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PRACTICE: Nicola Dalbeth and Bruce Arroll Commentary: controversies in NICE guidance on osteoarthritis BMJ 2008; 336: 504 [Full text]

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Glucosamine, an opinion-based prescription

Roberto Iovine   (28 March 2008)

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Bruce Arroll, Nicola Dalbeth   (2 April 2008)

Glucosamine, an opinion-based prescription 28 March 2008
Roberto Iovine, MD, Chief, Rehabilitation Ward, Azienda USL di Bologna, Italy Ospedale SS Salvatore, Via Enzo Palma 1, 40017 San Giovanni in Persiceto (BO) Send response to journal: Re: Glucosamine, an opinion-based prescription	How could the authors suggest the prespcription of glucosamine on the sole basis of patients' willingness to pay? This message flies in the face of what we know on the subject: published evidence suggests that glucosamine neither reduces symptoms nor progression of knee and hip OA (1- 3). 1. Towheed TE, Maxwell L, Anastassiades TP, Shea B, Houpt J, Robinson V, Hochberg MC, Wells G. Glucosamine therapy for treating osteoarthritis. Cochrane Database of Systematic Reviews 2005, Issue 2 2. Rozendaal RM et al., Effect of glucosamine sulfate on hip osteoarthritis. Ann Intern Med 2008; 148:268-277 3. Clegg DO, et al. Glucosamine, Chondroitin Sulfate, and the Two in Combination for Painful Knee Osteoarthritis. N Engl J Med 2006; 354:795- 808 Competing interests: None declared
Authors reply 2 April 2008
Bruce Arroll, Professor and Head of Dept General Practice and Primary Health Care University of Auckland Private Bag 92109 Auckland, Nicola Dalbeth Send response to journal: Re: Authors reply	Dear editor We thank Dr Iovine for his comments on our editorial regarding controversies in the NICE guidelines on osteoarthritis (OA) treatment(1). There were some aspects of the guideline that could not be discussed in detail due to space restrictions. As is clearly documented in the NICE guideline, the evidence on glucosamine is far from conclusive about lack of efficacy. We agree that there is a lot of variation in the findings but this may be explained by type of preparation, joint involvement and severity of the condition(2). Dr Iovine makes reference to the Cochrane review (2005) yet this review states that “…………….those studies evaluating the Rotta preparation show that glucosamine [sulphate] was superior to placebo in the treatment of pain and functional impairment resulting from symptomatic OA” (3). Subgroup analysis of the GAIT study did show some benefit with glucosamine hydrochloride combined with chondroitin for those with severe knee pain(4). A more recent randomized controlled trial, not included in the 2005 Cochrane review, has also shown benefit of glucosamine sulphate compared with placebo for knee OA symptoms(5). We entirely agree that our comment about patients being willing to pay for medication is not robust evidence of effectiveness. However we are intrigued how elderly patients (in New Zealand) who are not wealthy are prepared to pay for medication which give symptomatic benefit eg omeprazole but not for ACE inhibitors for hypertension. In summary, some (but not all) high quality studies demonstrate efficacy of glucosamine sulphate for symptom control in OA, and this agent does seem to be acceptable to many patients. The intention of highlighting this agent as part of our commentary was to emphasize the controversy, and to suggest that the last word has not yet been heard about glucosamine for treatment of OA. 1. Dalbeth N, Arroll B. Commentary: controversies in NICE guidance on osteoarthritis. Bmj 2008;336(7642):504. 2. Vlad SC, LaValley MP, McAlindon TE, Felson DT. Glucosamine for pain in osteoarthritis: why do trial results differ? Arthritis Rheum 2007;56(7):2267-77. 3. Towheed TE, Maxwell L, Anastassiades TP, Shea B, Houpt J, Robinson V, et al. Glucosamine therapy for treating osteoarthritis. Cochrane Database Syst Rev 2005(2):CD002946. 4. Clegg DO, Reda DJ, Harris CL, Klein MA, O'Dell JR, Hooper MM, et al. Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis. N Engl J Med 2006;354(8):795-808. 5. Herrero-Beaumont G, Ivorra JA, Del Carmen Trabado M, Blanco FJ, Benito P, Martin-Mola E, et al. Glucosamine sulfate in the treatment of knee osteoarthritis symptoms: a randomized, double-blind, placebo- controlled study using acetaminophen as a side comparator. Arthritis Rheum 2007;56(2):555-67. Competing interests: None declared