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Efficacy of glucosamine sulfate in lowering serum level of interleukin-1β in symptomatic primary knee osteoarthritis: Clinical and laboratory study
Alexandria Journal of Medicine (2014) xxx, xxx–xxx
Alexandria University Faculty of Medicine
Alexandria Journal of Medicine www.sciencedirect.com
Efficacy of glucosamine sulfate in lowering serum level of interleukin-1b in symptomatic primary knee osteoarthritis: Clinical and laboratory study Enas M. Shahine a b
a,*
, Abeer S. Elhadidi
b
Physical Medicine, Rheumatology and Rehabilitation Department, Faculty of Medicine, Alexandria University, Egypt Clinical Pathology Department, Faculty of Medicine, Alexandria University, Egypt
Received 27 July 2013; accepted 29 January 2014
KEYWORDS Glucosamine sulfate; Interleukin-1b; Primary knee osteoarthritis
Abstract Objective: To identify the effect of a-D glucosamine sulfate (GS) on serum level of interleukin-1b (IL-1b) in patients with symptomatic primary knee OA. Methods: Sixty patients (mean age = 52.2 ± 8.6 years), fulfilling the American College of Rheumatology criteria of idiopathic knee OA, were randomized to receive either 1500 mg a-D GS and 1200 mg Ibuprofen (group I), or only 1200 mg Ibuprofen (group II) daily for 12 weeks. Patients were followed up by the Visual Analogue knee pain Scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) functional index and quantitative detection of IL-1b serum levels. Reference serum level of IL-1b was determined in 20 matched healthy volunteers. Results: Group I showed significant progressive improvement in pain VAS and total WOMAC scale, pain, stiffness and function subscales during the follow up visits compared to group II. At baseline, both groups had significantly higher IL-1b serum level than the control group. On follow up group I showed significant progressive reduction in IL-1b serum level with a final level that was significantly lower than group II and was not significantly higher than the control group. In group II the reductions in IL-1b serum level did not reach the level of statistical significance and the final level persisted significantly higher than that of the control group. Conclusion: Adding a-D GS to treatment of primary symptomatic knee OA could relieve symptoms, improve function and affect some of the disease mechanisms. ª 2014 Alexandria University Faculty of Medicine. Production and hosting by Elsevier B.V. All rights reserved.
* Corresponding author. Tel.: +20 1278117577; fax: +20 3 5437245. E-mail address: [email protected] (E.M. Shahine). Peer review under responsibility of Alexandria University Faculty of Medicine.
Production and hosting by Elsevier
1. Introduction Osteoarthritis (OA) is the most common chronic synovial joint disorder and is generally characterized by articular cartilage deterioration. Although traditionally considered a non-inflammatory joint disease; it is now well appreciated that inflammatory mediators are produced by articular tissues in OA and
2090-5068 ª 2014 Alexandria University Faculty of Medicine. Production and hosting by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ajme.2014.01.006 Please cite this article in press as: Shahine EM, Elhadidi AS Efficacy of glucosamine sulfate in lowering serum level of interleukin-1b in symptomatic primary knee osteoarthritis: Clinical and laboratory study, Alex J Med (2014), http://dx.doi.org/10.1016/j.ajme.2014.01.006
2 have been implicated in disease pathogenesis.1 There is convincing evidence that interleukin-1b (IL-1b) and other inflammatory mediators, synthesized locally by synovial cells and chondrocytes, play a pivotal role in driving the pathways associated with OA pathogenesis and promote cartilage degradation.2 IL-1b is markedly increased in chondrocytes, synovial membrane and synovial fluid of osteoarthritic patients with a positive correlation between its expression and the severity of chondral damage and increasing grades of OA.3–5 IL-1b initiates the number of events leading to cartilage damage. This process involves inhibition of biosynthesis of proteoglycans in addition to promotion of their degradation. IL-1b has a repressive effect on glucuronosyltransferase involved in a key step in glycosaminoglycans biosynthesis,6 while it upregulates metalloproteinases (MMP), inducible nitric oxide synthase (iNOS), cyclooxygenase-2 (COX-2), Prostaglandin E2 and IL-6.7 Thus, IL-1b may be a therapeutic target in OA. The conservative treatment of OA is still limited to a few classes of medications, such as analgesic drugs, nonsteroidal anti-inflammatory drugs (NSAIDs), COX2 selective inhibitors and viscosupplementation, which provide primarily symptomatic relief but have not yet been demonstrated to interfere with the progression of the disease.8 D-Glucosamine, the biologically active form of glucosamine, serves as a metabolic precursor in the synthesis of the proteoglycans and glycosaminoglycans of cartilage matrix and synovial fluid. It possesses antiinflammatory efficacies against OA in animals and humans and is suggested to delay damage of cartilage and long-term progression of OA as a disease modifying anti-OA drug through its chondroprotective effect.9 It is believed that oral consumption of large quantities of glucosamine elevates its intra-articular concentrations and thereby enhances synthesis of the articular cartilage matrix. Despite the increased use of glucosamine sulfate (GS) in the treatment of OA, the mechanisms accounting for its in vivo antiarthritic activity are still unclear. The aim of the present study was to identify the suppressive effect of a-D glucosamine sulfate on serum level of IL-1b in patients with symptomatic primary knee OA as one of mechanisms which may affect the disease progression. Study design: Ibuprofen-controlled, a-D glucosamine sulfate study to evaluate its efficacy as a treatment for symptomatic primary knee OA. 2. Methods Sixty patients with age range of 46–62 years (52.2 ± 8.6), fulfilling the American College of Rheumatology criteria for idiopathic OA of the knee,10 were included in the study. Knee OA was documented by standardized weight bearing posteroanterior plain radiographic examination. Severity of OA was graded according to the Kellgren and Lawrence grading scale (KL).11 Evaluation of each joint compartment was performed with regard to the presence of joint space narrowing, osteophyte and subchondral sclerosis. Scoring of OA severity impact on patient’s functional status was determined by Lequesne’s algofunctional index (LFI).12 Patients were eligible to be included if they had knee pain on most days of the preceding month and in need for daily NSAIDs, had KL grade 2 or 3 and score >4 to 611 on LFI. By full history taking, thorough clinical examination and specified laboratory investigations; secondary knee OA, polyarticular or suspected inflammatory joint diseases, intra-articular or systemic corticosteroid use within 3 months prior to study, diabetes
E.M. Shahine, A.S. Elhadidi mellitus and administration of anticoagulants or antihypertensive were excluded. An informed written consent was obtained from all participants prior to enrollment in the study which was approved by the Local Medical Ethics Committee. After enrollment, demographic data were recorded for each patient. All patients underwent a complete history taking and clinical examination and were randomized to either study group by a computer generated randomization code. Thirty patients (group I) were allocated to receive 3 capsules of 500 mg a-D glucosamine sulfate, an active isomer of GS in addition to 1200 mg Ibuprofen daily, while 30 patients (group II) received a daily dose of 1200 mg Ibuprofen only. Patients were followed up until completion of a 12-week treatment course. In initial and 3 follow up visits (V1, V2, V3 and V4: baseline, weeks 4, 8 and 12, respectively) all the following were conducted: (1) Patients were asked to rate the severity of knee pain on a 0– 100 mm Visual Analogue Scale (VAS) (0; no pain-100; most severe pain). (2) Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) functional index was assessed.13 Assessment was carried for the total index and for the joint pain (5 questions), stiffness (2 questions), and limitation of physical function subscales (17 questions) each question scored on a scale from 0 to 4, with 0 indicating none and 4 indicating extreme; therefore 20, 8, 68 and 96 points, are the worst possible severity scores for pain, stiffness, limitation of physical function and total index, respectively. (3) Quantitative detection of IL-1b serum levels using commercially available enzyme linked immunosorbent assay (ELISA) quality-validated kit for human (ebioscience. North America, Europe/ International).14 Additionally, IL-1b serum level was determined in a control group of 20 age and sex matched healthy volunteers who had no clinical signs or symptoms of any arthritis and had KL radiographic score <1. Authors were not blind to group assignment. Compliance to medications was determined by asking the patients about missed doses. Safety was investigated by recording the occurrence of adverse events. 2.1. Statistical analysis Data were analyzed using SPSS version 17. Data were summarized using descriptive statistics: mean ± standard deviation (±SD). The statistical analysis was performed using paired sample t-tests for intra-group comparisons. While independent sample t-tests was used for inter-groups comparisons. A probability value (P value) 6 0.05 was considered statistically significant. 3. Results Of the 153 patients who underwent screening, 60 patients were randomized into the study groups. All patients in the two studied groups completed the 12-week treatment course without withdrawals or drop outs. Knee OA was moderate to severe at enrollment according to KL grading and LFI scores. Most patients in the 2 groups (63.3% of group I and 66.6% of group II) had bilateral knee OA. Table 1 demonstrates the comparable baseline characteristics of the two studied groups. Patients in both groups were comparable regarding KL grading, LFI scores, pain VAS as well as total WOMAC OA scale and its 3 subscales (P > 0.05). The mean age of the control group
Please cite this article in press as: Shahine EM, Elhadidi AS Efficacy of glucosamine sulfate in lowering serum level of interleukin-1b in symptomatic primary knee osteoarthritis: Clinical and laboratory study, Alex J Med (2014), http://dx.doi.org/10.1016/j.ajme.2014.01.006
Efficacy of glucosamine sulfate in lowering serum level of interleukin-1b in symptomatic primary Table 1
3
Patients’ demographic and clinical characteristics in the two studied groups at baseline.
Age of patients (years) Gender (man/woman) BMI (kg/m2) Disease duration (months) Number of symptomatic knees KL score LFI Pain VAS (mm) WOMAC OA index total scale Pain subscale Stiffness subscale Function subscale IL-1b (pg/ml)
Group I (n = 30)
Group II (n = 30)
p
52.7 ± 7.9 8/22 (men = 26.6%) 35.0 ± 6.2 6.1 ± 5.1 5 right, 6 left, 19 bilateral 2.7 ± 0.7 9.0 ± 1.2 60.5 ± 15.7 54.5 ± 10.5 11.3 ± 4.1 7.0 ± 2.3 36.2 ± 6.8 6.2 ± 0.6
51.6 ± 9.4 10/20 (men = 33.3%) 35.9 ± 5.6 5.0 ± 6.8 6 right, 4 left, 20 bilateral 2.5 ± 0.8 8.8 ± 2.1 69.0 ± 13.3 53.3 ± 10.3 10.9 ± 3.7 6.9 ± 1.6 35.5 ± 8.2 6.0 ± 0.6
.528 .703 .706 .258 .263 .980 .534 .073 .719 .753 .818 .772 .482
Except when indicated otherwise, values are the mean ± SD. P is significant if <0.05.
was 49.4 ± 9.2 years. They were 7 men (35%) and 13 women. Their mean BMI was 33.9 ± 5.2 kg/m2. The mean IL-1b serum level in the control group was 5.4 ± 0.5 pg/ml. Group I showed significant progressive and constant improvement in pain VAS and total WOMAC scale, pain, stiffness and function subscales during the 3 follow up visits compared to group II. Additionally, the final change in the pain VAS and total WOMAC scale, pain, stiffness and function subscales scores showed significant differences in favor of group I where the mean pain VAS decreased from 60.5 ± 15.7 mm at V1 to 18.2 ± 13.1 mm at V4 (70% reduction) in group I and from 69.0 ± 13.3 mm at V1 to 42.5 ± 14.7 mm at V4 (38.5% reduction) in group II (P < 0.001) and the mean total WOMAC score decreased from 54.5 ± 10.5 at V1 to 29.9 ± 8.6 at V4 (45.4% reduction) in group I and from 53.3 ± 10.3 at V1 to 45.2 ± 9.8 at V4 (15% reduction) in group II (P < 0.001) (Table 2). At V1, group I and group II had significantly higher mean IL-1b serum level than the control group (P = .001 and .003; respectively). On subsequent follow up (V2, V3 and V4), group I showed significant progressive reduction in mean IL-1b serum level (P = .002, .033 and .002; respectively). The final change in IL-1b serum level at V4 was significantly lower than V1 level in group I (P = .001) and was significantly lower than V4 level in group II (P = .001) (Tables 2 and 3). Additionally, it was not significantly higher than the control group’s level (P = .073). In group II there were reductions in mean IL-1b
serum level during V2, V3 and V4 but did not reach the level of statistical significance (P = .382, .360 and .358; respectively) and its final V4 level persisted significantly higher than the level of the control group (P = .017). Compliance to the study medication and safety was good without statistically significant differences in the proportion or pattern of adverse events between both groups. The most frequently reported complaints consisted predominantly of transient episodes of abdominal pain (5%), dyspeptic symptoms (12%), nausea and diarrhea. 4. Discussion Data of the present study showed that 12-week oral administration of a-D GS and NSAID could significantly improve primary knee OA pain, stiffness, limitation of function and lower the elevated serum level of IL-1b throughout the study compared to oral administration of NSAID solely for the same treatment period. Such results were obtained by assessment using the pain VAS and WOMAC index that is, the most widely used algo-functional index for knee OA. Therefore, aD GS could be classified as a symptom-modifying drug in OA. The main finding of this study is that a-D GS could reduce the increase of IL-1b serum level in patients with primary knee OA. Consistent with this data, an experimental study15 showed that reduction of IL-1b level occurred not only in the joints, but also in the serum of rats with adjuvant-induced arthritis
Table 2 Change in the VAS, WOMAC OA index scores and serum level of IL1-b in each group at week 12 (V4) compared with baseline (V1) values. Measure
Group I (n = 30) Difference mean ± SD
P
Difference mean ± SD
P
VAS WOMAC WOMAC WOMAC WOMAC IL-1b
42.2 ± 15.6 24.6 ± 7.3 7.6 ± 3.2 4.1 ± 2.1 12.9 ± 6.9 1.0 ± 0.7
.000* .000* .000* .000* .000* .000*
26.5 ± 17.3 8.1 ± 7.5 3.4 ± 2.8 2.1 ± 2.2 2.5 ± 7.4 .18±.3
.000* .000* .000* .000* .144 .149
*
total scale pain subscale stiffness subscale function subscale
Group II (n = 30)
P is significant if <0.05.
Please cite this article in press as: Shahine EM, Elhadidi AS Efficacy of glucosamine sulfate in lowering serum level of interleukin-1b in symptomatic primary knee osteoarthritis: Clinical and laboratory study, Alex J Med (2014), http://dx.doi.org/10.1016/j.ajme.2014.01.006
4
E.M. Shahine, A.S. Elhadidi Table 3
Comparison between the two studied groups regarding serum level of IL-1b at weeks 4, 8 and 12 follow up visits.
Measure
Group I (n = 30) mean ± SD
Group II (n = 30) mean ± SD
P
V2-IL1-b (pg/ml) V3-IL1-b (pg/ml) V4-IL1-b (pg/ml)
5.7 ± 0.6 5.4 ± 0.9 5.4 ± 0.6
5.9 ± 0.6 5.9 ± 0.5 5.9 ± 0.3
.300 .032* .001*
Values are the mean ± SD. * P is significant if <0.05.
fed on combination of GS and chondroitin sulfate. Cytokine analysis revealed increased inflammatory proteins in sera of OA patients compared to the control, including IL-1b, IL-1 receptors antagonist and IL-6. The levels of these cytokines were higher in OA synovial fluid than sera, consistent with their origin from joint tissue, indicating that local inflammation within OA joint tissues can be reflected in serum. The abnormal production and leakage of inflammatory cytokines into serum are analogous to that observed for biomarkers of joint tissue synthesis and degradation.16 On the contrary, serum concentration of IL-1b was found to be below detection limit in OA patients in another study.17 This contradiction might be explained by the fact that inflammatory cytokines in OA joints traffic through synovium and out into circulation, so they may or may not be present at higher than normal levels in sera of OA patients according to the magnitude of joint tissue inflammation. Participants in the present study had moderate to severe knee OA at enrollment. It was hypothesized that the effects of GS are better realized in patients with moderate to severe OA, which have greater involvement of IL-1b.18 It is not clear whether GS can modulate the intra-articular synthesis of IL-1b so it can lower its serum level or has another systemic mechanism in this regard. Future studies are needed to identify the mechanism responsible for systemic effect of GS in lowering serum level of IL-1b in patients with primary knee OA. Short-term studies designed to describe the pattern of the symptomatic effect of GS, showed a significantly better effect in decreasing pain in patients with primary knee OA compared to placebo therapy and conventional NSAID use in the first 4 weeks of treatment, with improvement in pain and function up to 40–50% relative to basal conditions within 12 weeks.19,20 The rapid effects on symptoms observed for short treatment courses are better explained by the anti-inflammatory effect of GS. In human osteoarthritic chondrocytes, it was found that GS blocks inflammatory signaling and inhibits the synthesis of proinflammatory mediators stimulated by IL-1b through a nuclear factor jB-dependent mechanism.21 Glucosamine sulfate suppresses IL-1b induced phospholipase A222,23 and COX-2 expression and activation,24 iNO22–24 and reactive oxygen species synthesis.23 It also reduces the intra-articular concentration of IL-1b and tumor necrosis factor-a.15,25 The long-term effects of GS in primary knee OA are thought to be related to its effect on cartilage. Pharmacokinetic studies have shown that, crystalline GS is bioavailable both systemically and in articular cartilage after oral administration.26,27 Glucosamine is incorporated into the components of the glycosaminoglycan chains by the chondrocytes,28 stimulates the synthesis of physiological proteoglycans,26 reverses some of the negative effects of IL-1b on cartilage metabolism. There are many reports suggesting that GS reverses the de-
crease in proteoglycan synthesis and in UDP-glucuronosyltransferase I mRNA expression induced by IL-1b.6 In the porcine cartilage explant model, GS showed a chondroprotective effects through inhibition of IL-1b effect on hyaluronic acid and sulfated glycosaminoglycan degradation.29 In articular chondrocytes culture, exogenous glucosamine effectively rendered the chondrocytes unresponsive to IL-1b stimulation.30 In the human articular chondrocytes model, GS inhibited the IL-1b-mediated increase of MMP activity.26,31 Additionally, GS suppresses the expression of the catabolic genes in human osteoarthritic explants.32 Thus it is suggested that the potential therapeutic effects of GS on pathological OA cartilage is more probably due to its ability to inhibit the deleterious effects of IL-1b signaling (anti-catabolic activities), rather than due to cartilage matrix biosynthesis (anabolic activities). There are reports showing that there was less joint space narrowing in knee OA patients who were on glycosaminoglycan over a period of 3 years, compared to placebo.33 Safety of GS during short-term treatment was significantly better than conventional NSAIDs.19,20 The present study confirmed good treatment tolerance over 12-week administration without significant toxic effect patterns being identified. Conclusion: incorporation of a-D GS to NSAID for primary symptomatic knee OA could relieve symptoms, improve function and affect some of the disease mechanisms. Monitoring of IL-1b is useful in monitoring treatment response in primary knee OA. Conflict of interest The authors declare no conflicts of interest. References 1. Attur M, Belitskaya-Le´vy I, Oh C, et al. Increased IL-1 beta gene expression in peripheral blood leukocytes is associated with increased pain and predicts risk for progression of symptomatic knee osteoarthritis. Arthritis Rheum 2011;63:1908–17. 2. Fernandes JC, Martel-Pelletier J, Pelletier JP. The role of cytokines in osteoarthritis pathophysiology. Biorheology 2002;39:237–46. 3. Marks PH, Donaldson ML. Inflammatory cytokine profiles associated with chondral damage in the anterior cruciate ligament-deficient knee. Arthroscopy 2005;21:1342–7. 4. Smith MD, Triantafillou S, Parker A, Youssef PP, Coleman M. Synovial membrane inflammation and cytokine production in patients with early osteoarthritis. J Rheumatol 1997;24:365–71. 5. Goldring MB, Birkhead JR, Suen LF, et al. Interleukin-1b – modulated gene expression in immortalized human chondrocytes. J Clin Invest 1994;94:2307–16.
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Efficacy of glucosamine sulfate in lowering serum level of interleukin-1b in symptomatic primary 6. Gouze JN, Bordji K, Gulberti S, et al. Interleukin-1beta downregulates the expression of glucuronosyltransferase I, a key enzyme priming glycosaminoglycan biosynthesis: influence of glucosamine on interleukin-1beta-mediated effects in rat chondrocytes. Arthritis Rheum 2001;44:351–60. 7. Valvason C, Musacchio E, Pozzuoli A, et al. Influence of glucosamine sulphate on oxidative stress in human osteoarthritic chondrocytes: effects on HO-1, p22 (Phox) and iNOS expression. Rheumatology (Oxford) 2008;47:31–5. 8. Hochberg MC, Altman RD, Brandt KD, et al. Guidelines for the medical management of osteoarthritis. II. Osteoarthritis of the knee. Arthritis Rheum 1995;38:1541. 9. Mevorach D, Menkes CJ. Osteoarthritis and chondroprotection. J Med Sci 1994;30:928. 10. Altman R, Asch E, Bloch D, et al. Development of criteria for the classification and reporting of osteoarthritis. Classification of osteoarthritis of the knee. Arthritis Rheum 1986;29:1039–49. 11. Kellgren JH, Lawrence JS. Radiologic assessment of osteoarthritis. Ann Rheum Dis 1957;16:494–502. 12. Lequesne MG. The algofunctional indices of hip and knee osteoarthritis. J Rheumatol 1997;24:779–81. 13. Bellamy N, Buchanan WW, Goldsmith CH, et al. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol 1988;15:1833–40. 14. Kricka LJ. Principles of immunochemical techniques. In: Burtis ER, Ashwood ER, editors. Teitz textbook of clinical chemistry and molecular diagnostics. 4th ed. Philadelphia: Elsevier Saunders; 2006. p. 219 vol. I. 15. Chou MM, Vergnolle N, McDougall JJ, et al. Effects of chondroitin and glucosamine sulfate in a dietary bar formulation on inflammation, interleukin-1beta, matrix metalloprotease-9, and cartilage damage in arthritis. Exp Biol Med 2005;230:255–62. 16. Attur M, Krasnokutsky-Samuels S, Samuels J, Abramson SB. Prognostic biomarkers in osteoarthritis. Curr Opin Rheumatol 2013;25:136–44. 17. Mannami K, Mitsuhashi T, Takeshita H, et al. Concentration of interleukin-1 beta in serum and synovial fluid in patients with rheumatoid arthritis and those with osteoarthritis. Nihon Seikeigeka Gakkai Zasshi 1989;63:1343–52. 18. Clegg DO, Reda DJ, Harris CL, et al. Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis. N Engl J Med 2006;354:795–808. 19. Mu¨ller-Fassbender H, Bach GL, Haase W, Rovati LC, Setnikar I. Glucosamine sulfate compared to ibuprofen in osteoarthritis of the knee. Osteoarthritis Cartilage 1994;2:61–9. 20. McAlindon TE, LaValley MP, Gulin JP, Felson DT. Glucosamine and chondroitin for treatment of osteoarthritis: a systematic quality assessment and meta-analysis. JAMA 2000;283:1469–75.
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21. Largo R, Alvarez-Soria MA, Diez-Ortego I, et al. Glucosamine inhibits IL-1beta-induced NF kappa B activation in human osteoarthritic chondrocytes. Osteoarthritis Cartilage 2003;11:290–8. 22. Chan PS, Caron JP, Rosa GJ, Orth MW. Glucosamine and chondroitin sulfate regulate gene expression and synthesis of nitric oxide and prostaglandin E(2) in articular cartilage explants. Osteoarthritis Cartilage 2005;13:387–94. 23. Pearson W, Orth MW, Karrow NA, Maclusky NJ, Lindinger MI. Anti-inflammatory and chondroprotective effects of nutraceuticals from Sasha’s Blend in a cartilage explant model of inflammation. Mol Nutr Food Res 2007;51:1020–30. 24. Chan PS, Caron JP, Orth MW. Short-term gene expression changes in cartilage explants stimulated with interleukin beta plus glucosamine and chondroitin sulfate. J Rheumatol 2006;33:1329–40. 25. Campo GM, Avenoso A, Campo S, et al. Efficacy of treatment with glycosaminoglycans on experimental collagen-induced arthritis in rats. Arthritis Res Ther 2003;5:R122–31. 26. Piperno M, Reboul P, Hellio Le Graverand MP, et al. Glucosamine sulfate modulates dysregulated activities of human osteoarthritic chondrocytes in vitro. Osteoarthritis Cartilage 2000;8:202–7. 27. Rovati LC, Girolami F, Persiani S. Crystalline glucosamine sulfate in the management of knee osteoarthritis: efficacy, safety, and pharmacokinetic properties. Ther Adv Musculoskelet Dis 2012;4:167–80. 28. Noyszewski EA, Wroblewski K, Dodge GR, et al. Preferential incorporation of glucosamine into the galactosamine moieties of chondroitin sulfate in articular cartilage explants. Arthritis Rheum 2001;44:1089–95. 29. Phitak T, Pothacharoen P, Kongtawelert P. Comparison of glucose derivatives effects on cartilage degradation. BMC Musculoskel Disord 2010;11:162–74. 30. Gouze JN, Gouze E, Popp MP, et al. Exogenous glucosamine globally protects chondrocytes from the arthritogenic effects of IL1beta. Arthritis Res Ther 2006;8:R173. 31. Shikhman AR, Kuhn K, Alaaeddine N, Lotz M. N-acetylglucosamine prevents IL-1b-mediated activation of human chondrocytes. J Immunol 2001;166:5155–60. 32. Uitterlinden EJ, Jahr H, Koevoet JL, et al. Glucosamine decreases expression of anabolic and catabolic genes in human osteoarthritic cartilage explants. Osteoarthritis Cartilage 2006;14:250–7. 33. Pavelka K, Gatterova J, Olejarova M, et al. Glucosamine sulfate use and delay of progression of knee osteoarthritis: a 3-year, randomized, placebo-controlled, double-blind study. Arch Intern Med 2002;162:2113–23.
Please cite this article in press as: Shahine EM, Elhadidi AS Efficacy of glucosamine sulfate in lowering serum level of interleukin-1b in symptomatic primary knee osteoarthritis: Clinical and laboratory study, Alex J Med (2014), http://dx.doi.org/10.1016/j.ajme.2014.01.006
Alexandria University Faculty of Medicine
Alexandria Journal of Medicine www.sciencedirect.com
Efficacy of glucosamine sulfate in lowering serum level of interleukin-1b in symptomatic primary knee osteoarthritis: Clinical and laboratory study Enas M. Shahine a b
a,*
, Abeer S. Elhadidi
b
Physical Medicine, Rheumatology and Rehabilitation Department, Faculty of Medicine, Alexandria University, Egypt Clinical Pathology Department, Faculty of Medicine, Alexandria University, Egypt
Received 27 July 2013; accepted 29 January 2014
KEYWORDS Glucosamine sulfate; Interleukin-1b; Primary knee osteoarthritis
Abstract Objective: To identify the effect of a-D glucosamine sulfate (GS) on serum level of interleukin-1b (IL-1b) in patients with symptomatic primary knee OA. Methods: Sixty patients (mean age = 52.2 ± 8.6 years), fulfilling the American College of Rheumatology criteria of idiopathic knee OA, were randomized to receive either 1500 mg a-D GS and 1200 mg Ibuprofen (group I), or only 1200 mg Ibuprofen (group II) daily for 12 weeks. Patients were followed up by the Visual Analogue knee pain Scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) functional index and quantitative detection of IL-1b serum levels. Reference serum level of IL-1b was determined in 20 matched healthy volunteers. Results: Group I showed significant progressive improvement in pain VAS and total WOMAC scale, pain, stiffness and function subscales during the follow up visits compared to group II. At baseline, both groups had significantly higher IL-1b serum level than the control group. On follow up group I showed significant progressive reduction in IL-1b serum level with a final level that was significantly lower than group II and was not significantly higher than the control group. In group II the reductions in IL-1b serum level did not reach the level of statistical significance and the final level persisted significantly higher than that of the control group. Conclusion: Adding a-D GS to treatment of primary symptomatic knee OA could relieve symptoms, improve function and affect some of the disease mechanisms. ª 2014 Alexandria University Faculty of Medicine. Production and hosting by Elsevier B.V. All rights reserved.
* Corresponding author. Tel.: +20 1278117577; fax: +20 3 5437245. E-mail address: [email protected] (E.M. Shahine). Peer review under responsibility of Alexandria University Faculty of Medicine.
Production and hosting by Elsevier
1. Introduction Osteoarthritis (OA) is the most common chronic synovial joint disorder and is generally characterized by articular cartilage deterioration. Although traditionally considered a non-inflammatory joint disease; it is now well appreciated that inflammatory mediators are produced by articular tissues in OA and
2090-5068 ª 2014 Alexandria University Faculty of Medicine. Production and hosting by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ajme.2014.01.006 Please cite this article in press as: Shahine EM, Elhadidi AS Efficacy of glucosamine sulfate in lowering serum level of interleukin-1b in symptomatic primary knee osteoarthritis: Clinical and laboratory study, Alex J Med (2014), http://dx.doi.org/10.1016/j.ajme.2014.01.006
2 have been implicated in disease pathogenesis.1 There is convincing evidence that interleukin-1b (IL-1b) and other inflammatory mediators, synthesized locally by synovial cells and chondrocytes, play a pivotal role in driving the pathways associated with OA pathogenesis and promote cartilage degradation.2 IL-1b is markedly increased in chondrocytes, synovial membrane and synovial fluid of osteoarthritic patients with a positive correlation between its expression and the severity of chondral damage and increasing grades of OA.3–5 IL-1b initiates the number of events leading to cartilage damage. This process involves inhibition of biosynthesis of proteoglycans in addition to promotion of their degradation. IL-1b has a repressive effect on glucuronosyltransferase involved in a key step in glycosaminoglycans biosynthesis,6 while it upregulates metalloproteinases (MMP), inducible nitric oxide synthase (iNOS), cyclooxygenase-2 (COX-2), Prostaglandin E2 and IL-6.7 Thus, IL-1b may be a therapeutic target in OA. The conservative treatment of OA is still limited to a few classes of medications, such as analgesic drugs, nonsteroidal anti-inflammatory drugs (NSAIDs), COX2 selective inhibitors and viscosupplementation, which provide primarily symptomatic relief but have not yet been demonstrated to interfere with the progression of the disease.8 D-Glucosamine, the biologically active form of glucosamine, serves as a metabolic precursor in the synthesis of the proteoglycans and glycosaminoglycans of cartilage matrix and synovial fluid. It possesses antiinflammatory efficacies against OA in animals and humans and is suggested to delay damage of cartilage and long-term progression of OA as a disease modifying anti-OA drug through its chondroprotective effect.9 It is believed that oral consumption of large quantities of glucosamine elevates its intra-articular concentrations and thereby enhances synthesis of the articular cartilage matrix. Despite the increased use of glucosamine sulfate (GS) in the treatment of OA, the mechanisms accounting for its in vivo antiarthritic activity are still unclear. The aim of the present study was to identify the suppressive effect of a-D glucosamine sulfate on serum level of IL-1b in patients with symptomatic primary knee OA as one of mechanisms which may affect the disease progression. Study design: Ibuprofen-controlled, a-D glucosamine sulfate study to evaluate its efficacy as a treatment for symptomatic primary knee OA. 2. Methods Sixty patients with age range of 46–62 years (52.2 ± 8.6), fulfilling the American College of Rheumatology criteria for idiopathic OA of the knee,10 were included in the study. Knee OA was documented by standardized weight bearing posteroanterior plain radiographic examination. Severity of OA was graded according to the Kellgren and Lawrence grading scale (KL).11 Evaluation of each joint compartment was performed with regard to the presence of joint space narrowing, osteophyte and subchondral sclerosis. Scoring of OA severity impact on patient’s functional status was determined by Lequesne’s algofunctional index (LFI).12 Patients were eligible to be included if they had knee pain on most days of the preceding month and in need for daily NSAIDs, had KL grade 2 or 3 and score >4 to 611 on LFI. By full history taking, thorough clinical examination and specified laboratory investigations; secondary knee OA, polyarticular or suspected inflammatory joint diseases, intra-articular or systemic corticosteroid use within 3 months prior to study, diabetes
E.M. Shahine, A.S. Elhadidi mellitus and administration of anticoagulants or antihypertensive were excluded. An informed written consent was obtained from all participants prior to enrollment in the study which was approved by the Local Medical Ethics Committee. After enrollment, demographic data were recorded for each patient. All patients underwent a complete history taking and clinical examination and were randomized to either study group by a computer generated randomization code. Thirty patients (group I) were allocated to receive 3 capsules of 500 mg a-D glucosamine sulfate, an active isomer of GS in addition to 1200 mg Ibuprofen daily, while 30 patients (group II) received a daily dose of 1200 mg Ibuprofen only. Patients were followed up until completion of a 12-week treatment course. In initial and 3 follow up visits (V1, V2, V3 and V4: baseline, weeks 4, 8 and 12, respectively) all the following were conducted: (1) Patients were asked to rate the severity of knee pain on a 0– 100 mm Visual Analogue Scale (VAS) (0; no pain-100; most severe pain). (2) Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) functional index was assessed.13 Assessment was carried for the total index and for the joint pain (5 questions), stiffness (2 questions), and limitation of physical function subscales (17 questions) each question scored on a scale from 0 to 4, with 0 indicating none and 4 indicating extreme; therefore 20, 8, 68 and 96 points, are the worst possible severity scores for pain, stiffness, limitation of physical function and total index, respectively. (3) Quantitative detection of IL-1b serum levels using commercially available enzyme linked immunosorbent assay (ELISA) quality-validated kit for human (ebioscience. North America, Europe/ International).14 Additionally, IL-1b serum level was determined in a control group of 20 age and sex matched healthy volunteers who had no clinical signs or symptoms of any arthritis and had KL radiographic score <1. Authors were not blind to group assignment. Compliance to medications was determined by asking the patients about missed doses. Safety was investigated by recording the occurrence of adverse events. 2.1. Statistical analysis Data were analyzed using SPSS version 17. Data were summarized using descriptive statistics: mean ± standard deviation (±SD). The statistical analysis was performed using paired sample t-tests for intra-group comparisons. While independent sample t-tests was used for inter-groups comparisons. A probability value (P value) 6 0.05 was considered statistically significant. 3. Results Of the 153 patients who underwent screening, 60 patients were randomized into the study groups. All patients in the two studied groups completed the 12-week treatment course without withdrawals or drop outs. Knee OA was moderate to severe at enrollment according to KL grading and LFI scores. Most patients in the 2 groups (63.3% of group I and 66.6% of group II) had bilateral knee OA. Table 1 demonstrates the comparable baseline characteristics of the two studied groups. Patients in both groups were comparable regarding KL grading, LFI scores, pain VAS as well as total WOMAC OA scale and its 3 subscales (P > 0.05). The mean age of the control group
Please cite this article in press as: Shahine EM, Elhadidi AS Efficacy of glucosamine sulfate in lowering serum level of interleukin-1b in symptomatic primary knee osteoarthritis: Clinical and laboratory study, Alex J Med (2014), http://dx.doi.org/10.1016/j.ajme.2014.01.006
Efficacy of glucosamine sulfate in lowering serum level of interleukin-1b in symptomatic primary Table 1
3
Patients’ demographic and clinical characteristics in the two studied groups at baseline.
Age of patients (years) Gender (man/woman) BMI (kg/m2) Disease duration (months) Number of symptomatic knees KL score LFI Pain VAS (mm) WOMAC OA index total scale Pain subscale Stiffness subscale Function subscale IL-1b (pg/ml)
Group I (n = 30)
Group II (n = 30)
p
52.7 ± 7.9 8/22 (men = 26.6%) 35.0 ± 6.2 6.1 ± 5.1 5 right, 6 left, 19 bilateral 2.7 ± 0.7 9.0 ± 1.2 60.5 ± 15.7 54.5 ± 10.5 11.3 ± 4.1 7.0 ± 2.3 36.2 ± 6.8 6.2 ± 0.6
51.6 ± 9.4 10/20 (men = 33.3%) 35.9 ± 5.6 5.0 ± 6.8 6 right, 4 left, 20 bilateral 2.5 ± 0.8 8.8 ± 2.1 69.0 ± 13.3 53.3 ± 10.3 10.9 ± 3.7 6.9 ± 1.6 35.5 ± 8.2 6.0 ± 0.6
.528 .703 .706 .258 .263 .980 .534 .073 .719 .753 .818 .772 .482
Except when indicated otherwise, values are the mean ± SD. P is significant if <0.05.
was 49.4 ± 9.2 years. They were 7 men (35%) and 13 women. Their mean BMI was 33.9 ± 5.2 kg/m2. The mean IL-1b serum level in the control group was 5.4 ± 0.5 pg/ml. Group I showed significant progressive and constant improvement in pain VAS and total WOMAC scale, pain, stiffness and function subscales during the 3 follow up visits compared to group II. Additionally, the final change in the pain VAS and total WOMAC scale, pain, stiffness and function subscales scores showed significant differences in favor of group I where the mean pain VAS decreased from 60.5 ± 15.7 mm at V1 to 18.2 ± 13.1 mm at V4 (70% reduction) in group I and from 69.0 ± 13.3 mm at V1 to 42.5 ± 14.7 mm at V4 (38.5% reduction) in group II (P < 0.001) and the mean total WOMAC score decreased from 54.5 ± 10.5 at V1 to 29.9 ± 8.6 at V4 (45.4% reduction) in group I and from 53.3 ± 10.3 at V1 to 45.2 ± 9.8 at V4 (15% reduction) in group II (P < 0.001) (Table 2). At V1, group I and group II had significantly higher mean IL-1b serum level than the control group (P = .001 and .003; respectively). On subsequent follow up (V2, V3 and V4), group I showed significant progressive reduction in mean IL-1b serum level (P = .002, .033 and .002; respectively). The final change in IL-1b serum level at V4 was significantly lower than V1 level in group I (P = .001) and was significantly lower than V4 level in group II (P = .001) (Tables 2 and 3). Additionally, it was not significantly higher than the control group’s level (P = .073). In group II there were reductions in mean IL-1b
serum level during V2, V3 and V4 but did not reach the level of statistical significance (P = .382, .360 and .358; respectively) and its final V4 level persisted significantly higher than the level of the control group (P = .017). Compliance to the study medication and safety was good without statistically significant differences in the proportion or pattern of adverse events between both groups. The most frequently reported complaints consisted predominantly of transient episodes of abdominal pain (5%), dyspeptic symptoms (12%), nausea and diarrhea. 4. Discussion Data of the present study showed that 12-week oral administration of a-D GS and NSAID could significantly improve primary knee OA pain, stiffness, limitation of function and lower the elevated serum level of IL-1b throughout the study compared to oral administration of NSAID solely for the same treatment period. Such results were obtained by assessment using the pain VAS and WOMAC index that is, the most widely used algo-functional index for knee OA. Therefore, aD GS could be classified as a symptom-modifying drug in OA. The main finding of this study is that a-D GS could reduce the increase of IL-1b serum level in patients with primary knee OA. Consistent with this data, an experimental study15 showed that reduction of IL-1b level occurred not only in the joints, but also in the serum of rats with adjuvant-induced arthritis
Table 2 Change in the VAS, WOMAC OA index scores and serum level of IL1-b in each group at week 12 (V4) compared with baseline (V1) values. Measure
Group I (n = 30) Difference mean ± SD
P
Difference mean ± SD
P
VAS WOMAC WOMAC WOMAC WOMAC IL-1b
42.2 ± 15.6 24.6 ± 7.3 7.6 ± 3.2 4.1 ± 2.1 12.9 ± 6.9 1.0 ± 0.7
.000* .000* .000* .000* .000* .000*
26.5 ± 17.3 8.1 ± 7.5 3.4 ± 2.8 2.1 ± 2.2 2.5 ± 7.4 .18±.3
.000* .000* .000* .000* .144 .149
*
total scale pain subscale stiffness subscale function subscale
Group II (n = 30)
P is significant if <0.05.
Please cite this article in press as: Shahine EM, Elhadidi AS Efficacy of glucosamine sulfate in lowering serum level of interleukin-1b in symptomatic primary knee osteoarthritis: Clinical and laboratory study, Alex J Med (2014), http://dx.doi.org/10.1016/j.ajme.2014.01.006
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E.M. Shahine, A.S. Elhadidi Table 3
Comparison between the two studied groups regarding serum level of IL-1b at weeks 4, 8 and 12 follow up visits.
Measure
Group I (n = 30) mean ± SD
Group II (n = 30) mean ± SD
P
V2-IL1-b (pg/ml) V3-IL1-b (pg/ml) V4-IL1-b (pg/ml)
5.7 ± 0.6 5.4 ± 0.9 5.4 ± 0.6
5.9 ± 0.6 5.9 ± 0.5 5.9 ± 0.3
.300 .032* .001*
Values are the mean ± SD. * P is significant if <0.05.
fed on combination of GS and chondroitin sulfate. Cytokine analysis revealed increased inflammatory proteins in sera of OA patients compared to the control, including IL-1b, IL-1 receptors antagonist and IL-6. The levels of these cytokines were higher in OA synovial fluid than sera, consistent with their origin from joint tissue, indicating that local inflammation within OA joint tissues can be reflected in serum. The abnormal production and leakage of inflammatory cytokines into serum are analogous to that observed for biomarkers of joint tissue synthesis and degradation.16 On the contrary, serum concentration of IL-1b was found to be below detection limit in OA patients in another study.17 This contradiction might be explained by the fact that inflammatory cytokines in OA joints traffic through synovium and out into circulation, so they may or may not be present at higher than normal levels in sera of OA patients according to the magnitude of joint tissue inflammation. Participants in the present study had moderate to severe knee OA at enrollment. It was hypothesized that the effects of GS are better realized in patients with moderate to severe OA, which have greater involvement of IL-1b.18 It is not clear whether GS can modulate the intra-articular synthesis of IL-1b so it can lower its serum level or has another systemic mechanism in this regard. Future studies are needed to identify the mechanism responsible for systemic effect of GS in lowering serum level of IL-1b in patients with primary knee OA. Short-term studies designed to describe the pattern of the symptomatic effect of GS, showed a significantly better effect in decreasing pain in patients with primary knee OA compared to placebo therapy and conventional NSAID use in the first 4 weeks of treatment, with improvement in pain and function up to 40–50% relative to basal conditions within 12 weeks.19,20 The rapid effects on symptoms observed for short treatment courses are better explained by the anti-inflammatory effect of GS. In human osteoarthritic chondrocytes, it was found that GS blocks inflammatory signaling and inhibits the synthesis of proinflammatory mediators stimulated by IL-1b through a nuclear factor jB-dependent mechanism.21 Glucosamine sulfate suppresses IL-1b induced phospholipase A222,23 and COX-2 expression and activation,24 iNO22–24 and reactive oxygen species synthesis.23 It also reduces the intra-articular concentration of IL-1b and tumor necrosis factor-a.15,25 The long-term effects of GS in primary knee OA are thought to be related to its effect on cartilage. Pharmacokinetic studies have shown that, crystalline GS is bioavailable both systemically and in articular cartilage after oral administration.26,27 Glucosamine is incorporated into the components of the glycosaminoglycan chains by the chondrocytes,28 stimulates the synthesis of physiological proteoglycans,26 reverses some of the negative effects of IL-1b on cartilage metabolism. There are many reports suggesting that GS reverses the de-
crease in proteoglycan synthesis and in UDP-glucuronosyltransferase I mRNA expression induced by IL-1b.6 In the porcine cartilage explant model, GS showed a chondroprotective effects through inhibition of IL-1b effect on hyaluronic acid and sulfated glycosaminoglycan degradation.29 In articular chondrocytes culture, exogenous glucosamine effectively rendered the chondrocytes unresponsive to IL-1b stimulation.30 In the human articular chondrocytes model, GS inhibited the IL-1b-mediated increase of MMP activity.26,31 Additionally, GS suppresses the expression of the catabolic genes in human osteoarthritic explants.32 Thus it is suggested that the potential therapeutic effects of GS on pathological OA cartilage is more probably due to its ability to inhibit the deleterious effects of IL-1b signaling (anti-catabolic activities), rather than due to cartilage matrix biosynthesis (anabolic activities). There are reports showing that there was less joint space narrowing in knee OA patients who were on glycosaminoglycan over a period of 3 years, compared to placebo.33 Safety of GS during short-term treatment was significantly better than conventional NSAIDs.19,20 The present study confirmed good treatment tolerance over 12-week administration without significant toxic effect patterns being identified. Conclusion: incorporation of a-D GS to NSAID for primary symptomatic knee OA could relieve symptoms, improve function and affect some of the disease mechanisms. Monitoring of IL-1b is useful in monitoring treatment response in primary knee OA. Conflict of interest The authors declare no conflicts of interest. References 1. Attur M, Belitskaya-Le´vy I, Oh C, et al. Increased IL-1 beta gene expression in peripheral blood leukocytes is associated with increased pain and predicts risk for progression of symptomatic knee osteoarthritis. Arthritis Rheum 2011;63:1908–17. 2. Fernandes JC, Martel-Pelletier J, Pelletier JP. The role of cytokines in osteoarthritis pathophysiology. Biorheology 2002;39:237–46. 3. Marks PH, Donaldson ML. Inflammatory cytokine profiles associated with chondral damage in the anterior cruciate ligament-deficient knee. Arthroscopy 2005;21:1342–7. 4. Smith MD, Triantafillou S, Parker A, Youssef PP, Coleman M. Synovial membrane inflammation and cytokine production in patients with early osteoarthritis. J Rheumatol 1997;24:365–71. 5. Goldring MB, Birkhead JR, Suen LF, et al. Interleukin-1b – modulated gene expression in immortalized human chondrocytes. J Clin Invest 1994;94:2307–16.
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Please cite this article in press as: Shahine EM, Elhadidi AS Efficacy of glucosamine sulfate in lowering serum level of interleukin-1b in symptomatic primary knee osteoarthritis: Clinical and laboratory study, Alex J Med (2014), http://dx.doi.org/10.1016/j.ajme.2014.01.006