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In Dr. Theo's Opinion:

This 'editorial' summarizes Dr. Theo's concerns regarding physicians often lack of consideration of alternative solutions for osteoarthritis.

SHOULD OUR CURRENT TREATMENT FOR OSTEOARTHRITIS BE CONSIDERED MALPRACTICE?

Almost all physicians are prescribing anti- inflammatory and pain medicine for osteoarthritis that does not actually improve the condition, but covers up the symptoms. Worst of all, and in clear violation of the Hippocratic Oath, since this medicine can indeed cause harm... Serious harm.

Anti-inflammatory drugs (prescription and over-the-counter, which include Advil®, Motrin®, Aleve®, Ordus®, aspirin, and over 20 others) alone cause over 16,500 deaths and over 103,000 hospitalizations per year in the US, according to a review article published in the New England Journal of Medicine 1. Most of the deaths are from bleeding, drug interactions and kidney damage. The estimated cost for hospitalizations and treatment for these problems exceeds $2 billion annually.

Meanwhile, substances that both improve pain and the structure of osteoarthritic joints are available. Furthermore, these substances, used by several million worldwide have not been associated with a single death or hospitalization.

How can we justify giving toxic drugs that do not improve a disease when there are readily available, non-toxic substances that treat pain more effectively and actually improve the disease process? It’s time we put an end to this unfortunate situation.

Jason Theodosakis, M.D.

1- Wolfe MM, et. al. NEJM 1999;340(24):1888-99

Time for a change… why we can no longer tolerate the status quo

Scenario: A patient comes into the doctor’s office with shortness of breath, fever and coughing. After a brief visit, the doctor correctly diagnoses bacterial pneumonia. To make the patient feel more comfortable, the doctor prescribes Tylenol for the fever and some cough medicine. The patient leaves the office, goes home and dies a short time after.

What’s wrong with this picture? Clearly the doctor should have prescribed a disease-modifying treatment, namely antibiotics, to address the cause of the problem (bacterial infection). Instead, the doctor chose to give the patient only symptom-modifying treatment for his cough and fever. Improper treatment can be worse than useless. The partially treated patient often does not know he is receiving inadequate treatment and is less likely to seek out proper care from another provider.

As sad as this scenario seems, this is what’s happening with many of the 43 million people who suffer from arthritis. People are getting symptom-modifying treatment when disease-modifying treatment is readily available. This is completely unacceptable and must change. Besides the unnecessary suffering, over 16,500 patients a year are dying from arthritis drugs that are only symptom-modifying. This is an indefensible violation of the Hippocratic Oath doctors take to "Do No Harm".

Joint pain is so common as we age that most people consider this to be a normal part of getting old. It’s not. Chronic joint pain is due to a disease, not aging. The disease is usually a form of arthritis, with osteoarthritis (OA) being the most common type. OA, also known as "wear and tear" arthritis or degenerative joint disease is the number one cause of chronic pain. Number one. The CDC says Arthritis is now the leading case of disability in America, and the Arthritis Foundation predicts a dramatic increase in arthritis cases over the next 20 years.

Why had we become so tolerant of this devastating disease? Doctors, interestingly, are largely to blame. Without becoming aware of the available disease-modifying treatment program for OA, doctors have prescribed billions of tablets of anti-inflammatory pills and Tylenol.

Information on the new disease-modifying treatments for OA has not been adequately disseminated. Even the most well read doctor misses over 99% of the new medical articles published each month. Most doctors read only portions of about 3-4 professional journals per month. There are over 2,100 biomedical journals published weekly or monthly. Thus more medical information is distributed each month than the average doctor will read in ten years. It’s no wonder that it often takes ten years or more for major medical breakthroughs to be accepted by the medical community as a whole.

The lag in the time for many doctors to accept that we now have a safer and more effective treatment for osteoarthritis is why patients often report "the doctor just said it’s a little arthritis" or "he said I have arthritis and prescribed some Tylenol for the pain". Most doctors today do not know that we have a treatment that actually can improve the structure of the joints and not just cover up the pain. Tens of thousands of people die annually because this information is not getting out quickly enough.

Diagnosing Osteoarthritis

The hallmark to good medical practice is to get a diagnosis first, so one knows that they’re treating the proper condition. Before treating OA, a proper diagnosis is essential. The diagnosis of OA is a clinical one. There are no laboratory tests, for instance, to detect whether one has or does not have OA. After getting a proper diagnosis with a good medical history and exam, doctors sometimes use x-rays or MRI to confirm the diagnosis. One should be aware that the disease often starts years before there are any findings on x-rays. Also, x-ray finding do not often correlate well with pain or dysfunction. One can have debilitating pain and still have normal x-rays or have terrible looking x-rays and not have pain. MRI scans of a joint can detect OA earlier, but since MRI scans can cost over $1,000, they are generally not covered by insurance as a diagnostic screening tool for OA. MRI scans are usually used to help determine whether or not one needs surgery, an uncommon event for OA sufferers until very late in the disease course.

The New Treatment for Osteoarthritis

The first, and most important treatment is to eliminate, if possible, the known causes of OA. A partial list includes gout (uric acid crystal excess), iron overload, injuries and obesity. Improving poor biomechanics, (body alignment, posture, and motion) may be the most important factor in treatment and prevention of OA. Exercise is also a critical treatment for OA. Each sufferer really needs an individualized prescription for his or her specific problem. Failure to do the proper exercise for a particular problem could actually worsen the condition.

Starting during the efforts to correct these problems, patients suffering from OA should be using a combination of the supplements glucosamine and chondroitin. Individually, each of these supplements has evidence that they are disease-modifying for OA. There is now evidence that the combination has a synergistic effect. Taking both supplements together is better than either supplement alone.

Glucosamine

Glucosamine has been shown, in over 15 clinical studies, to improve the symptoms of osteoarthritis at least as well as anti-inflammatory drugs and better than placebo. New evidence was presented November 17, 1999 at the 63rd annual meeting of the American College of Rheumatology, held in Boston to show that glucosamine can beneficially modify the osteoarthritis disease process. Here’s what we learned. Two hundred and twelve patients with osteoarthritis of the knee were enrolled in a 3-year, multi-center, double-blinded, randomized, placebo-controlled clinical trial. Joint space width of the knee (an indicator of cartilage thickness) was measured using a validated computerized technique before, during and after treatment with placebo or glucosamine. The findings: joint space actually increased slightly in the glucosamine while there was a significant loss of cartilage in the placebo group. Not surprisingly, the glucosamine-treated patients also had improvements in pain and function statistically higher than those taking the placebo.

For those unfamiliar with glucosamine, here’s some background… this supplement is actually produced from shells; usually crab or shrimp shells. It is also produced by the body and consumed in small quantities in the diet. In doses of 1.5 grams (much higher than we get from food), glucosamine has a profound effect on the joints. Supplemental glucosamine provides the cartilage cells in the joints with the basic material to produce new cartilage material. This is important because osteoarthritis is a disease that involves cartilage loss in excess of cartilage formation, yielding a net loss of cartilage. Glucosamine also inhibits some of the enzymes that break down cartilage in suffers of OA and beneficially influences some of the signal chemicals that lead to joint destruction and pain.

Chondroitin

This is another substance crucial to healthy cartilage and joint function. It is also important for the eyes. This is the substance that makes your eyes feel "squishy" when lightly touched. Chondroitin was actually the first supplement to show disease-modifying activity in treating osteoarthritis. On September 7, 1998 at the XIth EULAR Symposium in Geneva, professors G. Verbruggen and E.M. Veys from Ghent University in Belgium presented, and later published, an excellent study comparing chondroitin sulfate to placebo on finger osteoarthritis.

One hundred nineteen patients over age 40 were used in this randomized, double-blind, placebo-controlled, three-year study. Over have of the patients enrolled in the study already had x-ray signs of OA in their finger joints. After obtaining x-rays before the treatment and yearly for 3 years of treatment, the investigators found some convincing evidence. The placebo users had 3.3 times the number of cases of finger joints that progressed to the "erosive" phase of the disease compared to the chondroitin users. Chondroitin, taken by mouth, changed the disease course of osteoarthritis of the fingers by preventing the progression of the disease.

This is not the first study to suggest disease-modifying properties, but may be the first to offer direct proof. At least a dozen other clinical trials have documented that chondroitin has a long-lasting effect on improving patients with OA. In some studies, the benefit improved even after the chondroitin supplement phase of the studies was stopped, a real indication that chondroitin is not simply something that improves symptoms alone.

There has been some debate as to whether or not chondroitin molecules are too large to be absorbed in the body. This seems to be an irrelevant concern since over a dozen studies comparing chondroitin to placebo or anti-inflammatory drugs has proven that chondroitin, when taken by mouth, indeed has a significant beneficial effect. Obviously, something that does not get absorbed would have had no effect different from a placebo. In an effort to finally dispel the doubters, however, special absorption studies have been performed using a radioactive tag (an isotope of sulfur) to follow the chondroitin as it travels through the body. The result - about 13% of the substance is absorbed. Though this may not seem like a lot, this is a very significant finding. The rate of absorption of Fosamax®, the most powerful drug for treating osteoporosis, is less than 1%. Anyone familiar with pharmacology understands that the amount of a substance absorbed has nothing to do with its effect, but helps only with determining the proper dose to administer. It’s no wonder that the critics of chondroitin tend to be (less educated) medical personnel such as chiropractors, naturopaths and "nutritionists" with limited training or are people associated with companies that make products competitive with chondroitin.

Glucosamine and Chondroitin Together Better Than Either Alone

Questions often arise regarding the need to take both of these supplements together. Dr. Theodosakis’ contention has always been "yes", but this has been proven beyond the shadow of a doubt.

The absolute best way to determine if a substance improves the condition of joints is to actually look at the joint tissue under a microscope after treatment. This is exactly the kind of study Dr. Louis Lippiello and colleagues presented November 17th, 1999 at the 63rd annual meeting of the American College of Rheumatology in Boston. Since most people would not take kindly to having biopsies of cartilage removed from their joints, the researchers used rabbits. 36 rabbits were split into four groups: one group was fed glucosamine, one group chondroitin, one group glucosamine and chondroitin. All 4 groups were given the same regular "rabbit" feed so the fourth group was essentially getting a placebo (just the normal food). All the rabbits underwent a standard surgical procedure to accelerate the progression of osteoarthritis in the rabbits’ back legs.

After 16 weeks, the animals were sacrificed and biopsies of the cartilage was examined and graded using a standard system. As expected, the glucosamine and chondroitin groups had a less severe cartilage damage than the control groups (total cartilage grade of 16.6 for controls, 12.2 for glucosamine and 11.0 for chondroitin). The major news comes from the combination group. Rabbits fed both glucosamine and chondroitin had, by far, the least signs of cartilage damage of any of the groups (total cartilage score of 4.4!) This value, despite the small number of rabbits per group, was statistically significant.

In addition to the histologic (by microscope) grading of the cartilage, Dr. Lippiello and his colleagues also measured how well the supplements alone and in combination could stimulate production of cartilage components (called Glycosaminoglycans or GAGS). Compared to control, glucosamine increased GAG production by 32%, chondroitin by 32% but the combination increased production by 97%! The combination of the two supplements indeed had a synergistic effect.

Conclusion

Researchers are fascinated with glucosamine and chondroitin. Over 30 human clinical trials on these supplements have been performed. These studies indicate that the supplements can help improve symptoms, decrease the need for anti-inflammatory medication, reduce the need for surgery and actually decrease the deaths associated with the more toxic and risky treatments for osteoarthritis.

These supplements, along with ASU are currently the only substances known that can both help with the symptoms of osteoarthritis and improve the course of the disease.

Despite their supplement status in the U.S, these powerful drugs must be taken seriously.

Based on the cost/benefit/risk ratio of these supplements compared to other interventions (surgery and drugs), it's clear that the supplements will become the de-facto, first-line therapy for osteoarthritis.

Most educated physicians and even informed laypeople understand this and are using ASU, glucosamine and chondroitin for their osteoarthritis with remarkable results

We'll keep a close eye on the current developments in this area.


 
 

Learn about and purchase the book

90% of people who follow The Arthritis Cure treatment program don't need anti-inflammatories (like Aleve, Celebrex or Advil).
Dr. Theo warned people that these drugs, used first... read more

 

  

Copyright 1997-2005 Jason Theodosakis, M.D.
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