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Cost/Risks/Benefits of Glucosamine-Chondroitin vs Celebrex (celecoxib)

Cost (per day) $0.75-$1.25 $2.50-$7 1
Risks (Deaths/year) 0 16,500+ 2
Effects on Cartilage Benefits Damages 3
Interacts with other Drugs No Yes 4
Causes High Blood Pressure No Yes 5
Causes Bleeding ulcers No Yes 6
Causes Kidney/Liver Damage No Yes 7
Prescription Required No Yes 8
Time to achieve peak pain relief Weeks Days 9
Best on moderate to severe pain Yes No 10
Best on mild to moderate pain No Yes 11
Can be taken if sulfa drug allergic? Yes No 12
Insurance Coverage FSA or HSA  Some 13
Can be used in Diabetics Yes Caution 14
Can be taken with acetaminophen? Yes No 15
Can be taken with anti-inflammatory drugs? Yes No 16
Can be taken once daily Yes Yes 17
Can increse dose if needed for pain Yes No 18



1) Cost of Celebrex versus Glucosamine and Chondroitin.  The base price for Celebrex is $2.50 to $3.00 per day. People who take aspirin for the heart or are at high risk for ulcers who also take Celebrex are required to take an additional prescription medication (called proton pump inhibitors) to help prevent serious or deadly stomach bleeding from the Celebrex. Proton pump inhibitors are sold under the names: Nexium, Aciphex, Prolosec and Prevacid, and cost between $1 per day and $4.20 per day. Users of glucosamine and chondroitin are not required to take any additional medications for protection because they have no safety issues.

2) Risks of Deaths in Celebrex versus Glucosamine and Chondroitin. The difference in the death rates is perhaps the most striking. Worldwide, for almost two decades, no deaths have been attributed to glucosamine or chondroitin. In sharp contrast, anti-inflammatory drugs (Celebrex is one of about 20 brands) were estimated in 1998 cause over 16,500 deaths each year, mainly due to bleeding, kidney and liver damage, medication interactions, and acute allergies (Singh G.  Am J Med. 1998; 105 (1): 31S-38S.)

This number is probably much larger today, especially since the newer versions of anti-inflammatory drugs, called COX-2 selective inhibitors, dramatically increased the numbers of heart attacks and strokes over the first generation of medicines in the same category. At the same time, the number of US citizens taking these drugs has increased significantly since 1998, at least in part due to the immense advertising campaigns of the pharmaceutical companies. In 2004, Vioxx and later Bextra (both COX-2 selective inhibitors) were removed from the market by the FDA. Celebrex remains on the market at this time.

3) Effect on Cartilage for Celebrex versus Glucosamine and Chondroitin. Several studies have shown that glucosamine and chondroitin can help slow or prevent the loss of cartilage in the joints. At the same time, the three human, clinical studies done on NSAIDs (indomethacin, Celebrex and Vioxx) all showed that users of these drugs lost significant amounts of cartilage in as short as one-year.

4-7) Other Risks for Celebrex versus Glucosamine and Chondroitin. The specific reasons why the anti-inflammatory drugs, such as Celebrex lead to so many deaths and adverse reactions are explained in a number of summary documents, including this one from The New England Journal of Medicine. In addition, one only needs to look at the package inserts provided by the pharmaceutical companies to see how many potential problems users of these drugs may face, even with casual use. Here is the package insert for the drug Celebrex. Note that the FDA requires the drug be used in the lowest dose for the shortest period possible.

8) Need for Prescription and Doctor Visit? Celebrex is by prescription only. Many other anti-inflammatory drugs also require a prescription but there are three anti-inflammatory drugs widely available over-the-counter: ibuprofen, naproxen sodium, and ketoprofen. Aspirin, in high dose is also an anti-inflammatory, but the amount needed is usually about 18 or more full-size (325 mg) tablets per day. Aspirin is rarely used in this dose, mainly because of the risk of hearing loss due to toxicity.

Glucosamine and chondroitin are available without a prescription in the United States; they're sold freely over the counter as dietary supplements. Certain countries, including France, Germany and Spain require prescriptions for glucosamine and chondroitin. In Sweden, glucosamine and chondroitin were recently sold as nonprescription, supplements, but the regulatory status has changed so that these are now sold by prescription. It is our understanding that Pfizer pharmaceutical company (maker of Celebrex) had involvement in altering this regulatory status.

9) Time to Achieve Peak Effect Celebrex versus Glucosamine and Chondroitin. Most of the studies on glucosamine and chondroitin show that the supplements start to achieve significant pain relief within about eight to 12 weeks. Maximum pain relief might take longer however, usually six months - that's why it's important for people to stay on these dietary supplements before deciding whether or not they have sufficient pain relief. In rare cases, people are experiencing further relief from the dietary supplements by continuing to take them for nine to 12 months. Celebrex, along with most other anti-inflammatory drugs, allows users to experience pain relief in the few days with maximum pain relieving effect occurring after a few weeks. That's one of the major benefits of using anti-inflammatories.

The slower onset of activity for glucosamine and chondroitin is the main reason why (the impatient) public in the U. S., along with their prescribing doctors, are still utilizing pain relievers such as acetaminophen and anti-inflammatory drugs including Celebrex as the first line intervention for people experiencing osteoarthritis pain. Dr. Theo is trying to alter the prescribing habits of the physicians by instructing them to recommend both glucosamine and chondroitin and a pain reliever or anti-inflammatory drug at the same time, to allow for maximum, fast pain relief. Then, after a period of eight weeks or more, people experiencing pain due to the osteoarthritis should be able to wean off of their anti-inflammatory drug or pain reliever and simply remained on the supplements glucosamine and chondroitin.

10-11) Best use of Celebrex versus Glucosamine and Chondroitin. Not until the completion of the glucosamine/chondroitin arthritis intervention trial (GAIT) did we really understand that these supplements glucosamine and chondroitin were actually more effective in moderate to severe pain from osteoarthritis whereas the prescription drug Celebrex was better for those with mild pain. The only problem with this finding is that doctors are not supposed to prescribe Celebrex for patients with mild pain - patients are instructed to use acetaminophen or even a topical (rub-on) pain reliever. This leaves physicians in a quandary, why would they even prescribe Celebrex for any patients with osteoarthritis?

There still are valid reasons to use anti-inflammatory drugs, namely if a patient experiences obvious signs of inflammation and needs rapid relief. Signs of inflammation due to osteoarthritis include: swelling, warmth, redness an acute pain that is not due to an infection or other treatable cause. In any event, this is not preclude the physician from also prescribing the supplements, along with the anti-inflammatory drug as mentioned in the answer above, comment 9).

12) Can Celebrex or Glucosamine and Chondroitin Be Used in Those Who Are Sulfur Allergic? This is an important issue because people can die from sulfa drugs if they are allergic. The sulfate in chondroitin (and in one form of glucosamine) is an inorganic form, the same as the sulfate found in foods. Allergies to inorganic sulfur are non-existent. Sulfur is the third most common mineral in the body.

Too often, people confuse sulfate with sulfa, a completely different molecule. About 10% of the population has allergies to sulfa drugs (which includes drugs classified as sulfonamides.) Sulfa refers to an organic, ring-structured molecule. Celebrex does cause sulfa drug allergies and must be avoided in those with sulfa allergies. People with sulfa drug allergies can safely take sulfate-containing products including glucosamine sulfate or chondroitin sulfate.

13) Are Celebrex or Glucosamine and Chondroitin Covered by Insurance in the US? Insurance companies do not reimburse or subsidize dietary supplements of any kind. If one has a HSA (Health Savings Account) of FSA (Flexible Spending Account), the cost for ASU/Glucosamine/Chondroitin products may qualify for 100% reimbursement. A physician needs to write, on a Prescription pad, "<name of a specific brand> of supplements for osteoarthritis."

14) Do Celebrex or Glucosamine and Chondroitin Require Extra Caution in Diabetic Patients? Diabetes is a risk factor for osteoarthritis so OA is common in diabetic patients. Since anti-inflammatory drugs can damage the kidneys and diabetes is a significant risk for kidney disease, an effective alternative is even more important for those with diabetes. The risk/benefit ratio for glucosamine/chondroitin versus NSAIDs is even better than for those without diabetes. Glucosamine/Chondroitin have been shown to have no significant effect on blood sugar. In fact, the available evidence suggests that glucosamine users had lower blood sugar compared to those taking a placebo. For an excellent review of the studies on this topic, read this.

15) Can Celebrex or Glucosamine and Chondroitin Be Used in Those Taking Acetaminophen (e.g. Tylenol?) Acetaminophen (e.g. Tylenol) is processed in the liver. The maximum daily dose is 4 grams per day. People with liver disease or who consumer more than two servings of alcohol are not supposed to take any acetaminophen. Since NSAIDs are also processed in the liver, people are warned against using acetaminophen with anti-inflammatories. No such warning exists with glucosamine/chondroitin. Recently, acetaminophen has been shown to cause over 480 deaths per year, mostly from liver failure. In addition, in the Nurse's Health Study, even low-dose acetaminophen doubled the chance of high blood pressure in healthy, middle-aged women.

16) Can Celebrex or Glucosamine and Chondroitin Be Used in Those Who Are Taking Other Anti-Inflammatory Drugs? Thousands of people die each year by combining two or more anti-inflammatory drugs such as ibuprofen, aspirin, naproxen and Celebrex. The risk of taking just one of these drugs dramatically increases one's risk of having a bleeding ulcer. Taking two together increases that risk by nine times!

No such increased risk is found by combining an anti-inflammatory drug with glucosamine/chondroitin.

Since anti-inflammatory drugs work quicker but need to be halted as soon as possible due to safety concerns, many physicians are also prescribing glucosamine/chondroitin along with the drugs. In fact, the supplements might help offset some of the potential damage to the drugs cause on the health of the cartilage. At least one cartilage experiment showed that adding glucosamine/chondroitin prevented cartilage degradation caused by Celebrex.

The supplements are meant to be used of long-term, many months or even years in duration. Since the supplements might take a few months to reach full effect (some people notice in effect within a couple of weeks), it's a good idea to be on the supplements for a period of several weeks before trying to wean off acetaminophen or an anti-inflammatory drug.

17) What's the Best Way to Take Celebrex or Glucosamine and Chondroitin? The supplements actually work better when taken once a day compared to splitting them up throughout the day. This was one of the problems with the NIH GAIT (study). Subjects took the supplements three times a day and might not have achieved the proper concentration necessary for maximal effect. If the supplements are taken once a day, the blood level of the supplements achieves the peak and this in turn stimulates the cartilage cells in a beneficial manner.

Pain medications and anti-inflammatory drugs often differ in their dosing requirements. Acetaminophen, for instance, is often given split over four times a day. anti-inflammatory drugs such as ibuprofen are given three times a day, some of the prescription agents, including Celebrex are given twice or once a day. A medication is not necessarily stronger or weaker because it has to be given more times per day, this difference is just an effect due to the speed at which the drug is processed and eliminated from the body. In fact, the twice daily anti-inflammatory drug naproxen sodium was slightly more effective than the once a day drug Celebrex in a head-to-head comparison.

18) Can the Dose of Celebrex or Glucosamine and Chondroitin Be Increased if Necessary? Over-the-counter and prescription medicine has a very narrow "therapeutic window." This means a drug might give its intended response in a certain dose, but if that does is exceeded, the drug might become toxic and lead to permanent harm. Acetaminophen (e.g. Tylenol) is a good example. Even though a healthy person without liver disease, who consumes little or no alcohol can take up to 4 g of acetaminophen per day, permanent and perhaps fatal liver failure can occur if a person consumes 7.5 g per day - less than double the daily maximum dose.

When it comes to acetaminophen, a pain reliever or anti-inflammatory drugs, whether they are over-the-counter or prescription, taking doses higher than recommended can clearly be life-threatening. This is not the case with glucosamine/chondroitin. some studies have used higher doses, 2000 mg of glucosamine per day and up to 4500 mg a day for chondroitin. In fact, some people do much better by increasing their dose, usually by taking one or two extra tablets of a particular product. With regards to ASU (avocado -- soybean unsaponifiables), research on double the dose, 600 mg a day, has shown to be both safe and effective. As with any change in medication or dietary supplements, be sure to consult with a physician first.




Copyright 1997-2005 Jason Theodosakis, M.D.
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