In my family medicine clinic I take care of many patients with painful arthritis who are struggling to maintain a healthy and active lifestyle. Most manage with the usual acetaminophen and NSAIDs, but for many that's not enough. Quite a few of my patients are on much stronger pain medicines that require them to deal with many side effects. It's no surprise that so many people with arthritis try supplements that are said to help with pain and mobility. But which ones really work, and which ones are a waste of money?
To better help my patients, I reviewed the research literature on supplements, and I'd like to share what I learned with others. Please feel free to share this with your colleagues and loved ones.
Please note that this review discusses osteoarthritis and not rheumatoid arthritis, a much more serious inflammatory disease.
Don't forget the basics
Before I dive into my findings, I can't stress enough that no supplement is as important as keeping your bones healthy with diet and exercise. No matter how painful your osteoarthritis, multiple studies show long-term benefits from light activity and mind-body exercises such as tai chi and yoga. A healthy diet full of calcium and anti-inflammatories (fruits and vegetables) is also crucial. Women of all ages should make sure they're getting enough calcium and vitamin D.
And since obesity is a major cause of arthritis, especially in the knees, it’s always important to control your weight, no matter your age or what medicines you’re taking.
A look at 6 supplements
Now, here's what I found about supplements.
Glucosamine and chondroitin
- People may be surprised that the evidence for the effectiveness of this very popular combination isn't actually as strong as most think. One reviewer says, "It appears that most of the positive studies were funded by manufacturers of glucosamine products, and most of the studies performed by neutral researchers failed to find benefit." What seems certain from reviews such as Cochrane is that you should stick with glucosamine sulfate (the Rotta preparation) and not glucosamine hydrochloride. Fortunately, most formulations seem to be the first, more effective one.
- I was intrigued by the two studies that showed possible actual improvement in osteoarthritic joints with the use of glucosamine and chondroitin. But drugmakers sponsored these studies, and many others don't show much, if any, improvement. Most of my primary-care colleagues are unenthusiastic about this supplement. Still, I think it's reasonable to try it for three to six months, and then stop if there’s no improvement in pain and movement.
- The usual dose of glucosamine sulfate seems to be 1,500 milligrams, and the price isn't too bad. For example, a generic from Costco is only $6.40 a month. One note: Most glucosamine supplements seem to also contain MSM (methylsulfonylmethane). While the evidence for this supplement is very poor, at least there's no reported harm.
- I'm more impressed by SAMe than glucosamine for osteoarthritis. The Natural Medicines Database says that "multiple clinical trials show that taking SAMe orally is superior to placebo and comparable to NSAIDs, including the COX-2 inhibitor celecoxib (Celebrex), for decreasing symptoms associated with osteoarthritis. SAMe is associated with fewer adverse effects than NSAIDs and is comparable in reducing pain and improving functional limitation."
- Cost could be a limitation, however. Most studies used 600 to 1,200 milligrams daily, and taking 400 milligrams twice a day (using the best values on iHerb, for example) would cost at least $45 to $50 a month. But other studies using only 400 to 600 milligrams a day also showed effectiveness. That would bring the monthly cost to about $20.
- SAMe is reported to take up to a month to ease symptoms of osteoarthritis. Otherwise, it could be a good option for many. If you take SAMe for three months and don't notice any improvement, stop taking it.
- Glucosamine and SAMe seem to have the most research and probably should be tried first.
The next level of research on supplements for osteoarthritis includes:
This wonderful spice seems to have some health benefits, including alleviating pain. There are a few double-blind studies that do show improvement in pain, similar to improvement from NSAIDs such as ibuprofen but with less risks to the stomach. Most studies used 500 milligrams twice a day. There seem to be a few formulas that combine ginger and boswellia, which could be a better value.
Indian frankincense (boswellia)
This is another ancient medicine that has a few randomized studies that show benefits for arthritis pain and function, comparable to the usual NSAID medicine. Benefits also seem to last up to a month after stopping the medicine, while an NSAID stops working immediately. Indian frankincense takes about a week to start working. There aren't a lot of studies of Indian frankincense, but it's promising and perhaps worth a try. The dose seems to be 100 to 300 milligrams a day, divided into two doses.
Avocado soy unsaponifiables (ASU)
This oil extract is a very interesting chemical. Researchers are excited because they believe it may actually heal damaged cartilage, or at least slow down the progression of damage from arthritis. A few randomized control trials have shown reductions in pain and stiffness and improvements in joint function. But a longer study didn't show much benefit, and other studies haven't found improvements in joints. It also may take a few weeks to notice an effect from avocado soy unsaponifiables. Still, this could be an interesting option if the more traditional supplements haven’t worked for you. The usual daily dose seems to be 300 to 600 milligrams.
Here's another wonderfully fragrant root that also seems to benefit arthritis. The evidence is relatively limited, however, and it seems to take more than three months to notice a benefit. There also are quite a few side effects, especially if patients are also taking blood thinners such as coumadin, aspirin or NSAIDs. I'd be hesitant to try ginger as a supplement, but it sure is lovely in food!
Let's step back now and review the evidence, especially from my favorite evidence-based sources, all of which are certified by the Health on the Net Foundation as sources of trustworthy medical information. By the way, I strongly recommend that you use the foundation’s HONCode search engine anytime you’re looking for medical advice, especially about supplements.
The Natural Medicines Database, a fantastic resource for doctors, favors topical capsicum, glucosamine sulfate and SAMe as "likely safe and effective." The database says these substances are “possibly effective and likely safe”: beta-carotene; chondroitin sulfate; ginger; Indian frankincense (boswellia); turmeric; and vitamin C.
The Cochrane Library, a well-respected independent review board, looked at herbals for osteoarthritis in 2014 and found poor evidence for most supplements. It only found sufficient data for two herbals: boswellia, which it slightly favored over ASU. Other studies found lukewarm evidence for glucosamine sulfate.
The Natural & Alternative Treatments database, which you can access on sites such as iHerb.com or ConsumerLab.com, has an osteoarthritis review that favors SAMe, ginger, UC-II collagen and boswellia, with more mixed data on glucosamine, MSM and omega-3 fish oils.
The National Center for Complementary and Integrative Health, a federal agency, has an osteoarthritis review that doesn't strongly recommend any herbals, including glucosamine, which it still classifies as of "uncertain" impact.
Where to buy?
I'm a big fan of Costco's supplements for value and quality. For online purchases, the iHerb website is easy to use, with very good prices and free access to The Natural & Alternative Treatments database. iHerb is also fantastic for shipping to other countries. When I lived in China, we used iHerb constantly for very little in added shipping costs.
Since there's such a wide range of active ingredients in these unregulated herbals, I highly recommend the independent ConsumerLab.com, which has tested thousands of supplements and has objective data on which brands are the best, for quality and value.
My bottom line
In general, if a supplement does no harm and there’s evidence that it may ease pain and improve quality of life, why not try it?
But do these two things first:
- Make sure a supplement doesn't have bad side effects when taken with your prescription drugs. You can use Medscape’s free drug interaction checker, which includes supplements as well as prescription drugs.
- Don't forget to tell your doctor which supplements you use! Your provider needs to be aware of potential side effects and drug interactions, especially with blood thinners.
For most people with osteoarthritis, trying a supplement on top of the usual treatments is perfectly reasonable. I'd start with three-month trials of glucosamine and chondroitin sulfate, and then SAMe. My next choices could include boswellia, ASU or turmeric.
If one works, keep going with it. You could also consider adding a second supplement for extra benefit. Good luck!
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