Dr. Theo's Opinion:
'editorial' summarizes Dr. Theo's concerns regarding physicians
often lack of consideration of alternative solutions for osteoarthritis.
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? Its time we put an end to this unfortunate
MM, et. al. NEJM 1999;340(24):1888-99
why we can no longer tolerate the status quo
Scenario: A patient comes
into the doctors 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
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
As sad as this scenario
seems, this is whats 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. Its 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. Its 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 its 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.
The hallmark to
good medical practice is to get a diagnosis first, so one knows that theyre
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
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.
Heres 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, heres 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.
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. Its 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
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
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
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.