Osteoarthritis is the most prevalent chronic articular disease, in which pain is one of the main symptoms and a major determinant of functional loss. Several therapeutic options have been proposed, including glucosamine, but its actual usefulness has not yet been established. To answer this question, we searched in Epistemonikos database, which is maintained by screening multiple databases. We identified 11 systematic reviews including 35 randomized trials answering the question of interest. We extracted data, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. We concluded it is not clear whether glucosamine decreases pain or improves functionality in osteoarthritis because the certainty of the evidence is very low.
Osteoarthritis refers to a clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life. It is the most common form of arthritis, and one of the leading causes of pain and disability worldwide. The most commonly affected peripheral joints are the knees, hips and small hand joints. Although pain, reduced function and effects on a person’s ability to carry out their day-to-day activities can be important consequences of osteoarthritis, pain in itself is of course a complex biopsychosocial issue, related in part to person expectations and self-efficacy, and associated with changes in mood, sleep and coping abilities. There is often a poor link between changes on an X-ray and symptoms: minimal changes can be associated with a lot of pain and modest structural changes to joints oftencan occur without with minimal accompanying symptoms. Contrary to popular belief, osteoarthritis is not caused by ageing and does not necessarily deteriorate. There are a number of management and treatment options (both pharmacological and non-pharmacological), which this guideline addresses and which offer effective interventions for control of symptoms and improving function. Osteoarthritis is characterised pathologically by localised loss of cartilage, remodelling of adjacent bone and associated inflammation. A variety of traumas may trigger the need for a joint to repair itself. Osteoarthritis includes a slow but efficient repair process that often compensates for the initial trauma, resulting in a structurally altered but symptom-free joint. In some people, because of either overwhelming trauma or compromised repair, the process cannot compensate, resulting in eventual presentation with symptomatic osteoarthritis; this might be thought of as ‘joint failure’. This in part explains the extreme variability in clinical presentation and outcome that can be observed between people, and also at different joints in the same person. There are limitations to the published evidence on treating osteoarthritis. Most studies have focused on knee osteoarthritis, and are often of short duration using single therapies. Although most trials have looked at single joint involvement, in reality many people have pain in more than one joint, which may alter the effectiveness of interventions. This guideline update was originally intended to include recommendations based on a review of new evidence about the use of paracetamol, etoricoxib and fixed-dose combinations of NSAIDs plus gastroprotective agents in the management of osteoarthritis. Draft recommendations based on the evidence reviews for these areas were presented in the consultation version of the guideline. Stakeholder feedback at consultation indicated that the draft recommendations, particularly in relation to paracetamol, would be of limited clinical application without a full review of evidence on the pharmacological management of osteoarthritis. NICE was also aware of an ongoing review by the MHRA of the safety of over-the-counter analgesics. Therefore NICE intends to commission a full review of evidence on the pharmacological management of osteoarthritis, which will start once the MHRA’s review is completed, to inform a further guideline update. Until that update is published, the original recommendations (from 2008) on the pharmacological management of osteoarthritis remain current advice. However, the GDG would like to draw attention to the findings of the evidence review on the effectiveness of paracetamol that was presented in the consultation version of the guideline. That review identified reduced effectiveness of paracetamol in the management of osteoarthritis compared with what was previously thought. The GDG believes that this information should be taken into account in routine prescribing practice until the intended full review of evidence on the pharmacological management of osteoarthritis is published (see the NICE website for further details).
OBJECTIVES: Systematic review of outcomes of three treatments for osteoarthritis (OA) of the knee: intra-articular viscosupplementation; oral glucosamine, chondroitin or the combination; and arthroscopic lavage or debridement.
DATA SOURCES: We abstracted data from: 42 randomized, controlled trials (RCTs) of viscosupplementation, all but one synthesized among six meta-analyses; 21 RCTs of glucosamine/chondroitin, 16 synthesized among 6 meta-analyses; and 23 articles on arthroscopy. The search included foreign-language studies and relevant conference proceedings.
REVIEW METHODS: The review methods were defined prospectively in a written protocol. We sought systematic reviews, meta-analyses, and RCTs published in full or in abstract. Where randomized trials were few, we sought other study designs. We independently assessed the quality of all primary studies.
RESULTS: Viscosupplementation trials generally report positive effects on pain and function scores compared to placebo, but the evidence on clinical benefit is uncertain, due to variable trial quality, potential publication bias, and unclear clinical significance of the changes reported. The Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT), a large (n=1,583), high-quality, National Institutes of Health-funded, multicenter RCT showed no significant difference compared to placebo. Glucosamine sulfate has been reported to be more effective than glucosamine hydrochloride, which was used in GAIT, but the evidence is not sufficient to draw conclusions. Clinical studies of glucosamine effect on glucose metabolism are short term, or if longer (e.g., 3 years), excluded patients with metabolic disorders. The best available evidence for arthroscopy, a single sham-controlled RCT (n=180), showed that arthroscopic lavage with or without debridement was equivalent to placebo. The main limitations of this trial are the use of a single surgeon and enrollment of patients at a single Veterans Affairs Medical Center. No studies reported separately on patients with secondary OA of the knee. The only comparative study was an underpowered, poor-quality trial comparing viscosupplementation to arthroscopy with debridement.
CONCLUSIONS: Osteoarthritis of the knee is a common condition. The three interventions reviewed in this report are widely used in the treatment of OA of the knee, yet the best available evidence does not clearly demonstrate clinical benefit. Uncertainty regarding clinical benefit can be resolved only by rigorous, multicenter RCTs. In addition, given the public health impact of OA of the knee, research on new approaches to prevention and treatment should be given high priority.
Osteoarthritis is the most prevalent chronic articular disease, in which pain is one of the main symptoms and a major determinant of functional loss. Several therapeutic options have been proposed, including glucosamine, but its actual usefulness has not yet been established. To answer this question, we searched in Epistemonikos database, which is maintained by screening multiple databases. We identified 11 systematic reviews including 35 randomized trials answering the question of interest. We extracted data, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. We concluded it is not clear whether glucosamine decreases pain or improves functionality in osteoarthritis because the certainty of the evidence is very low.
