Diet, lifestyle changes, and nutraceuticals can make a world of difference for arthritis patients, said Nicholas DiNubile, MD, an orthopedic surgeon.
Dr. DiNubile, who practices in Philadelphia, specializes in cartilage regenerative procedures. He sees hundreds of arthritis patients each year. Most have been to primary care doctors before coming to him. He believes primary care is, “missing the boat on the benefits of lifestyle changes and nutritional supplements.”
Before he considers operating on arthritis patients, he first tries lifestyle change. “Ninety percent of what I do is knee-related, so weight loss is a very big issue. If you’re dealing with overweight patients, and you’re trying to keep them on their own knees as long as possible, you’ve got to get them to lose weight,” said Dr. DiNubile, who is also a team physician for the Philadelphia 76ers. He outlined his approach to bone and joint health in a book called FrameWork (Rodale).
A good Mediterranean diet rich in omega-3s and olive oil, but low in pro-inflammatory trans-fats and refined carbs, is essential. “We know certain foods are pro-inflammatory. Arthritis is an inflammatory disease, so diet can affect it in many ways,” he told Holistic Primary Care.
Always ask patients about dietary supplement use. He estimated that up to half of his arthritis patients have already experimented with joint health supplements. Unfortunately, most don’t get the information or the supplements from their doctors. “They’re really on their own.”
Glucosamine and chondroitin are mainstays in Dr. DiNubile’s practice, and the data from the first phase of GAIT will not change his recommendations. “I had hope that GAIT would be a definitive trial. From what I’ve seen, I don’t think it is. It’s another piece of the puzzle, but not the whole picture.” He added that he will continue to recommend glucosamine/chondroitin for treating osteoarthritis (OA), and to speed recovery after chondrocyte transplant and other procedures.
Outcomes with chondroitin and glucosamine are very product-dependent. Especially for chondroitin sulfate, bioavailability and absorption are key factors. “You need to use a low molecular weight chondroitin. The only one available in the US is CSb Bio-Active, from Bioiberica,” said Dr. DiNubile who has no financial interest in this or any other company. CSb Bio-Active is available in the product called Cosamin DS, from Nutramax. “You need to tell patients what to buy or they end up buying on price and getting suboptimal products.” Some people don’t respond to glucosamine/chondroitin because they don’t take it long enough. “Everyone wants a quick result. This is at least a 2-month commitment.”
According to Jason Theodosakis, MD, a sports medicine specialist who was on the steering committee for GAIT, chondroitin and glucosamine have synergistic effects. Chondroitin increases synthesis of hyaluronan, aggregation of aggrecan, and matrix production. It protects proteoglycans, and inhibits collagenase, elastase and other cartilage-degrading enzymes. Glucosamine increases chondrocyte adhesion to fibronectin, downregulates matrix metalloproteinases, reduces NFkB, prostaglandin E2, and type II collagen antibodies. It is also an antioxidant.
But these are not the only natural products that can help patients with arthritis. Zyflamend (NewMark), the herbal combination containing turmeric, ginger and other anti-inflammatory herbs, inhibits both COX-1 and COX-2, and can quell inflammatory pain in many patients. Because its effects are less specific and less extreme than pharmaceutical COX-2 inhibitors, the risk of adverse effects is far lower. Similarly, new data just published in Biomedicine & Pharmacotherapy showed that pycnogenol, an extract from French Maritime Pine bark, markedly reduces blood levels of COX-1 and 2 in arthritis patients. The reductions occur within 30 minutes of taking pycnogenol (NHS Horphag) at a dose of 300 mg.
LitoZin (EuroPharma), a new antioxidant from certain species of rose hips grown in Scandinavia, is also proving effective for arthritis. Originally discovered by a Danish farmer whose arthritis improved when he ate a lot of rosehip jam, LitoZin contains galactolipids that are active anti-inflammatory compounds. A study of 94 hip/knee OA patients recently published in the Scandinavian Journal of Rheumatology showed LitoZin reduced pain and stiffness, lowered consumption of pain meds and improved quality of life. Earlier studies show similar efficacy. Moreover, LitoZin frequently gives symptom relief within 3 weeks.
Drs. DiNubile and Theodosakis both see promise in a new product called Limbrel (Primus Pharmaceuticals), a combination of two specific flavonoids that appear to have COX-1, COX-2 and LOX inhibitory effects. Limbrel is categorized as a medical food and requires a prescription. “Pilot studies look good, and a larger phase 3 clinical trial is currently in process,” Dr. Theodosakis told Holistic Primary Care. Because it is a prescription product, it is covered by a number of insurers. The cost is about $80–$90 per month in a dose of 250 mg twice daily.
