Good “Joint” Decisions

By Stephen Holt, M.D.

There are approximately 55 million Americans with arthritis. The commonest type of arthritis is referred to as osteoarthritis, and it is often associated with osteoporosis (www.antiporosis.com, Holt S, “The Antiporosis Plan, Wellness Publishing, Newark, NJ, 2002). The cause of many types of arthritis remains unknown but common features of arthritic disorder include pain, joint stiffness and restrictive mobility of joints which are associated with damage to cartilage and joints and ongoing inflammation. Cartilage can be protected by certain natural substances and glucosamine appears to be the most important chondro-protective (chondro = cartilage) agent known in natural medicine. Many people are seeking alternatives to standard drug treatments for arthritis. The most commonly used drugs to treat arthritis belong to a class of pharmaceuticals called non-steroidal-anti-inflammatory drugs which are termed NSAID, as an abbreviation.

Modern nutritional technology is providing ways of assisting with chondro-protection (protection of cartilage in joints) and reducing inflammation using several botanical or herbal agents. The most advanced dietary supplements for the management of bone and joint health include chondro-protective agents, such as high-quality glucosamine and a number of herbal or botanical remedies that may diminish inflammation. This short article emphasizes the importance of combining these approaches in dietary supplement. The use of glucosamine, with or without chondroitin, has been superseded by the use of natural agents that can inhibit key enzymes that cause inflammation, such as the cyclooxygenase enzymes (COX-1 and COX-2 enzymes) which are inhibited variably by NSAID.

Arthritis drug warnings not heeded!
The medical literature of the past three decades is replete with warnings about the adverse effects of NSAID. These drugs are associated with more than 60% of all life-threatening bleeding from the upper digestive tract and they contribute to lower gastrointestinal bleeding. The morbidity and mortality from NSAID use are most apparent in the elderly — the principal target in the population for their use and the most vulnerable. Mature individuals invariably suffer from “thin bones and creaky joints”. NSAID dangers are acutely apparent when one recognizes that they are the commonest reason for adverse drug side effects reported to the FDA.

Limitations of NSAID – Safety of COX-2 inhibitors
For two decades, the “me-too” category of NSAID has seen new product introductions, which are variations on a standard pharmacological (drug) theme of cyclooxygenase (COX) inhibition. COX enzymes catalyze prostaglandin production and they occur in at least two isoforms, COX-1 and COX-2. Traditional NSAID inhibit both isoforms of cyclooxygenase, whereas newer forms of NSAID (e.g. Rofecoxib or Celecoxib) more selectively inhibit COX-2. The notion that COX-1 plays an essential role in normal gut and platelet function, and COX-2 is induced by inflammatory processes, afforded medical practitioners a “new promise” for the enhanced safety, but not necessarily efficacy, of NSAID that work only on COX-2. The new promise has not been completely realized.

NSAID that inhibit Cox-2 enzymes are not completely friendly drugs. They can cause peptic ulcers and gastrointestinal bleeding. Recent studies confirm that COX-2 inhibition causes significant decreases in renal function, at least equivalent, if not greater than, regular NSAID. One may anticipate that liver impairment may occur in some patients taking COX-2 inhibition. Thus, the massive swing toward the human prescription use of COX-2, NSAID compared with regular NSAID (inhibition of COX-1 and COX-2) may not be as reassuring as hitherto supposed. As with all new classes of drugs, time will tell and there are some underexplored worries about COX-2 inhibition.

Natural COX-2 inhibitors
Inhibiting the enzyme COX-2 in a potent manner using a drug is associated with unwanted side effects. However, there is a series of naturally occurring compounds found in herbs and botanicals that show an ability to inhibit COX-2, apparently without the side effects experienced with COX-2 inhibitor drugs. Individuals who are interested in this novel approach are referred to the websites www.naturesbenefit.com with reference to Arthrotrim™ and www.naturalcox-2inhibitor.com. In brief, these natural agents include: Barberry Bark, Goldenthread, Feverfew, Ginger Root, Green Tea, Tulsi Leaves, Hops, Oregano, Rosemary Leaf, Scullcap, Turmeric, Nettle Leaves and Polygonum Cuspidatum. One interesting herb is Phellodendron amurense, which has been produced in an extract form with clear COX-2 inhibiting activity.

The basis of this knowledge has resulted in the development of a dietary supplement called Arthrotrim™ (www.naturesbenefit.com), which is a proprietary blend of natural agents that have important effects on body structures and functions (e.g. anti-inflammatory potential, potential pain-relieving properties, and beneficial effects on soft tissues associated with joints). One may think that inhibiting COX-2 is a bad idea, given the outcome of some uses of COX-2 inhibitor drugs, but nature appears to provide a mechanism to inhibit COX-2 in a beneficial manner that is safe, effective and gentle. Much more research is required to define the role of “natural”, COX-2 inhibition.

Doing away with NSAID?
So pernicious are the problems of NSAID usage and so common are bone and joint problems, that many consumers are seeking alternative, natural remedies. People with arthritis often self-medicate and, after all, the OTC availability of NSAID is in its old, “regular” format (non-specific COX-1 and COX-2 inhibition). The iatrogenic (healthcare or medical- practitioner-induced) diseases caused by NSAID provide powerful stimuli for patients, physicians and pharmacists to avoid their use. However, the enigma remains: NSAID are the most commonly used drugs of all pharmaceutical categories.

Can we do away with NSAID use?
I believe we have some real options in natural therapies to at least reduce the need for NSAID and, on occasion, completely avoid their use. We have learned that there are several bone and joint nutritional supplements for which there is mounting evidence of efficacy and clear advantages in terms of safety, over NSAID usage.

With perhaps the exception of Ayurvedic tree resins (Boswellic acids and Guggulsterones), most orally administered natural remedies for joint disorders take “many days” (or sometimes weeks) to be completely effective. For example, the natural anti-inflammatory actions of glucosamine, chondroitin can take as long as twelve weeks before maximal benefits are achieved. However, no drug therapy to date has been shown to significantly alter the natural history (overall outcome) of the progression of arthritis. In contrast, I believe that nutritional approaches will both help prevent arthritis and alter its clinical course.

Controlled, comparative clinical studies of certain NSAID and glucosamine show that NSAID “win out” in terms of symptomatic relief early in treatment, but over time, the benefits of glucosamine equilibrate with those of NSAID and even result in better treatment outcome! In fact, we know that certain NSAID may damage cartilage, whereas glucosamine and other natural substances have cartilage regenerative powers. This short overview of natural ways to joint health is mandatory because of the strong association of “thin bones and creaky joints” (see www.antiporosis.com).

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