When I was training as rheumatologist in the 1990’s, it would have been fairly common for a rheumatologist to offer reassurance to a newly diagnosed patient with Osteoarthritis (OA) by telling them how lucky they were not to have rheumatoid arthritis. At that time rheumatologists weren’t terribly good at effectively treating Rheumatoid arthritis (RA) or Osteoarthritis (OA) but as RA tended to get worse much more quickly, it was a consolation of sorts.

Hand osteoarthritis

Modern treatments for RA are now very effective at reducing symptoms of the disease and are also capable of dramatically slowing its progression. The treatments are so good in fact, that it has made us all realize how poor we still are at treating OA. It is ironic therefore, that I find myself 20 years later, contemplating that some of my OA patients might fair better if they had RA. If recent media reports are to be believed, help may be on the way for OA sufferers in the form of a nutritional supplement. Sound familiar? Read on….

Osteoarthritis

OA is by far the commonest form of arthritis. It is thought to be a largely degenerative disease but its cause is unknown. The disease can effect any joint but commonly affects the hands where is affects 50% of the population over the age of 60 years. Although it tends to be a more slowly progressive condition than untreated RA, severe OA can be every bit as disabling and destructive as bad rheumatoid arthritis. Originally thought to be primarily a disorder of cartilage (cartilage becomes damaged all OA patients), we now know that this may not be the whole story. There’s some evidence from MRI scans, that one of the first structures to become affected in OA is the ligaments around joints and theres also some evidence of problems occurring the bone and in the lining cells (synovium) of the joint.

Treatments for OA

Whereas there are lots of treatments for the  symptoms of OA, most rheumatologists agree that none of the available treatments have any meaningful impact on disease progression. Glucosamine Sulphate, a fish derived cartilage supplement, was in vogue for a number of years. Recent, and mainly negative results (from a bigger, and more rigorously performed NIH sponsored study) have resulted in the tide turning on Glucosamine. Despite a dwindling in the evidence for its effectiveness, it continues to be taken by many OA patients.
Just when you thought it was safe to back in the water

Chondroitin Sulphate – New trial published

A recent publication in the Sept 2011 edition of the Arthritis and Rheumatism journal has confirmed that Chondroitin Sulphate, another fish derived dietary supplement is safe and is more effective than placebo treatment in the treatment of some symptoms of osteoarthritis of the hand.  The study suggests that patients who have hand OA and who take 800mg of pharmaceutical grade Chondroitin Sulphate every day for 3 months, have pain scores which are  significantly better than those who have taken placebo tablets. Pain scores in the treatment group improved by an average of 8.8 (on a scale ranging from 0 to 100) more than in those those taking placebo treated patients. Despite the apparent small improvement in pain scores, the requirement for additional pain relief in the form of paracetamol / acetaminophen was unchanged in the Chondroitin sulphate taking patients.

There was also a statistically significant improvement in hand function (patients could do more with their hands) amounting to 3 points on a 30 point scale and they loosened out more quickly in the morning (by about 4 mins) compared to those on placebo. These benefits only occurred  in those who have been taking the drug for 3 months. The study didn’t report what happened patients after the 6 month protocol ended so its not clear whether any of the benefit was sustained.

Does is work?

The reported improvement in arthritis pain in the Chondroitin Sulphate treated patients was small. Whatever the small improvements in these outcome measures, there is no evidence from this study that chondroitin sulphate had any effect on the metabolism of cartilage.

Low expectations

It is a measure of the low expectations that we have for the treatment of OA that a study like this would have been published at all. Most studies of the effectiveness of a new treatment in RA, for example, would demand an improvement of at least 20% in a number of outcome measures and most rheumatologists wouldn’t be happy with response rates of at least 50 – 70% or complete remission. We have along way to go before we achieve anything near this OA. OA is likely to derive from disease processes in a number of structures within joints, and perhaps its naiive to expect that a drug directed at one component like cartilage might have an effect on all of the others.

Better than nothing?

Although Chondroitin sulphate may be a little better than taking nothing at all, I would be surprised if many rheumatologists will be routinely recommending it to their OA patients. It is unlikely that any scepticism within in the rheumatology community will prevent the inevitable marketing push from nutriceutical companies promoting this product on the basis of these largely disappointing results.

Fortunately there are many options available that make this disease more bearable for people but the search for a treatment to halt its progress continues.

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  1. Juliet
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