Arthritis

A recent media release has created significant interest in stem cell therapy as a treatment for osteoarthritis. Is the hype and promise created able to be substantiated?

In real estate parlance, I would use the old chestnut – “Caveat Emptor” – Buyer Beware.

Osteoarthritis is a condition characterized by generalized wear/loss of joint surface layer (articular cartilage) on 2 opposing joint surfaces. This can create pain, swelling, stiffness and functional deficit. Unfortunately once this joint surface layer is damaged or worn it has virtually no ability to heal itself. Osteoarthritis or articular cartilage wear develops because of multiple reasons – age, activity, obesity, injury to the joint surface or important supporting structures such as ligaments or menisci, joint malalignment, activation/release of bad biomolecules and probably other reasons that have yet to be identified. Osteoarthritis is a complex disorder with many facets.

The basic science behind stem cell treatments is interesting. In a nutshell, stem cells are the “parents” of different lines of tissue cells. Mesenchymal stem cells are capable of differentiating (transforming) into muscle, tendon, bone or joint surface cells (chondrocytes) given the right circumstances and environment. These chondrocytes are important in looking after the joint surface layer but have a very limited regenerative (repair) capacity. Basic laboratory studies have shown stem cells are capable of producing joint surface like tissue in some circumstances. It is thought in some circles that injecting stem cells into an arthritic joint may enable some repair or restoration of a joint surface layer. The theory sounds good – but does it work in practice?

Well we don’t know. To date unfortunately there are no randomised published scientific studies in peer review journals that indicate that stem cell injections reconstitute articular cartilage and allow for reversal of an arthritic process. I’m always a bit wary of treatments that are hailed as “miracles” in the media, before there are any credible published results. Using patient testimonials or observational registries as a support for stem cell therapy does NOT constitute proof of treatment success. This is not the way that reputable centres and individuals seek to promote themselves, their treatments and their businesses.

Interestingly here in Australia and in the US, the relevant health regulatory authorities have approved stem cell therapy only for the treatment of some leukaemias and blood disorders. For all other conditions it is considered experimental treatment but there is no regulation over patients receiving treatment that involves the use of their own stem cells. The Therapeutic Goods Administration has hinted that there will be a crackdown on centres promoting and undertaking stem cell treatments for non approved conditions.

I recognize that there are patients with osteoarthritis for whom conventional treatment techniques don’t result in a lot of improvement and for whom surgical procedures are not ideal. Unfortunately these people are vulnerable and are easily lured into trying unproven and often expensive treatment modalities with the promise of a cure. I’m not against stem cell or any other reasonable treatments for osteoarthritis and we certainly don’t want to stifle innovation and progress and credible research.

Stem cell therapy needs to be undertaken in a controlled and responsible manner by practitioners who are genuinely looking to help sufferers and to try and find answers to osteoarthritis through responsible and rigorous research that is subject to scrutiny by the scientific community. We do not need the current unregulated “free for all” approach to stem cell therapy that currently exists, undertaken by medical businesses with questionable motives. If you are considering these treatments, do your homework and go in with open eyes. Do not be blinded by media hype for a treatment that offers much but to date has produced little.

For more information on stem cell therapies, the Stem Cells Australia website at http://www.stemcellsaustralia.edu.au/ is an excellent educational resource put together by most of the major universities and research organisations in Australia.

There are some excellent handouts regarding stem cell therapies that are downloadable for patients at:

https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/rm001a_stem_cell_treatments_faq_131220.pdf

http://www.stemcellsaustralia.edu.au/AboutUs/Document-Library/Patient-Information.aspx

I’m often asked what I really think about Glucosamine and Chondroitin for Osteoarthritis.

Osteoarthritis can be a debilitating joint condition and is the 4^th leading cause of disability in the world. It is caused by a progressive deterioration and a generalised loss of a cushioning tissue (called articular cartilage) that sits on and protects the bone surfaces of a joint. This loss of the articular cartilage layer of a joint causes pain, stiffness, often swelling and a loss of function. This can affect work, recreations and simple activities of daily living causing a reduction in “quality of life”.

Glucosamine and Chondroitin are important constituent molecules of the articular cartilage layer. This layer however has many other molecules, cells and internal fibres and how they are all arranged together is extremely complex. Articular cartilage is one of the few tissues in the body, which once damaged, has no mechanism to repair itself. This is why osteoarthritis (and other forms of arthritis) remains a great unsolved medical problem. There is NO treatment to date (medications, injectable therapies or surgical treatment) that has been shown to reverse or cure osteoarthritis.

The use of glucosamine and chondroitin has gained popularity as a treatment for osteoarthritis. In Australia and the US, these substances are viewed as “natural” joint supplements and not medications for which a prescription is required. As such they are readily available over the counter in chemists, health food shops and via on-line stores. They are promoted quite aggressively by multinational wellness/bio-ceutical companies with large marketing budgets, claiming both symptomatic and joint cartilage protection benefits. In some European countries, only a medical practitioner can prescribe these supplements.

Glucosamine and Chondroitin have been extensively studied in humans and animals over the last 15 years. In terms of arthritic pain the results of scientific studies is conflicting. Some studies indicate benefit over placebo (sugar pill treatment) and others do not. In general, the poorest designed studies with the greatest bias (manufacturer sponsored studies) show the best results and the better designed studies show no difference. No study has demonstrated that either glucosamine or chondroitin or a combination of the two leads to repair or reconstitution of articular cartilage.

The largest and best designed clinical trial has been the GAIT or Glucosamine/chondroitin Arthritis Intervention Trial conducted in the US and funded by the National Institutes of Health without any industry sponsorship. They looked at over 1580 patients who were assigned to various treatments including a placebo group and found over a 6 month period that glucosamine and chondroitin, alone or together, did not reduce osteoarthritis knee pain more effectively than placebo. About a third (570) of these patients continued treatment for 2 years and no treatment group showed reconstitution of joint space or even a slowing of osteoarthritic disease.

No study has demonstrated any serious side effects with glucosamine or chondroitin treatment. Glucosamine is prepared from shellfish shells and people allergic to seafood should use with caution, although most sensitivity is to seafood flesh rather than shells. There are preparations of glucosamine made from plant products. Chondroitin may interact with some blood thinning agents.

My overall feeling is that for most individuals with osteoarthritis there is little downside to taking these supplements but there is also probably little benefit for most. Anecdotally I have seen patients who feel these products are beneficial and if this is the case, they can probably be continued quite safely. If desired, a trial of glucosamine can be undertaken, however if no benefit is identified after 2-3 months, they probably should be discontinued. There is no evidence to suggest that prolonged use of glucosamine or chondroitin slows the progression of osteoarthritis.