Cartilage supplements:

glucosamine and chondroitin

Alexandrina Ferreira Mendes

Laboratory of Pharmacology, Faculty of Pharmacy
And Center for Neuroscience and Cell Biology
University of Coimbra
Coimbra, Portugal Curia, April 23rd 2010
 Glucosamine salts:
sulfate and hydrochloride
In vitro: chondrocyte, synoviocyte and cartilage explant cultures
↑ synthesis of:
ECM components (aggrecan, collagen II)
Anti-inflammatory mediators (HO-1)

↓ catabolic and pro-inflammatory responses to IL-1β:

↓ activation of NF-κB, iNOS, COX-2, MMPs,
ADAMTS
↑ expression of HO-1, proteoglycans, collagen II

Concentration range: 1-25000 µM

Largo et al. Osteoarthritis Cartilage. 2003;11:290-8

Toegel et al. Osteoarthritis Cartilage. 2008; 16:1205-12

Alexandrina Ferreira Mendes

 Chondroitin Sulfate

In vitro: chondrocyte, synoviocyte and cartilage explant cultures

↓ catabolic and pro-inflammatory responses to IL-1β:

↓ activation of NF-κB, p38, ERK1/2, iNOS, COX-2, PLA2,
MMPs

Glucuronic ac. N-acetylgalactosamine Glucuronic ac. N-acetylgalactosamine

Chondroitin-4-sulfate Chondroitin-6-sulfate

n= 20-40 disaccharide units Alexandrina Ferreira Mendes

 Common mechanism of action:
NF-κ
κB inhibition

TNF-α Pro-inflammatory
IL-1β, IL-18 pro-catabolic
cytokines
IL-6, IL-8
MMPs Matrix degradation
ADAMTS
iNOS Inflammation
COX-2
.

Excellent efficacy in vitro and in vivo (animal models)

Alexandrina Ferreira Mendes
 Some recently completed clinical trials
Reference Sponsor Total daily Size/duration Outcome (JSN,
dose, mg WOMAC, Lequesne)

Lancet. Rottapharm 1500 N=106/arm; 3 yr significant ≠ from

Glucosamine 2001;357:251-6 placebo
sulfate (GS) Arch Intern Med. Rottapharm 1500 N=101/arm; 3 yr significant ≠ from
2002;162:2113-23 placebo
Glucosamine Arthritis Rheum. GAIT (NIH) 1500 N≈300/arm; 2 yr no significant ≠ from
hydrochloride 2008; 58:3183-91 placebo
(G.HCl)
Arthritis Rheum. GAIT (NIH) 1200 N≈300/arm; 2 yr no significant ≠ from
Chondroitin 2008; 58:3183-91 placebo

sulfate (CS) Arthritis Rheum. STOPP 800 N≈300/arm; 2 yr significant ≠ from

2009;60:524-33 placebo

G.HCl+CS Arthritis Rheum. GAIT (NIH) 1500 + 1200 N≈300/arm; 2 yr no significant ≠ from
2008; 58:3183-91 placebo

Reference Sponsor Total daily Size/duration Outcome (Pain)

dose, mg
G.HCl, CS, N Engl J Med. GAIT (NIH) 1500, 1200, N≈300/arm; no significant ≠ from
G.HCl+CS 2006;354:795-808 1500+1200 24 weeks placebo
(significant improvement with
combination in moderate-
severe pain)

Alexandrina Ferreira Mendes

 Glucosamine salts and chondroitin
sulfate

Sulfate seemingly more effective than hydrochloride

Large discrepancy between efficacy in vitro and in vivo vs clinical
trials
Cmax (~10 µM)<< concentration range in vitro (1-25000 µM)
Cmax << Km transport in human chondrocytes (normal ≈ 1.1 mM,
OA ≈ 1.5 mM)
Discrepant results between clinical trials;
possible causes: patient selection, late endpoints, dosage
regimen, source of drug/compound

Black et al. Health Technol Assess. 2009; 13:1-148

Block et al. Osteoarthritis Cartilage. 2010; 18:5-11
Rosa et al., Arthritis Res Ther. 2009; 11:R80 Alexandrina Ferreira Mendes
 Patient selection

Early stage OA ≠ late stage

↑ Aggrecanases ↑ MMPs
Aggrecan degradation

Collagen degradation

Reversible Irreversible

Glucosamine sulphate, 1500 mg/day + walking, N=36, ages 40-73, no daily

medication (analgesics included), 6 weeks:
Improvement in WOMAC scores, physical activity and function

Bay-Jensen et al. Rheumatol Int. 2010; 30:435-42

Ng et al. Arthritis Res Ther. 2010;12:R25 Alexandrina Ferreira Mendes
 Endpoints/outcome
measures
Slow changes in JSN ⇒ low sensitivity
Low reproducibility (improved w/ MRI)

Earlier and quantifiable endpoints/outcome measures

and biomarkers
sensitive, specific, reproducible
disease staging
discriminate fast and slow progressors
Alexandrina Ferreira Mendes
 Dosage regimen
Source of drug/compound
Single dose vs multidosing
Implications on Cmax

Drugs vs nutritional supplements

EC: drugs and/or nutritional supplements

USA: nutritional supplements ⇒ less stringent

requirements (purity, composition, dosage,
pharmacokinetics, pharmacodynamics)

Block et al. Osteoarthritis Cartilage. 2010; 18:5-11

Reginster et al. Rheumatology (Oxford). 2007;46:731-5. Alexandrina Ferreira Mendes
 Glucosamine and
Chondroitin sulphate
Positive effects on symptomatic and
structural outcomes of knee OA (still
debated)

Trend to combination more effective

than either alone

Symptomatic and structure modifying properties

enhanced in early OA?
Alexandrina Ferreira Mendes
 Hyaluronic acid:
viscosupplement or drug?
Viscoelastic properties
lubrication
load absorption

Glucuronic ac.
MW Sodium hyaluronate ≈ 400-500 kDa
N-acetylglucosamine
MW Crosslinked hyaluronan ≈ 6000 kDa
Marshall et al. J Orthop Res. 2000; 18:416-25

Alexandrina Ferreira Mendes

 Hyaluronic acid:
viscosupplement or drug?
In vitro: chondrocyte and synoviocyte cultures
↓ p38 activation, NO production, mitochondrial DNA damage,
apoptosis,

↑ mitochondrial DNA repair capacity, ATP levels

Hylan better than HA in improving growth factor expression

profile in synoviocytes

In vitro: animal models

↑ GAG content after acute injury
Grishko et al. J Biol Chem. 2009; 284:9132-9
Kaplan et al. Am J Sports Med. 2009;37:2323-7
Lee et al. J Orthop Res. 2010; 28:492-6
Takahashi et al. Int J Mol Med. 2004;14:139-44 Alexandrina Ferreira Mendes
 Hyaluronic acid:
viscosupplement or drug?
Clinical trials (mainly retrospective or pilot
prospective studies)

Pain reduction

Functional improvement

Excellent tolerability

Castellacci & Polieri. Drugs Exp Clin Res. 2004;30:67-73

Migliori et al. Arthritis Res Ther. 2009;11:R183
Alexandrina Ferreira Mendes
 SYmptomatic Slow Acting Drugs for
OsteoArthritis ─ SYSADOA

Current Drugs Main features

Glucosamine sulphate
Delayed effects

Chondroitin sulfate
Reduce NSAID use
Diacerhein
Carry-over effects
Hyaluronic acid

Alexandrina Ferreira Mendes

Cellular Immunology and Oncobiology Group:
Chondrocyte Biology and Osteoarthritis Research