Arthritis AJN, American Journal of Nursing, February 2004 Clinical Topic: Pain management Expires: 02/28/2007

TNF Inhibitors: A New Age in Rheumatoid Arthritis Treatment iana !" An#erson Ph , $N A N! Ameri"an ourna# o$ Nursing February 2004 %olume &04 Number 2 Pages '0 ( ') %#u"osamine and &steoarthritis Ju#ith A" *la+eley ,*A, *-cN A N! Ameri"an ourna# o$ Nursing %ioleta ." -" $ibeiro N-c, ,-, *N-c February 2004 %olume &04 Number 2 Pages /4 ( /0 1 2004 !ippincott 2illiams 3 2il+ins, 4nc" %olume &04526, February 2004, pp /4(/0 7lucosamine an# 8steoarthritis: 7lucosamine pro#ucts, sai# to slo9 or e:en halt the progression of osteoarthritis, are rising in popularity" *ut #o they 9or+; <F.AT=$.-: C.> *la+eley, Ju#ith A" ,*A, *-cN? $ibeiro, %ioleta ." -" N-c, ,-, *N-c Ju#ith A" *la+eley is an associate professor an# %ioleta ." -" $ibeiro is an honorary research professor at the -chool of Nursing of ,emorial =ni:ersity of Ne9foun#lan#, -t" John@s, NF, Cana#a" Contact author: Abla+eleBmun"ca" The author of this article has no significant ties, financial or other9ise, to any company that might ha:e an interest in the publication of this e#ucational acti:ity" As she tells frien#s an# family, osteoarthritis robbe# ')(year(ol# Anne Fairban+s of a happy retirement an# Cblac+ene# my gol#en years"D -e:ere pain afflicte# both of her +nees as 9ell as her cer:ical an# lumbar spine" ,uscle relaEants an# nonsteroi#al antiinflammatory #rugs 5N-A4 s6 allo9e# her to function, but she nonetheless became increasingly incapacitate# an# #epresse# as her symptoms 9orsene#" To#ay, &2 years after #iagnosis, ,s" Fairban+s is houseboun# an# spen#s most of her time in her recliner or in be#" Although ,s" Fairban+s@s #ecline 9as eEtreme, she@s far from alone: 20"F million Americans, mostly 9omen, suffer from some #egree of osteoarthritis" & 2hile it@s not al9ays incapacitating, this #egenerati:e Aoint #isease affects the fingers an# the 9eight( bearing Aoints of the spine, +nees, an# hips" ,ost freGuently cause# by 9ear an# tear on the Aoints, osteoarthritis is particularly pre:alent among the el#erly" 4n the =nite# -tates, for eEample, )/H of those ages F/ an# ol#er suffer from osteoarthritis" 2

4n its early stages, osteoarthritis is characteriIe# by pain an# stiffness" -tiffness is usually 9orse in the morning an# after prolonge# sitting but ten#s to impro:e 9ith mo:ement" For eEample, after sitting for a 9hile, .mily 2hite, F2, laughs as she struggles to get out of her chair" C4@m rusting up,D she says" CNee# an oil Aob"D 8nce out of her chair, ho9e:er, she can mo:e about 9ith little or no #ifficulty" Pain, on the other han#, is more #ebilitating" At first, it occurs only 9ith mo:ement of the affecte# Aoint" *ut as the con#ition progresses, pain can become a chronic, unrelenting problem, e:en 9hen Aoints are at rest" 4n the case of ,s" Fairban+s, intractable pain hin#ers almost e:ery mo:ement" First(line #rug therapies for osteoarthritis inclu#e acetaminophen, topical analgesics, an# N-A4 s" The latter can ha:e serious a#:erse effects, such as gastric ulceration, renal insufficiency, an# prolonge# blee#ing time" 4f pain an# inflammation are not controlle#, glucocorticoi# inAections can be gi:en" J Ko9e:er, none of these therapies slo9s or re:erses the #egenerati:e process of osteoarthritis" To fin# a safe alternati:e treatment, many people ha:e turne# to glucosamine pro#ucts" 7lucosamine is sai# to slo9 or e:en halt the progression of osteoarthritis, in a##ition to ha:ing a 9ea+ antiinflammatory effect, re#ucing pain, an# impro:ing the range of motion in affecte# Aoints" 4 2hile promising results ha:e been reporte#, research fin#ings are still inconclusi:e" .:en so, its popularity has gro9n" 4n 200& global retail sales of glucosamine pro#ucts totalle# L&"2 billion, an# they@re eEpecte# to increase by about 2&H each year" / Claims of the benefits of glucosamine are increasingly common in a#:ertising an# in consumer publications, an# starting glucosamine therapy is as easy as a Guic+ trip to the local pharmacy or grocery store" Met, because glucosamine is consi#ere# a #ietary supplement, the Foo# an# rug A#ministration 5F A6 #oesn@t regulate it an# its manufacture isn@t stan#ar#iIe#" ietary supplements are manufacture# by many #ifferent companies an# sol# in :arying #osages an# at 9i#ely ranging prices, often in combination 9ith other compoun#s, such as chon#roitin sulfate or methylsulfonylmethane 5,-,6" Ko9 can consumers choose from among the many options; 4s glucosamine a :iable therapy; C8!!A7.N, P$8T.87!MCAN-, AN 7!=C8-A,4N. The pathogenesis of osteoarthritis lies in the #estruction of cartilage, possibly as a result of the loss of collagen an# proteoglycansNthe buil#ing bloc+s of cartilage" ',F Collagen, the fibrous protein that ma+es up connecti:e tissue, an# proteoglycans, 9hich pro:i#e the cartilage@s resilience, are essential to the :iscoelasticity of cartilage" As the #isease progresses, the articular cartilage, a thin layer of cartilage co:ering the bones in Aoints, roughens, becomes pitte#, an# e:entually ero#es" Kypertrophy of the un#erlying bone an# formation of osteophytes may also occur" 7lucosamine, an amino sugar synthesiIe# in the bo#y from glucose an# the amino aci# glutamine, helps regenerate #amage# cartilage by pro:i#ing the substrate for the pro#uction of proteoglycans" 4 4nsi#e the cartilage cell 5+no9n as the chon#rocyte6, glucosamine is synthesiIe# into glycosaminoglycans 57A7s6" 2hen attache# to a core protein, chains of 7A7s become proteoglycans, the eEtracellular component of cartilage"

Proteoglycans are configure# li+e bottle(brushes an# inter9o:en 9ith tubeli+e collagen fibers that pro:i#e strength an# support an# anchor the relati:ely fe9 chon#rocytes in the eEtracellular matriE" The gel(li+e proteoglycans are strongly hy#rophilic 5cartilage consists of F0H 9ater6, pro:i#ing fleEibility an# cushioning" 7lucosamine manufacturers recommen# #osages of &,/00 mg per #ay, ta+en orally in three eGual #oses" ,ost of the clinical trials that reporte# glucosamine effecti:eness ha:e use# this #osage an# route of a#ministration" Fin#ings ha:e suggeste# that this regimen may be effecti:e in a#ults, although some sources a#:ise increasing the #osage to 2,000 mg #aily in a#ults 9ho 9eigh more than 200 lbs", an# #ecreasing it to &,000 mg #aily in those un#er &20 lbs" 4,) F47=$.

Figure &" 8steoarthritic Joint 8steoarthritis is a #egeneration of the articular cartilage capping the en#s of the bones in syno:ial Aoints" Pathologic changes inclu#e roughening an# pitting of the cartilage surface, thinning of the cartilage layer, an# ultimately, #enu#ing of the bone" ConseGuently, there is a narro9ing of the Aoint space" *ecause the cartilage can no longer bear 9eight place# on the Aoint an# the bones grin# against one another, the un#erlying bone becomes remo#ele#, resulting in osteophyte 5bone spur6 formation at the outer ri#ges of the Aoint, the #e:elopment of cystli+e structures, an# sclerosis 5har#ening of the bone from increase# #ensity6" -oft tissue s9elling an# increase# flui# in the syno:ial ca:ity 5Aoint effusion6 cause enlargement of the Aoint" 7lucosamine is most often obtaine# from chitin, foun# in the eEos+eleton of shellfish, but it can also be chemically synthesiIe#" Pac+age# as oral tablets or capsules, the most common commercial compoun#s are glucosamine sulfate, N(acetyl(glucosamine, an# glucosamine hy#rochlori#e" 0

CK88-4N7 AN =-4N7 7!=C8-A,4N. 2e in:estigate# the self(me#ication practices of glucosamine users by con#ucting a small(scale sur:ey of '/ ol#er a#ults 5o:er /0 years of age6 9ho use# the supplement" &0 8nly 20H of participants began ta+ing glucosamine as a result of a physician@s recommen#ation? the rest attribute# their #ecisions to the influence of frien#s, family, a#:ertising, boo+s, magaIine or ne9spaper articles, or the a#:ice of health(foo# store employees" .ighty(siE percent of those sur:eye# 9ere managing their o9n treatment, )2H use# glucosamine regularly, an# 'FH belie:e# it ha# a beneficial effect on symptoms" 8nly one(thir#, ho9e:er, follo9e# the recommen#e# #osage of &,/00 mg per #ay? more than one(thir# too+ either 2,000 mg or &,000 mg or less per #ay" Those remaining :arie# the #osage accor#ing to ho9 they felt, ho9 long they ha# been using the treatment, orNamong those ta+ing supplements combining glucosamine 9ith ,-, or chon#roitinNaccor#ing to ho9 much glucosamine 9as present in the tablet" Ko9 often participants too+ the supplement also :arie#: from one to three times a #ay" -e:en reporte# ta+ing glucosamine to treat either rheumatoi# arthritis or fibromyalgia, although no e:i#ence supports the use of glucosamine for such con#itions" F47=$.

Figure 2" The $ole of 7lucose an# 4ts eri:ati:es in the Pro#uction of Cartilage Although cartilage has no bloo# supply, syno:ial flui# is rich in nutrients, inclu#ing glucose, 9hich is use# by the chon#rocytes 5&6" 4n normal cartilage pro#uction, the #eri:ati:es of glucose 5glucosamine, galactose, an# glucuronic aci#6 form chains calle# glycosaminoglycans 57A7s6" Those forme# by the #eri:ati:es of glucose inclu#e hyaluronic aci#, chon#roitin sulfate, an# +eratan sulfate" The latter t9o bin# to protein cores 9ithin the cell an# are eEcrete# into the eEtracellular matriE 526? there they bin# to the longer hyaluronic aci# chains 5J6" 2hen boun# to the hyaluronic aci#, these 7A7O protein structures 5proteoglycans6, 9hich resemble bottle brushes, constitute the

hy#rophilic, gel(li+e, cushioning portion of the cartilage" *un#les of collagen fibrils form the three(#imensional support of cartilage tissue" The theory behin# oral glucosamine supplementation is that the chon#rocytes 9ill ta+e it up, in effect CpreferringD it to the more rea#ily a:ailable glucose an# glutamine 5an amino aci# reGuire# for synthesis of glucosamine6, an# more cartilage 9ill be pro#uce#" 2hile the results of this stu#y can@t be 9i#ely generaliIe#, they #o suggest the nee# for public e#ucation in the correct use of glucosamine an# the treatment of osteoarthritis" They also suggest the :alue of super:ision of glucosamine use by a health care professional" .FF4CACM $eginster an# colleagues foun# that glucosamine effecti:ely controlle# osteoarthritis symptoms an# pro#uce# some re:ersal of the #isease process" && This three(year, #ouble( blin#, placebo(controlle# stu#y, base# on a ran#om sample of 2&2 patients, sho9e# that those gi:en glucosamine sulfate eEperience# Cno significant loss of Aoint spaceD an# sho9e# impro:ement in their osteoarthritis symptoms as measure# by the 2estern 8ntario an# ,c,aster =ni:ersities 8steoarthritis 4n#eE 5+no9n as the 28,AC6" ,ost glucosamine trials to #ate ha:e been of shorter #uration, an# many ha:e sho9n promising results" For eEample, in a three(month, ran#omiIe#, #ouble(blin#, placebo( controlle# trial of 2/2 outpatients 9ith osteoarthritis of the +nee, Noac+ an# colleagues foun# glucosamine sulfate to be as 9ell tolerate# as placebo an# conclu#e# that it Cmay be a safe an# effecti:e symptomatic slo9 acting #rug for osteoarthritis"D &2 Thie an# colleagues compare# glucosamine sulfate 9ith ibuprofen an# foun# that glucosamine pro:i#e# a significantly greater #ecrease in pain among patients 9ith temporoman#ibular Aoint osteoarthritis" &J Ko9e:er, using the 28,AC in an eight(9ee+ open(label trial of patients 9ith osteoarthritis of the +nee, Koupt an# colleagues foun# Cno significant #ifference in pain re#uction bet9een the glucosamine hy#rochlori#e an# placebo groups,D although they #i# state that their results suggeste# that glucosamine hy#rochlori#e may be effecti:e for some patients" &4 -ince 2000, three metaanalyses ha:e eEamine# the effecti:eness of glucosamine" ,cAlin#on an# associates re:ie9e# &/ #ouble(blin#, ran#omiIe#, placebo(controlle# trials lasting four 9ee+s or longer an# conclu#e# that Csome #egree of efficacy appears probable for these <glucosamine> preparations"D &/ To9hee# an# associates re:ie9e# &' ran#omiIe#, controlle# trials an# conclu#e# that more research 9as nee#e#" &' An# most recently, $ichy an# associates stu#ie# the reporte# effects in &/ stu#ies of either glucosamine or chon#roitin on osteoarthritis of the +nee an# foun# treatment 9ith either glucosamine or glucosamine plus chon#roitin to be effecti:e" &F The 7lucosamineOChon#roitin Arthritis 4nter:ention Trial 57A4T6 9ill in:ol:e more than &,/00 a#ults 40 years of age an# ol#er in a t9o(year, multisite trial comparing glucosamine, chon#roitin sulfate, celecoEib 5CelebreE6, an# a combination of glucosamineOchon#roitin sulfate against placebo in the treatment of +nee pain associate#

9ith osteoarthritis" &) A substu#y 9ill assess 9hether the supplements slo9 or stop the progression of +nee osteoarthritis" -ponsore# by the National Center for Complementary an# Alternati:e ,e#icine, the National 4nstitutes of Keath, the epartment of %eterans Affairs, an# the epartment of %eterans Affairs Cooperati:e -tu#y Program, the stu#y is currently un#er 9ay? stu#y results shoul# be a:ailable 9ithin three years" A %.$-. .FF.CT- AN C8NT$A4N 4CAT48NA#:erse effects, 9hich are sel#om reporte#, inclu#e s+in rashes? peripheral e#ema? tachycar#ia? transitory central ner:ous system reactions such as #ro9siness an# hea#ache? an# mil# gastrointestinal symptoms such as #yspepsia, nausea, ab#ominal pain, #iarrhea, an# flatulence" 4,),&0,20 2hile gastrointestinal blee#ing an# other serious a#:erse effects of N-A4 s ha:en@t been reporte# by people ta+ing glucosamine, it@s not +no9n 9hether long(term use pro#uces other serious complications" iuretics may #ecrease the effecti:eness of glucosamine" &0,20 People 9ho are allergic to the chitin in shellfish from 9hich glucosamine is eEtracte# shoul# a:oi# glucosamine" / 2omen 9ho are breastfee#ing an# chil#ren shoul# also a:oi# using glucosamine because its effects in those populations are un+no9n" 20 $esults of in :itro stu#y of glucosamine an# in :i:o stu#y in rats suggest that it can impair insulin secretion an# cause beta(cell secretory #ysfunction similar to that seen in patients 9ith type 2 #iabetes" 2& For this reason, an# because the glucosamine molecule is glucose base#, it coul# be harmful to patients 9ith #iabetes or those 9ith impaire# glucose tolerance" 7lucosamine may also increase resistance to insulin an# to anti#iabetic agents? people 9ith #iabetes 9ho use the supplement shoul# be particularly #iligent in monitoring bloo# glucose le:els" &0,20 N=$-4N7 4,P!4CAT48NNurses can help ensure that patients 9ho self(treat are 9ell informe# an# can lobby the go:ernment for stronger regulations" Patient e#ucation" 7lucosamine users shoul# un#erstan# that research on the effecti:eness of glucosamine is still inconclusi:e an# that eEisting e:i#ence refers primarily to a #aily #osage of &,/00 mg of glucosamine sulfate, ta+en in three #oses of /00 mg" =ntil further information is a:ailable, patients shoul# be encourage# to follo9 this #osage" They shoul# also be a#:ise# that, li+e all supplements, glucosamine is minimally regulate#, an# fe9 rules go:ern the 9ays in 9hich it@s mar+ete#" There is no assurance that 9hat@s on the label accurately reflects 9hat@s in the bottle" Patients beginning glucosamine therapy, therefore, may be 9ell a#:ise# to try one or more of the preparations a:ailable on the mar+et an# choose the one they fin# most effecti:e" *ecause of potential #rugO#rug interactions, patients ta+ing glucosamine pro#ucts shoul# be urge# strongly to inform pro:i#ers" 4t@s also important to tell patients that symptom

relief 9on@t be imme#iate? reporte# benefits are usually felt one to three months after initiating treatment" 4n the interim, they shoul# continue other therapies for controlling pain an# stiffness" 4nformation on glucosamine can be foun# at health foo# stores, through pharmacists, on the 4nternet, an# in natural health magaIines an# research Aournals" .ncourage your patients to become informe#" iscuss the critical appraisal of information an#, in particular, claims base# on anec#otal e:i#ence" !obbying" Through professional associations, nurses can use their collecti:e po9er to lobby the appropriate go:ernment agencies 5such as the F A6 to test glucosamine pro#ucts currently on the mar+et" This 9oul# ensure that supplements meet basic stan#ar#s? for eEample, that the supplements contain the substances that manufacturers claim an# that the substances are not contaminate# by foreign or #angerous ingre#ients" 4f strong e:i#ence is foun# sho9ing glucosamine to be effecti:e in slo9ing or e:en re:ersing the progression of osteoarthritis, the supplement shoul# be ma#e a:ailable to e:eryone, irrespecti:e of purchasing po9er" !obbying the appropriate go:ernment organiIations an# pri:ate health insurance companies 9ill be the first step to9ar# ensuring such a:ailability" Complete the C. test for this article by using the mail(in form a:ailable in this issue or by going to 8nline C. at http:PP999"aAnonline"comP" After rea#ing this article an# TNF 4nhibitors: A Ne9 Age in $heumatoi# Arthritis Treatment, 9hich begins on the neEt page, ta+e the test on page '0 to earn J"/ hours of continuing e#ucation cre#it" $.F.$.NC.&" The Arthritis Foun#ation" 8steoarthritis 58A6 <2eb page>" 200J" http:PP999"arthritis"orgPcon#itionsP#iseasecenterPoa"asp" <ConteEt !in+> 2" *runner !-, et al" *runner an# -u##arth@s teEtboo+ of me#ical(surgical nursing" Phila#elphia: !ippincott? 2000" <ConteEt !in+> J" 8steoarthritis treatments <2eb page>" 200J" http:PP999"hop+ins( arthritis"som"Ahmi"e#uPosteoPosteoQtreat"html" <ConteEt !in+> 4" Professional gui#e to complementary an# alternati:e therapies" -pringhouse, PA: -pringhouse? 200&: 2JJO4" <ConteEt !in+> /" Jar:is !" *.4 to launch =-(base# glucosamine pro#uction" Chemical ,ar+et $eporter 2002" <ConteEt !in+>

'" !ing -, *athon J" 8steoarthritis pathophysiology <2eb page>" 200J" http:PP999"hop+ins(arthritis"som"Ahmi"e#uPosteoPosteoQpatho"html" <ConteEt !in+> F" *eers ,, *er+o9 $" 8steoarthritis an# neurogenic arthropathy" 4n: ,erc+ manual of #iagnosis an# therapy" &Fth e#" $ah9ay, NJ: ,erc+? &00F" p" 440O/&" <ConteEt !in+> )" Ruhn ,A, et al" Kerbal therapy an# supplements: a scientific an# tra#itional approach" Phila#elphia: !ippincott? 2000: J')OF&" <ConteEt !in+> 0" National Nutritional Foo#s Association" 7lucosamine <2eb site>" 200J" http:PP999"nnfa"orgPser:icesPsciencePbgQglucosamine"htm" <ConteEt !in+> &0" *la+eley JA, $ibeiro %" A sur:ey of self(me#ication practices an# percei:e# effecti:eness of glucosamine pro#ucts among ol#er a#ults" Complement Ther ,e# 2002? &05 J6:&/4O'0" <ConteEt !in+> &&" $eginster JM, et al" !ong(term effects of glucosamine sulphate on osteoarthritis progression: a ran#omise#, placebo(controlle# clinical trial" !ancet 200&? J/F5 02/26:2/&O'" <ConteEt !in+> &2" Noac+ 2, et al" 7lucosamine sulfate in osteoarthritis of the +nee" 8steoarthritis Cartilage &004? 25 &6:/&O0" <ConteEt !in+> &J" Thie N,, et al" .:aluation of glucosamine sulfate compare# to ibuprofen for the treatment of temporoman#ibular Aoint osteoarthritis: a ran#omiIe# #ouble blin# controlle# three(month clinical trial" J $heumatol 200&? 2)5 '6:&J4FO//" <ConteEt !in+> &4" Koupt J*, et al" .ffect of glucosamine hy#rochlori#e in the treatment of pain of osteoarthritis of the +nee" J $heumatol &000? 2'5 &&6:242JOJ0" <ConteEt !in+> &/" ,cAlin#on T., et al" 7lucosamine an# chon#roitin for treatment of osteoarthritis: a systematic Guality assessment an# meta(analysis" JA,A 2000? 2)J5 &&6:&4'0OF/" <ConteEt !in+> &'" To9hee# T., et al" 7lucosamine therapy for treating osteoarthritis" Cochrane atabase -yst $e: 200&5 &6: C 00204'" <ConteEt !in+> &F" $ichy F, et al" -tructural an# symptomatic efficacy of glucosamine an# chon#roitin in +nee osteoarthritis: a comprehensi:e meta(analysis" Arch 4ntern ,e# 200J? &'J5 &J6: &/&4O22" <ConteEt !in+> &)" 7lucosaminePChon#roitin Arthritis 4nter:ention Trial 57A4T6 <2eb page>" 200J" http:PPclinicaltrials"go:PctPsho9PNCT000J2)00;or#erS&" <ConteEt !in+> &0" Nursing herbal me#icine han#boo+" -pringhouse, Pa": -pringhouse? 200&: 204" <ConteEt !in+>

20" C2 F, J$ A" Professional han#boo+ to complementary an# alternati:e therapies" -pringhouse, PA: -pringhouse? 200&: J40O/J" <ConteEt !in+> 2&" *al+an *, unning *." 7lucosamine inhibits gluco+inase in :itro an# pro#uces a glucose(specific impairment of in :i:o insulin secretion in rats" iabetes &004? 4J5 &06:&&FJO0" <ConteEt !in+> 2ithout a Prescription -elf(me#ication creates ne9 options, rene9s li:es" !ee .lman has been running #aily since &0)J, an# she@s an a:i# tennis player" *ut about three years ago, an achy, s9ollen, right +nee too+ the pleasure out of her athletic acti:ity" -he un#er9ent surgery to repair tears in the +nee, follo9e# by physiotherapy" 4t 9asn@t long before she resume# her #aily run" *ut the 9ea+ +nee ma#e it impossible for ,s" .lman to play tennis" Then a fe9 months after surgery, she began ha:ing #ifficulty #escen#ing stairs" -he consulte# another orthope#ic specialist, 9ho thought that arthritis 9as contributing to the problem" Ke sche#ule# another operation for a fe9 months later" *ut she ne:er ha# the secon# proce#ure" 7lucosamine an# chon#roitin spare# her the operation an# brought tennis bac+ into her life" ,s" .lman began self(me#icating 9ith glucosamine an# chon#roitin in February 200J" *y April, she coul# 9al+ #o9n stairs 9ithout #ifficulty" -he pic+e# up her tennis rac+et again an# no9 plays regularly" C4@m going to be ta+ing this for the rest of my life" 4t@s li+e a miracle" 4 ha:e no Tachy@ #ays no9,D sai# ,s" .lman, a mar+eting consultant in Cambri#ge, ,assachusetts" !i+e many 9ho #eci#e to try glucosamine, she #i# not consult a health care pro:i#er" -he began ta+ing it at a frien#@s suggestion" ,s" .lman chose #ouble(strength Cosamin -" .ach capsule contains /00 mg glucosamine hy#rochlori#e, 400 mg chon#roitin sulfate, an# J mg manganese" .lman 9as attracte# by the label@s claim that this is the only Cbran# pro:en effecti:e in controlle#, publishe# ="-" stu#ies to re#uce Aoint pain an# protect cartilage"D The pac+age also calls the pro#uct the Cnumber(one #octor an# pharmacist recommen#e# bran#"D -he 9as gla# the label state# that the entire #osage coul# be ta+en all at once" Follo9ing label #irections, she starte# 9ith three capsules a #ay an# lo9ere# the #aily #ose to t9o pills after three months" A bottle of 2J0 capsules costs her L'/, although ,s" .lman recently foun# a #ifferent bran# of similar composition for consi#erably less" Although ,s" .lman #i# not as+ a physician or nurse for a#:ice on ta+ing glucosamine, other patients might" Ko9 shoul# you respon#; -houl# you ta+e a proacti:e approach, on the chance that patients 9ho ha:e hear# stories of success 9ith glucosamine might #eci#e to try it 9ithout gui#ance from a health care professional;

-usan !uc+, $N, CNN, a holistic nurse an# clinical nutritionist in Flori#a, #eals 9ith such issues all the time" -he as+s patients 9ho complain of Aoint pain about their use of supplements" Then she often suggests three +in#s: omega(J fatty aci#s, 9hich ha:e antiinflammatory effects? glucosamine sulfate plus chon#roitin? an# a goo# multi:itamin" -he also recommen#s eEercise, such as 9al+ing" CThere are #ifferent forms of glucosamine" 4 prefer glucosamine sulfate because it goes best to the cartilage, ligaments, an# ten#ons,D !uc+ sai#" C4 thin+ the combination 9ith chon#roitin is better than glucosamine alone"D 2hen e#ucating patients, !uc+ emphasiIes that glucosamine is not an instant pain relie:er li+e ibuprofen" 4t ta+es up to &2 9ee+s for glucosamine to ha:e a noticeable effect" C4 tell patients that glucosamine is a natural substance that helps the bo#y strengthen its ability to repair itself" *ecause this process ta+es time, they shoul# +eep ta+ing other pain relie:ers as nee#e#,D she sai#" 2ith the 9i#e array of pro#ucts on the mar+et, patients may be confuse# about 9hich one is best" C4f nurses are going to suggest these pro#ucts, they shoul# see 9hat@s a:ailable in their area,D !uc+ sai#" A useful resource is http:PP999"consumerlab"comPan# the relate# boo+ 7ui#e to *uying %itamins an# -upplements 5200J, Consumer!ab"com6" *oth the 2eb site an# the boo+ present results of Consumer!ab"com@s in#epen#ent testing of #ietary supplements an# in#icate ho9 accurate the pro#uct@s list of ingre#ients is"N !aurie !e9is 4#eas for Nursing $esearch U .Eplore the public@s un#erstan#ing an# use of glucosamine pro#ucts" U 4n:estigate nursing +no9le#ge about these an# other supplements" U .Eamine ho9 prepare# nurses are to teach patients about proper glucosamine use" U Participate in clinical trials testing glucosamine@s efficacy, :arious #osages, an# #ifferent routes of a#ministration C. Collection ' A## to Planner ' Ta+e Test UContact Kours? Contact KoursPA#:ance# Pharmacology Kours For more information about ta+ing C. on NursingCenter, :ie9 our Kelp an# Accre#itation 4nformation"