Glucosamine: What's in a brand?

I recently did a couple of CATs Download catglucosamine_and_knee_oastructural_efficacy.doc  Download catglucosamine_and_knee_oasymptomatic_efficacy1.doc  about glucosamine supplementation due to the fact that many of my patients with osteoarthritis would ask me if it would help them along with the manual therapy and exercise I was providing them. (Plus, it fulfilled an academic assignment--kill two birds with one stone, right?)  Anyway, after searching for the most recent evidence, I found a 2006 Cochrane Review on the symptomatic efficacy of glucosamine and a 2005 systematic review of the structural efficacy of this supplementation.  It appears from the evidence that glucosamine is structurally effective at slowing the degenerative process of OA as measured by radiographic evidence of joint space narrowing.  As far as symptomatic efficacy, the evidence is not as favorable as it used to be.  In a 2005 Cochrane Review, glucosamine taken for 6 weeks improved both pain and function over placebo. But when the most recent review added newer and higher quality studies, the conclusions were not as uniform. The desired benefits of decreased pain and increased function, it seems, depended on the functional index used (WOMAC vs. Lequene) and the type of glucosamine preparation taken (Rotta brand vs. Non-Rotta brand).  The eight higher quality studies and those using non-Rotta preparations of glucosamine failed to show benefit in pain and WOMAC function.  Studies evaluating the Rotta preparation and when all 20 RCTs in the Cochrane review were analyzed together (including lower quality and older studies) glucosamine was superior to placebo in improving pain (28% improvement from baseline) and functional impairment (21% improvement from baseline) using the Lequene index, but were not superior using the WOMAC index.  So, what's in a brand?  What's unique about the Rotta brand that is making it more effective than the others in reducing pain and improving function?  I haven't found the answer yet and thought I would pose that question to the EIM bloggers.  I did a quick search around the city I live in to check prices of glucosamine supplementation and could not find the Rotta brand, but other brands sold for between $0.36 and $0.85 per dose.  I finally found the Rotta brand Dona online and it sold for about $1.17 per dose.  So do you think they know "the evidence" and are using it to their advantage?  On a side note, thanks to Rob Wainner who alerted me to a more recent article not included in the 2006 version of the Cochrane review.  In this study published in the NEJM Download Clegg_2006_NEJM_GlucosamineKneeOA.pdf they found that glucosamine and chondroitin sulfate alone or in combination did not reduce pain effectively in the overall group of patients with OA of the knee.  But exploratory analyses suggested that the combination of glucosamine and chondroitin sulfate may be effective in the subgroup of patients with moderate to severe knee pain. (essentially the majority of OA patients who get referred to PT for therapy). Lends more evidence for subgroups and matched intervention!

In any extent, I welcome any and all comments about glucosamine brands and their effectiveness.

Evan

Comments

[Selena Horner]

Evan, I read something a few years back on glucosamine (can't remember where I read it or in what), but the take home message was that this particular supplement is not FDA approved or regulated. In testing a variety of brands of the supposed same product, well, some brands didn't have the actual supplement in them; some of them didn't have the adequate amount of the supplement in them. So, as one reads literature on the effects of supplementation, I always wonder, well, was the supplement in the product? Again, another trust issue - how come we can't trust that when we purchase something that the something we assume is in the product is really in the product?

Geesh, between this topic and that off-label drug topic what downers - I mean, I don't like the idea that I have to lose trust and become more critical of everything! When can you trust something you buy or read?

[Carlos Estevez]

Im w you Selena, thats why we must educate our patients to be skeptical and seek some substantial data to back a "Pill's" claim at least in the dark world of vitamins/suplements...Although im still having a hard time convincing my wife of not jumping into the latest claim on TV/radio..i think shes just rebellling against my advice. :)
'Some of my counterparts in the Air Force passed this one down. Its called COSAMIN DS http://www.nutramaxlabs.com/products/human/cosamin/index.asp
This particular brand has been used in several studies. Latest one by the NIH (National Institute of Health). >1000 randomized subjects comparing this brand of gluco+chondroitin vs. placebo, vs. celecoxib, vs. chondroitin, vs. glucosamine alone. At the end of the study there was a significant improvement of moderate/severe knee pain.
Check out the following link, it appears that this particular brand has undergone quite a bit of research, including "The Military Journal" for some of you military folks outthere.
http://www.nutramaxlabs.com/products/human/cosamin/documents/ConsumerCosaminCandE.pdf
Ive had several pnts report pos. results within 3-5 weeks of taking the product. Price is around $23/bottle 1 mo supply for "load up" phase, thereafter each bottle may last 2 mos. depending on dosage.

[Larry Benz]

Outstanding post. BTW, your EIM team was recently called upon for a very innovative product called Elations (www.elations.com) that is being test marketed in KY due to our hi arthritis rate (3rd in US). We reviewed the literature and advised them on the evidence. Check it out!

[Mike Puniello]

There was a good talk on supplements at Combined Sections meeting in Feb'06. The speaker discussed research for different supplements. She recommended a website www.consumerlabs.com which is like a "Consumer Reports" type of organization. They test supplements to verify the contents and give a chart of the brands they tested along with the percent of the substance it contains; as well as a "recommend" rating. The supplements made in Europe are regulated and must contain what they actually state on the bottle. Amazingly, Consumer Labs tested some supplements that do not contain any of the substance they advertise, so you are buying sugar. I recommend that my patients visit the website if they are considering supplements.

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