Abstract
The aim of this systematic review was to evaluate the efficacy and safety of all types of Curcuma longa extract versus placebo for knee osteoarthritis (OA) treatment. The research was conducted by using the databases of PubMed, Embase, Scopus, and Cochrane Library through April 2021. Randomized controlled trials (RCTs) that compared the effect of Curcuma longa extract with placebo for patients with knee OA were considered eligible. The pooled results were expressed as mean differences or relative risks with 95% confidence intervals. A total of 10 RCTs with 783 patients were eligible for this meta-analysis. The pooled analysis showed that Curcuma longa extract was associated with significantly better pain relief and functional improvement compared with placebo for knee OA. Moreover, the smallest effect sizes of VAS for pain and WOMAC total score exceeded the minimum clinically important differences (MCIDs). Current evidence indicates that, compared with placebo, Curcuma longa extract has more benefit in pain relief and functional improvement for symptomatic knee OA. However, considering the potential heterogeneity in the included studies, more future high-quality RCTs with large sample sizes are necessary to confirm the benefits of Curcuma longa extract on knee OA.
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Affiliation(s)
- Wenli Dai
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Wenqiang Yan
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Xi Leng
- Medical Imaging Center, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jing Chen
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Xiaoqing Hu
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Yingfang Ao
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
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12
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Wang Z, Singh A, Jones G, Winzenberg T, Ding C, Chopra A, Das S, Danda D, Laslett L, Antony B. Efficacy and Safety of Turmeric Extracts for the Treatment of Knee Osteoarthritis: a Systematic Review and Meta-analysis of Randomised Controlled Trials. Curr Rheumatol Rep 2021; 23:11. [PMID: 33511486 DOI: 10.1007/s11926-020-00975-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE OF THE REVIEW Finding appropriate pharmacological options to treat osteoarthritis (OA) remain challenging. We aimed to determine the efficacy and safety of all types of turmeric extracts for the management of knee OA. RECENT FINDINGS Sixteen RCTs of up to 16 weeks duration including 1810 adults with knee OA were included. Eleven RCTs compared the efficacy of turmeric extracts with placebo and five with active comparators (NSAIDs). The overall risk bias of included RCTs was moderate. Turmeric extracts significantly reduced knee pain (SMD - 0.82, 95% CI - 1.17 to - 0.47, I2 = 86.23%) and improved physical function (SMD - 0.75, 95% CI - 1.18 to - 0.33, I2 = 90.05%) compared to placebo but had similar effects compared to NSAIDs. BMI was the major contributor to heterogeneity in the placebo-controlled studies (explained 37.68% and 67.24%, respectively, in the models) and modified the effects of the turmeric on pain and physical function with less improvement with higher BMI (SMD 0.26 95% CI 0.04 to 0.48; SMD 0.48 95% CI 0.21 to 0.74). No significant between-group differences were reported for either biochemical markers or imaging outcomes. Turmeric extracts had 12% fewer adverse events than NSAIDs and similar rates to placebo. Turmeric extract is a safe and effective option for the symptomatic management of knee OA, compared to placebo or NSAIDs. However, current evidence from short-term studies is heterogeneous and has moderate risk of bias leading to some uncertainty about the true effect.
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Affiliation(s)
- Zhiqiang Wang
- Menzies Institute for Medical Research, University of Tasmania, Private Bag 23, Hobart, Tasmania, 7000, Australia
| | - Ambrish Singh
- Menzies Institute for Medical Research, University of Tasmania, Private Bag 23, Hobart, Tasmania, 7000, Australia
| | - Graeme Jones
- Menzies Institute for Medical Research, University of Tasmania, Private Bag 23, Hobart, Tasmania, 7000, Australia
| | - Tania Winzenberg
- Menzies Institute for Medical Research, University of Tasmania, Private Bag 23, Hobart, Tasmania, 7000, Australia
| | - Changhai Ding
- Menzies Institute for Medical Research, University of Tasmania, Private Bag 23, Hobart, Tasmania, 7000, Australia
- Clinical Research Centre, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Arvind Chopra
- Centre for Rheumatic Diseases, Apollo Jehangir Hospital, Pune University, Pune, India
| | | | | | - Laura Laslett
- Menzies Institute for Medical Research, University of Tasmania, Private Bag 23, Hobart, Tasmania, 7000, Australia
| | - Benny Antony
- Menzies Institute for Medical Research, University of Tasmania, Private Bag 23, Hobart, Tasmania, 7000, Australia.
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13
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Paultre K, Cade W, Hernandez D, Reynolds J, Greif D, Best TM. Therapeutic effects of turmeric or curcumin extract on pain and function for individuals with knee osteoarthritis: a systematic review. BMJ Open Sport Exerc Med 2021; 7:e000935. [PMID: 33500785 PMCID: PMC7812094 DOI: 10.1136/bmjsem-2020-000935] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2020] [Indexed: 12/21/2022] Open
Abstract
Purpose To determine whether supplementation with turmeric or curcumin extract effects pain and physical function in individuals with knee osteoarthritis (OA). Second, we investigated the therapeutic response (pain and function) of turmeric compared with non-steroidal anti-inflammatory drugs (NSAIDs). Methods A search was conducted in MEDLINE, Embase, CINAHL and Cochrane Review. Inclusion criteria included randomised controlled trials reporting pain and physical function in humans with knee OA comparing turmeric therapy with NSAIDs or no therapy. Two reviewers screened 5273 abstracts. Risk of bias and quality were assessed via Cochrane Collaboration tool and CONSORT (Consolidated Standards of Reporting Trials) 2010, respectively. Results Ten studies were included in the final analysis. Eight had high methodological quality and two were categorised as good with a mean CONSORT quality score of 21.1. Nine studies had adequate sequence generation and six had adequate allocation concealment. Participants and outcome assessors were blinded in eight studies. Three of the studies compared turmeric therapy to NSAIDs. All 10 studies showed improvement in pain and function from baseline with turmeric therapy (p≤0.05). In three studies comparing turmeric to NSAIDs, there were no differences in outcome scores (p>0.05). In all studies there were no significant adverse events in the turmeric therapy group. Conclusion Compared with placebo, there appears to be a benefit of turmeric on knee OA pain and function. Based on a small number of studies the effects are similar to that of NSAIDs. Variables such as optimal dosing, frequency and formulation remain unclear at this time.
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Affiliation(s)
- Kristopher Paultre
- Department of Family Medicine, University of Miami Sports Medicine Institute, Coral Gables, Florida, USA.,Department of Orthopedics, University of Miami Sports Medicine Institute, Coral Gables, Florida, USA
| | - William Cade
- Department of Orthopedics, University of Miami Sports Medicine Institute, Coral Gables, Florida, USA
| | - Daniel Hernandez
- Department of Family Medicine, Jackson Memorial Hospital, Miami, Florida, USA
| | - John Reynolds
- Department of Health Informatics, University of Miami School of Medicine Louis Calder Memorial Library, Miami, Florida, USA
| | - Dylan Greif
- Department of Orthopedics, University of Miami Sports Medicine Institute, Coral Gables, Florida, USA
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14
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Ait Abdellah S, Gal C, Leblanc A, Trouvin AP, Perrot S. Clusters of Responders and Predictive Factors for Response to Supplementation with Boswellia, Turmeric, and Red Algae Extracts in Painful Knee Osteoarthritis: A Prospective Observational Study Using an Arsenal of Patient-Centered Measures. Open Access Rheumatol 2021; 13:1-13. [PMID: 33447100 PMCID: PMC7802896 DOI: 10.2147/oarrr.s287078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/17/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose This observational study evaluated a combination of boswellia, turmeric, and red algae extracts in patients with knee osteoarthritis (KOA). Given the growing interest in patient-centered care in osteoarthritis, effects were assessed by an arsenal of patient-reported outcome measures (PROMs): Patient Acceptable Symptom Scale (PASS), Minimal Clinically Important Improvement (MCII), Patient Global Impression of Change (PGIC), and Lequesne algofunctional index (LAFI). Patients also completed a list of 17 items on pain quality. Patients and Methods Patients with painful unilateral or bilateral KOA had to take 1-4 capsules per day of a dietary supplement containing boswellia, turmeric, and red algae extracts for 90 days. Patients completed PROMs on Days 0 (baseline), 10, 20, 30, 60, and/or 90. Results A total of 118 patients [female: 69.5%; age: 62.9 (9.5) years, mean (SD)] were included in the study and took at least one capsule. Mean (SD) follow-up duration was 100.7 (54.9) days. Pain relief was maximal on Day 90: 64.5% of patients were responders (positive PASS); 68.8% and 58.4% had MCII and PGIC scores indicating positive effect (score ≥3) or global improvement (score ≥5); 73.3% (versus 47.5% at baseline) were mildly/moderately disabled (LAFI score <8); 55.2% had meaningful decrease (-30%) in pain intensity (VAS), 35.1% (versus 59.2% at baseline) took analgesics as supplementary treatment. Median time to the first PASS change was 34 days. Pain intensity (VAS), as well as two pain characteristics (ie, "Stabbing pain" and "Widespread pain"), were independent factors associated with non-response on Day 30. Four clusters of responders were isolated according to pain characteristics, with one cluster exhibiting a higher responder rate. Conclusion The results of this preliminary study suggest that the combination of boswellia, turmeric, and red algae extracts tested could improve KOA patients. Beyond these results, this study showed the importance of PROMs and specific pain qualitative descriptors for the accurate evaluation of dietary supplement approaches in painful conditions.
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Affiliation(s)
| | - Caroline Gal
- Clinical Research Department, PiLeJe Laboratoire, Paris, France
| | - Anne Leblanc
- Applied Research Department, PiLeJe Laboratoire, Paris, France
| | | | - Serge Perrot
- Pôle Ostéo-Articulaire, Hôpital Cochin, Paris, France
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15
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A Systematic Review of the Clinical Use of Curcumin for the Treatment of Osteoarthritis. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1291:265-282. [PMID: 34331696 DOI: 10.1007/978-3-030-56153-6_16] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Osteoarthritis is characterized by degeneration of joint structure over time, resulting in limitation of joint mobility. There is growing evidence that curcumin has anti-inflammatory properties and could be a potential therapeutic option for chronic inflammatory diseases. Hence, curcumin could potentially have a positive impact on osteoarthritis symptoms. This systematic review aimed to estimate the effects of curcumin on osteoarthritis. We systematically searched PubMed, ISI, Scopus, and Google Scholar up to March 4, 2020 to identify randomized controlled trials that evaluated the effects of consumption of all types of curcumin compounds in the treatment of osteoarthritis, especially in patients with knee osteoarthritis. Seventeen trials were identified. The duration of the included studies varied from 4 weeks to 8 months. Across all trials, 13 studies involved screening using Western Ontario and McMaster Universities (WOMAC) scores and 11 studies used visual analog scales (VAS) for recording pain from baseline to post-intervention. There was a significant improvement in VAS and overall WOMAC scores with oral administration of various types of curcumin formulations with no severe adverse effects. In conclusion, different types of curcumin compounds may be beneficial as an alternative or complementary agent for the management of osteoarthritis. Moreover, certain curcumin compounds with higher bioavailability tended to show more positive effects.
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Marton LT, Barbalho SM, Sloan KP, Sloan LA, Goulart RDA, Araújo AC, Bechara MD. Curcumin, autoimmune and inflammatory diseases: going beyond conventional therapy - a systematic review. Crit Rev Food Sci Nutr 2020; 62:2140-2157. [PMID: 33938775 DOI: 10.1080/10408398.2020.1850417] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Autoimmune and inflammatory diseases affect innumerous people and are considered a significant cause of morbidity and mortality worldwide and Curcuma sp can work as important therapies in the approach of these diseases. For this reason the aim of this review is to evaluate the effects of Curcuma or curcumin in five autoimmune and/or inflammatory diseases for instance, Inflammatory Bowel Disease, Osteoarthritis, Systemic Lupus Erythematous, Psoriasis, and Sclerosis. MEDLINE, EMBASE, and Cochrane Library were searched and PRISMA guidelines were used to build this systematic review. Curcuma sp or curcumin have been gaining ground in the treatment of autoimmune and inflammatory diseases due to the wide range of bioactive compounds capable of exerting substantial anti-inflammatory and antioxidant actions. The effects can be associated with improvement of symptoms and induction of remission in Inflammatory Bowel Disease patients; reduction of erythema and induration of lesions in psoriasis; and slow down the disease progression in patients with sclerosis. Furthermore, curcumin shows effects equivalent to ibuprofen and diclofenac, without the adverse effects generally reported by patients. Curcuma or its derivatives can be used safely and efficiently as adjuvants or as a main therapy for these diseases that increase year by year in the world population.
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Affiliation(s)
| | - Sandra Maria Barbalho
- Medical School of Marília, UNIMAR, Marília, São Paulo, Brazil.,Food Technology of Marilia, Marília, São Paulo, Brazil.,Postgraduate Program in Structural and Functional Interactions in Rehabilitation, UNIMAR, Marília, SP, Brazil
| | | | - Lance Alan Sloan
- Texas Institute for Kidney and Endocrine Disorders, Lufkin, TX, USA.,Department of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Ricardo de Alvares Goulart
- Postgraduate Program in Structural and Functional Interactions in Rehabilitation, UNIMAR, Marília, SP, Brazil
| | - Adriano Cressoni Araújo
- Medical School of Marília, UNIMAR, Marília, São Paulo, Brazil.,Postgraduate Program in Structural and Functional Interactions in Rehabilitation, UNIMAR, Marília, SP, Brazil
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