Veterinarians have prescribed it for years for high-priced polo
ponies and creaky old dogs. More recently, it's been hyped as a
``cure'' for human arthritis. But a dietary supplement called
glucosamine had been dismissed as quackery by many mainstream
doctors.
Until now.
Earlier this month a respectable long-term European study on
glucosamine won a prominent place on the program of the American
College of Rheumatology meetings in Boston. And on September 30,
the National Institutes of Health announced it will launch a $6.6
million study of glucosamine and a similar supplement called
chondroitin, one of the most expensive clinical trials ever
conducted of any ``alternative'' therapy.
But glucosamine and chondroitin are not the only hot new areas
in arthritis. Researchers are paying respectful attention to
acupuncture, tai chi, stinging nettle (it may cut down on the need
for conventional painkillers), and other complementary therapies.
They're also excited about new science-based approaches such as
cox-2 inhibitors (already on the market) and metalloprotease
inhibitors (still experimental). Arthritis researchers say they're
finally beginning to understand how to attack the most common form
of the disabling disease, called osteoarthritis -- the deterioration
of the cartilage that cushions each joint, generally causing
symptoms after age 45.
Currently, 23 million Americans suffer from osteoarthritis -- one
in every eight adults. (Another 2.1 million have rheumatoid
arthritis, an autoimmune disease that strikes younger adults,
usually women.) As the baby boomers enter the osteoarthritis-prone
years, the number of sufferers will swell.
Nothing except heart disease causes more disability, and no
disease robs more people of their ability to walk, climb stairs,
and even do something as simple as rise from a sitting position.
Fortunately, ``there's a lot of progress in osteoarthritis,'' says
rheumatologist David T. Felson of Boston University School of
Medicine. ``The emerging paradigm is that this is a disease that
needs to be treated with multiple approaches.''
That includes alternative treatments. Even before the NIH study
is off the drawing boards, leading US arthritis specialists are
recommending glucosamine to their patients -- not as a cure, but as
something that reduces pain in some people and may (or may not)
retard the progress of the disease, depending on whether the
European study results can be confirmed.
``Try it for 30 days,'' Boston University rheumatologist David
T. Felson told 62-year-old Maureen Palmer last week at Boston
Veterans Affairs Medical Center, where she is participating in a BU
study of osteoarthritis. ``I'm putting all my patients on this
stuff. It's completely safe, and it's worth trying.''
Palmer, a fifth-grade schoolteacher with a painful right knee,
says her primary care doctor was skeptical of glucosamine when she
asked about it. ``Now I think I'll give it a try,'' she said.
Specialists' open-mindedness about alternative therapies is
underscored by a new 286-page ``Guide to Alternative Therapies''
published by the Arthritis Foundation, a nonprofit research and
service organization. The guide sorts through the scientific
evidence (or lack thereof) on 80 arthritis nostrums and ``healing
systems,'' from Ayurveda and qi gong to copper bracelets and
Thunder God Vine.
The Arthritis Foundation undertook the project because it was
getting 5,000 telephone queries a month about alternative
therapies. ``We had no position except `we don't know,' '' says Dr.
William J. Arnold, who chaired the foundation's task force on
alternative medicine.
To be sure, not all arthritis specialists are receptive to
alternative therapies. ``To some extent the Arthritis Foundation
has given credibility to a lot of things that don't deserve it,''
complains Dr. Donald M. Marcus, a Houston rheumatologist.
Despite lingering skepticism among their colleagues, many
arthritis specialists see their field as an emerging model for the
marriage of scientific and complementary approaches. On the
scientific side, leading researchers paint an expansive picture of
the future of osteoarthritis treatment.
``We're going to be able to treat the pain better with safer
agents. In the next decade, if not sooner, we'll be able to give
you things that will slow the disease,'' says Dr. Roland D.
Moskowitz of Case Western Reserve University of Cleveland. ``And
we're going to able to resurface joints with biological materials,
not only to treat the disease but to repair the damage.''
Some new approaches come from surprising directions. For
instance, there's some evidence that a common antibiotic may slow
joint damage or even prevent osteoarthritis. Dr. Kenneth D. Brandt
of the University of Indiana is overseeing a large federally
sponsored trial of doxycycline, a synthetic version of the
antibiotic tetracycline, in people with osteoarthritis or at high
risk for the disease. Tetracyclines inhibit enzymes that soften and
break down cartilage.
Until recently, researchers thought that osteoarthritis was
simply a matter of wear and tear, a grinding down of the slick,
elastic cartilage that cushions and lubricates the ends of all
bones.
Mechanical forces certainly play a role, especially in
initiating the damage. Earlier injury, whether from athletics or
repetitive overuse in the workplace, increases the risk for later
arthritis by three- to six-fold. Maureen Palmer's knee arthritis is
the price she's paying for a ski injury nearly 30 years ago.
With each step, weight-bearing joints must bear a force
equivalent to up to six times total body weight. Thus, it makes
sense that there's a strong link between osteoarthritis and excess
weight. Overweight individuals have four to five times the risk of
osteoarthritis.
But mechanical forces do not totally explain osteoarthritis.
Overweight individuals have a higher risk of arthritis in the hands
too, suggesting that obesity exerts a systemic effect. Inheritance
plays a role too, especially in arthritis of the hand. So do
hormones, since women's risk of the disease rises sharply after
menopause, when estrogen levels decrease sharply.
Diet also affects osteoarthritis, especially once the process
has begun. Researchers think this may be due in part to the effects
on cartilage from oxidation -- a central mechanism of age-related
tissue damage.
In a study of participants in the well-known Framingham Heart
Study, Felson's group found those with the highest dietary intake
of vitamin C, an antioxidant, had one-third the risk of developing
knee pain from arthritis compared to individuals with the lowest
vitamin C levels. Vitamin C may also facilitate cartilage repair.
Vitamin E, another antioxidant, apparently has less effect on
the progression of arthritis, but its anti-inflammatory effects may
explain why some studies suggest vitamin E supplements may ease
pain in some patients.
For now, the best advice specialists can offer to osteoarthritis
sufferers is to attack the disease with a combination of lifestyle,
medical, and dietary interventions -- and ultimately, joint
replacement surgery when all else fails.
At the top of the list are weight loss and exercise.
``Even a little weight loss can make a difference,'' says
Brandt, the Indiana arthritis specialist. Framingham data show that
a weight loss of 11 pounds in women of medium height reduced the
risk of painful knee arthritis by half.
Exercise -- especially gentle and progressive resistance exercise
that strengthens leg muscles -- is getting increased attention among
arthritis researchers. This doesn't mean going to a gym and working
out like Schwarzenegger; cheap ankle weights or elastic bands, used
faithfully at home to do leg-lifting exercises, will do the trick.
``It takes very little physical activity to improve fitness,'' says
Brandt. ``Even the very elderly can do it.''
One reason is that stronger leg muscles brace the knee and hip
joints, reducing the wobble that comes with age-related loosening
of ligaments. Increased joint stability in turn protects cartilage
from the cycle of injury, enzymatic breakdown, and inflammation.
A Tufts University study presented at the Boston rheumatology
meeting showed a home exercise regimen improved leg strength by 71
percent and reduced arthritic knee pain by 36 percent. A larger
exercise study from England showed similar improvements in knee
pain and physical function.
When painkillers are necessary, doctors often advise the old
standby acetaminophen (Tylenol or generic brands) if inflammation
is not an issue, although users should be cautious about combining
this drug with alcohol to avoid liver damage. To relieve both pain
and inflammation, the standard recommendation has been
non-steroidal anti-inflammatories (NSAIDs), but chronic use of
NSAIDs such as ibuprofen and naproxen can erode the stomach lining
and cause potentially dangerous bleeding.
The new cox-2 inhibitors celecoxib (Celebrex) and rofecoxib
(Vioxx) appear to avoid this problem entirely while maintaining
equal efficacy against osteoarthritis pain and inflammation,
according to two studies published last week in the Journal of the
American Medical Association.
It's no accident that Celebrex has vaulted into first place
among prescription painkillers. But Celebrex and Vioxx cost from
$90 to $120 a month, which can be prohibitive for many people,
especially if they have little or no prescription drug coverage.
Eventually, Moskowitz thinks, ``more cox-2 inhibitors will come out
and the price will come down.''
Whatever improvements emerge in medical therapy -- conventional
or alternative -- many osteoarthritis patients will eventually run
out of stop-gap options. For them, the ultimate treatment is an
artificial knee or hip. ``Total knee and hip replacement have
totally revolutionized arthritis treatment, in terms of keeping
people walking and off crutches,'' Moskowitz says. ``When patients
say, `Doc, this is really interfering with my lifestyle and the
medicines aren't helping anymore,' it's appropriate to take the
risk.''
Thomas Ercoline, 64, is glad he did. After conventional medicine
and acupuncture no longer relieved the excruciating pain caused by
his knee arthritis, the Peterborough, N.H. man had joint
replacement surgery in July.
``Initially the pain was worse than the arthritis. The first two
weeks after the operation you wonder why you had it done,''
Ercoline said. ``But when I found I could walk up and down stairs
again, and walk with a normal gait, it sure was worth it.''
