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Authors

  1. Martin, Mary Susan
  2. Van Sell, Sharon
  3. Danter, Joyce

Abstract

Osteoarthritis (OA) is a leading cause of disability in the United States. Current treatment focuses on symptom relief and improving a patient's overall function. Pharmacological treatments aim to correct symptomatic complaints as well as structural problems in OA. Glucosamine (sulfate or hydrochloride) and chondroitin sulfate have been linked as an optional treatment in OA for several years. There is controversy, however, surrounding their use and efficacy. The American Academy of Orthopaedic Surgeons published clinical practice guidelines in 2008 that recommended against the use of glucosamine and chondroitin sulfate (p. ii). Despite conflicting results on the degree of efficacy, the most current research suggested that glucosamine and chondroitin sulfate have the potential to provide pain-relieving benefits as well as possibly decrease the effects of joint space narrowing. The purpose of this article was to document the most current research evidence on the use and efficacy of glucosamine and chondroitin sulfate supplements for patients with symptomatic OA of the knee as well as create an evidence-based, best practice educational tool describing a treatment algorithm for nurse practitioners treating a patient with symptomatic OA of the knee.

 

Article Content

According to the Centers for Disease Control and Prevention (CDC, 2010), osteoarthritis (OA) is a "disease characterized by degeneration of cartilage and its underlying bone within a joint as well as bony overgrowth" (p. 1). Osteoarthritis can affect any joint, but it is most common in the hip and knee. The wearing away of cartilage occurring in OA causes bones to rub together. This impact causes pain, swelling, and joint stiffness, which can lead to a debilitating state in affected adults.

 

Osteoarthritis is a leading cause of disability in the United States, and it has no known cure at the present time. It is important to continue researching the most effective ways to treat this disease. Current treatment focuses on symptom relief as well as improving a patient's overall function. There are physician guidelines in place to aid in the treatment of patients with symptomatic OA of the knee; however, there is a need for a treatment algorithm for nurse practitioners, including, but are not limited to, education, weight loss/control, and physical therapy, as well as oral, topical, and injectable medications.

 

The pharmacological treatments aim to correct symptomatic complaints as well as structural problems in OA. According to Nandhakumar et al. (2009), "Among these pharmacological treatments and despite serious adverse effects associated with their long-term use, [nonsteroidal anti-inflammatory drugs] NSAIDs remain among the most widely prescribed drugs for OA, mainly for relief of pain" (p. 36). Nonsteroidal anti-inflammatory drugs are commonly known to help relieve pain; however, they are also known to cause serious side effects, especially in the older population. Unfortunately, it is this older population who is more likely to suffer from OA of the knee.

 

Purpose

Nurse practitioners treat patients suffering from symptomatic OA of the knee in a primary care office and, more commonly, in an orthopaedic office. This article created an algorithm for the nurse practitioner in an orthopaedic office setting who is treating a patient with symptomatic OA of the knee.

 

Glucosamine (sulfate or hydrochloride) and chondroitin sulfate are two dietary supplements that have been linked as an optional treatment in OA for several years. There is controversy, however, surrounding their use and efficacy. The purpose of this article was to document the most current research evidence on the use and efficacy of glucosamine and chondroitin sulfate supplements for patients with symptomatic OA of the knee.

 

The article enhances and expands the knowledge for clinical providers in orthopaedics as well as for nurse practitioners in primary care. An evidence-based, best practice educational tool describing a treatment algorithm for nurse practitioners treating a patient with symptomatic OA of the knee, including the use of glucosamine and chondroitin sulfate, was presented.

 

Justification

According to the National Institutes for Health (NIH, 2010) "Fact Sheet," OA is a disease in which occurrence increases with age (p. 2). The NIH stated, "By 2030, an estimated 20% of Americans-about 70 million people-will have passed their 65th birthday and will be at increased risk for OA" (NIH, 2010, p. 2). As the population continues to age, the occurrence of OA will continue to rise. The CDC (2010) reported that OA affects 240 persons for every 100,000 persons each year, and 4.3 million of those affected are adults older than 60 years (pp. 1-2). In addition, the CDC (2010) reported approximately 7.1 million total ambulatory care visits in one year with OA as the primary diagnosis (pp. 1-2).

 

Glucosamine and chondroitin sulfate have been attracting the attention of clinical providers as well as lay people for many years. These two supplements, according to Dahmer and Schiller (2008), "are among the most popular dietary supplements sold in the United States. The U.S. consumer market for glucosamine and chondroitin was estimated at $810 million in 2005" (p. 471). Many clinical trials regarding the efficacy of these supplements have shown conflicting results.

 

The American Academy of Orthopaedic Surgeon (AAOS) published clinical practice guidelines in 2008 that recommended against the use of glucosamine and chondroitin sulfate (AAOS, 2008, p. ii). However, the most current research suggested that glucosamine and chondroitin sulfate have the potential to provide pain-relieving benefits as well as possibly decreasing the effects of joint space narrowing in OA of the knee. The current research does not report multiple cases of serious adverse effects from the use of glucosamine and chondroitin sulfate (Dahmer & Schiller, 2008, p. 473). Therefore, it is imperative that a review of literature be completed to determine the evidence-based, best practice use of glucosamine and chondroitin sulfate in the treatment of symptomatic OA of the knee.

 

Methodology

A comprehensive, evidence-based systematic literature review was conducted with assistance from the Texas Woman's University online library services. The electronic databases utilized from the Texas Woman's University online library included Ebsco, PubMed, CINAHL plus full text, HealthWatch, Health Source: Nursing/Academic Edition, MEDLINE with full text, Newspaper Source, and TOPICsearch. Other search engines such as Google and Mednar were utilized for websites including the National Guideline Clearinghouse, CDC, NIH, and the Cochrane library. The search engines were also used to identify orthopaedic society websites including the American Association of Hip and Knee Surgeons, the AAOS, and the National Association of Orthopaedic Nursing. Medical and nursing texts were utilized as secondary sources.

 

Key words used in the search included osteoarthritis, knee, glucosamine, chondroitin, supplement, criteria, clinical guidelines, treatment, pain, evidence-based, algorithm, acupuncture. Identification of practice guidelines was a priority and resulted in the most current published in 2008. Therefore, primary research analysis included articles from January 2007 to January 2011.

 

There were several exclusions in the research analysis. Research included only studies and articles written in the English language, as well as those studies on patients older than 18 years. The research analysis included studies and reviews up to, but not including, surgical intervention such as arthroscopy and/or arthroplasty. The research analysis included only studies on glucosamine and chondroitin in the form of a vitamin supplement. Chronic pain research and guidelines were not included because of the complexity of underlying structural and/or neuronal damage in a patient's knee beyond the scope of OA. Guidelines for a chiropractic treatment were excluded because it is not a treatment consistent with the care for OA in the AAOS.

 

The results of a comprehensive evidence-based research search represented the current research and were incorporated into the recommended "Nurse Practitioner's Algorithm for Treatment of Symptomatic Osteoarthritis of the Adult Knee."

 

Review of Literature

Two guidelines for OA of the knee recognized in the National Guidelines Clearinghouse were evaluated for their consistency of treatment for a nurse practitioner treating a patient with OA of the knee. In 2008, the National Collaborating Centre for Chronic Conditions in London, England, created a guideline titled, "The Care and Management of Osteoarthritis in Adults" (National Collaborating Centre for Chronic Conditions, 2008, p. 1). The second guideline created by the AAOS was an evidence-based clinical practice guideline titled, "Treatment of Osteoarthritis of the Knee (Non-Arthroplasty)" (AAOS, 2008). The abbreviated AAOS guideline was found at http://guidelines.gov. The organizational website, http://www.aaos.org, contained the complete clinical practice guideline from which the article refers.

 

The guidelines created by the National Collaborating Centre for Chronic Conditions are more consistent with England's protocols and regulations. The guideline had two algorithms discussing holistic assessment as well as an overview of targeted treatment for OA (National Collaborating Centre for Chronic Conditions, 2008, p. 7). In addition, the clinical guidelines were not exclusive to the knee.

 

The AAOS 2008 evidence-based clinical practice guideline for the treatment of symptomatic OA of the knee emphasized patient treatment from education and lifestyle modifications to oral medications, injections, and surgical intervention, and is applied to physicians in the field of orthopaedics. The AAOS evidence-based clinical practice guideline is consistent with regulations and care provided in the United States. Therefore, the AAOS guideline served as a foundation for modification for evidence-based clinical practice guidelines for nurse practitioners in the treatment of OA of the knee. The most extensive modification encompassed the AAOS recommendation 12, which stated "glucosamine and/or chondroitin sulfate or hydrochloride [should] not be prescribed for patients with symptomatic OA of the knee" (AAOS, 2008, p. iv).

 

A comprehensive analysis of the literature provided the evidence for suggesting that glucosamine and chondroitin sulfate daily may be useful as a complementary or alternative therapy for the nurse practitioner treating a patient with symptomatic OA of the knee. Seven highly significant research studies published between January 2007 and January 2011 evaluated the efficacy of glucosamine sulfate or hydrochloride and chondroitin sulfate in the treatment of OA of the knee. The NIH conducted the Glucosamine/Chondroitin Arthritis Intervention Trial and, in 2008, published a report of the "first, large-scale, multicenter clinical trial in the United States to test the effects of the dietary supplements glucosamine hydrochloride (glucosamine) and sodium chondroitin sulfate (chondroitin sulfate) for the treatment of knee osteoarthritis" (NIH, 2008, p. 40).

  
Figure 1 - Click to enlarge in new windowFigure 1. Nurse practitioner's algorithm for treatment of symptomatic osteoarthritis of the adult knee. Modified from the

The NIH study helped to determine whether glucosamine and chondroitin sulfate used separately or together reduced pain in patients with OA. Previous studies had conflicting results; therefore the Glucosamine/Chondroitin Arthritis Intervention Trial (2008) was created to "test the short-term effectiveness of glucosamine and chondroitin sulfate in reducing pain in a large number of participants with knee osteoarthritis" (NIH, 2008, p. 40). The study contained 1,583 participants and measured the effectiveness of glucosamine and chondroitin individually as well as in combination against the effectiveness of celecoxib (Celebrex) and a placebo.

 

The NIH (2008) did not find statistically significant results for the participants with mild pain; however, in "participants with moderate-to-severe pain, glucosamine combined with chondroitin sulfate provided statistically significant pain relief compared with placebo" (p. 42). The report continued, "because of the small size of this subgroup, these findings should be considered preliminary and need to be confirmed in further studies" (NIH, 2008, p. 42). The dosages used to find these results were as follows:

 

glucosamine alone: 1500 mg daily given as 500 mg three times a day, chondroitin sulfate alone: 1200 mg daily given as 400 mg three times a day, glucosamine plus chondroitin sulfate combined: same doses-1500 mg and 1200 mg daily. (NIH, 2008, p. 41)

 

Important to note was that there were 77 serious adverse effects reported, of which, only 3 were caused by study treatments (NIH, 2008, p. 40).

 

An article by Dahmer and Schiller (2008) stated, "despite conflicting results in studies, there is no clear evidence to recommend against its (glucosamine's) use" (p. 471). The authors outline several studies that provide conflicting results on the usefulness of glucosamine and/or glucosamine and chondroitin sulfate. The studies referenced show that glucosamine and/or chondroitin sulfate showed improvement in pain and stiffness. A few of the studies showed some evidence of decreased joint space narrowing after the participants took glucosamine and/or chondroitin for a period of time, usually 2-3 years (Dahmer & Schiller, 2008, p. 472).

 

Most importantly, the authors noted that "the reported adverse effects have been generally uncommon and minor" (Dahmer & Schiller, 2008, p. 473). Although glucosamine is made from the shell of shellfish, "there have been no reports of reactions in persons with shellfish allergies who take glucosamine" (Dahmer & Schiller, 2008, p. 473). The authors stated that there has been one report of glucosamine magnifying the effects of warfarin (Coumadin), one account of an allergic reaction, and one report of shortness of breath in a participant with previously diagnosed asthma (Dahmer & Schiller, 2008, p. 473).

 

Dahmer and Schiller (2008) encouraged open discussion with patients and providers about the controversy surrounding the effectiveness of glucosamine and chondroitin sulfate (p. 474). The authors continued, "it would be reasonable to support a 60-day trial of glucosamine sulfate. The decision to continue therapy can then be left to patients on an individual basis" (Dahmer & Schiller, 2008, p. 474). This source recommended glucosamine at a dose of 500 mg three times daily to total 1500 mg a day (Dahmer & Schiller, 2008, p. 474).

 

Kirkham and Samarasinghe (2009) authored a review of the usefulness of glucosamine. The authors focused on the claim that glucosamine can "restore articular cartilage in patients with damaged or osteoarthritic joints" (Kirkham & Samarasinghe, 2009, p. 72). The authors describe two methods of modifying the effects of OA:

 

Agents that improve pain and joint function (paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs)) are symptom modifying, whereas those that alter the progression of cartilage loss are structure modifying. It is controversial whether glucosamine sulphate is the first commercially available structure-modifying drug. (Kirkham & Samarasinghe, 2009, p. 73)

 

Kirkham and Samarasinghe (2009) related, "it is possible that glucosamine causes an anti-inflammatory effect, and this may explain its claimed pain-relieving ability" (p. 74). The authors stated that glucosamine is "safer than other anti-inflammatory drugs" (Kirkham & Samarasinghe, 2009, p. 74). Kirkham and Samarasinghe (2009) concluded, however, that "there is little evidence that glucosamine can accomplish some of its claimed benefits in patients, particularly in terms of restoring joint cartilage or slowing the progression of arthropathies" (p. 75). Kirkham and Samarasinghe (2009) examined a study of glucosamine use versus placebo in diabetic patients. The results suggested "that glucosamine is safe for type-II diabetic patients" (p. 74).

 

A study in India conducted by Nandhakumar et al. (2009) compared the use of glucosamine hydrochloride, glucosamine sulfate, and NSAIDs. The study of 45 patients found that "glucosamine in both its hydrochloride and sulfate forms is definitely useful in decreasing pain and improving functional ability and joint mobility so as to enhance the quality of life of patients with OA of the knee" (Nandhakumar et al., 2009, p. 37). The authors continued, stating that "in terms of tolerability and safety, both of the glucosamine drugs are good, evidenced by patient compliance and the fact that there were no untoward adverse effects noted during the study" (Nandhakumar et al., 2009, p. 37).

 

A meta-analysis was completed by Lee, Woo, Choi, Ji, and Song (2010) with the purpose "to investigate the structural efficacies of glucosamine sulfate and chondroitin sulfate in patients with OA of the knee" (p. 358). The analysis compared six research studies (two involving glucosamine sulfate, four with chondroitin sulfate) with a total of 1,502 participants. The authors' meta-analysis showed no significant effect of glucosamine sulfate versus the control after 1 year of treatment; however, after 2-3 years of treatment, the authors found that "glucosamine sulfate revealed a small to moderate protective effect on minimum JSN [joint space narrowing]" (Lee et al., 2010, p. 359). The authors explained that "the same protective pattern was observed for chondroitin sulfate by meta-analysis over 1 and 2 years" (Lee et al., 2010, p. 362).

 

Lee et al. (2010) concluded,

 

this meta-analysis suggests that glucosamine sulfate and chondroitin sulfate may delay the natural radiological progression of OA of the knee. The long-term administration of daily oral glucosamine sulfate at 1,500 mg over a minimal period of 3 years or daily oral chondroitin sulfate at 800 mg over a minimal period of 2 years may retard degenerative processes affecting knee joint cartilage. (p. 362)

 

The authors urged that their analysis be used with caution and reiterate that additional studies on the structural effects of glucosamine sulfate and chondroitin sulfate are needed (Lee et al., 2010).

 

The Osteoarthritis Research Society International completed a review of research evidence between January 21, 2006, and January 31, 2009 "to update evidence for available therapies in the treatment of hip and knee osteoarthritis" (Zhang et al., 2010, p. 476). The authors evaluated 64 systematic reviews, 266 randomized controlled trials, and 21 new economic evaluations regarding all proposed treatments for OA of the hip and/or knee. The authors found that "evidence for glucosamine products having a possible structure-modifying effect in patients with knee or hip OA remains controversial" (Zhang et al., 2010, p. 485). However, specifically for the knee, the authors found "the pooled [effect size] ES for slowing of joint space loss in the medial compartment of the knee in the two trials in patients with knee OA, which included 414 patients, was small but significant" (Zhang et al., 2010, p. 485).

 

Another research article by Uitterlinden et al. (2008) suggested from the results of their experiment that glucosamine hydrochloride "increases the production of HA [hyaluronic acid] in synovium" (p. 6). This study assessed the effectiveness of glucosamine hydrochloride, N-acetyl-glucosamine, and glucose added to human osteoarthritic synovium explants in respect of HA growth. The authors found that "glucosamine hydrochloride significantly increased HA production compared to control" (Uitterlinden et al., 2008, p. 1).

 

Uitterlinden et al. (2008) proposed that the increase in HA with glucosamine hydrochloride worked because it "simply led to more building blocks that are required for the synthesis of HA" (p. 5). The authors stated that "our result should be interpreted as a proof of concept on the possible working mechanism of GlcN [glucosamine] in HA" (Uitterlinden et al., 2008, p. 5). The seven research articles supported the suggestion that glucosamine and chondroitin are appropriate for a complementary or alternative therapy for use by a nurse practitioner treating a patient with symptomatic OA of the knee as reflected in the "Nurse Practitioner's Algorithm for Adult Treatment of Symptomatic Osteoarthritis of the Knee."

 

The AAOS evidence-based clinical practice guideline for the treatment of symptomatic OA of the knee consisted of 22 suggestions or recommendations divided into eight categories. The first section was patient education and lifestyle modifications of patients with symptomatic OA of the knee. The first suggestion was that "patients with symptomatic OA of the knee be encouraged to participate in self-management educational programs such as those conducted by the Arthritis Foundation, and incorporate activity modifications (e.g. walking instead of running; alternative activities) into their lifestyle" (AAOS, 2008, p. ii).

 

The second AAOS recommendation stated that "regular contact to promote self-care is an option for patients with symptomatic OA of the knee" (AAOS, 2008, p. ii). Third, the AAOS recommended that patients

 

who are overweight (as defined by a BMI > 25), should be encouraged to lose weight (a minimum of five percent (5%) of body weight) and maintain their weight at a lower level with an appropriate program of dietary modification and exercise. (AAOS, 2008, p. ii)

 

The first three recommendations are described as the first steps in treating a patient with symptomatic OA of the knee.

 

In addition, the CDC (2010) reported that a modifiable risk factor for knee OA is excess body mass. Although the NIH agreed that, in general, overweight persons are at an increased risk for OA, they found that "overweight people who walked or jogged regularly were no more or less likely to have OA joint damage than their overweight, sedentary peers" (NIH, 2010, p. 1).

 

The second category in the AAOS clinical practice guideline was physical therapy and rehabilitation. The AAOS developed three recommendations for rehabilitation efforts for patients with symptomatic OA of the knee. The three recommendations are as follows: (a) patients "be encouraged to participate in low-impact aerobic fitness exercises," (b) "range of motion/flexibility exercises are an option," and (c) "quadriceps strengthening for patients with symptomatic OA of the knee" (AAOS, 2008, p. iii). The CDC (2010) agreed with the previous recommendation, documenting risk factors for OA that include structural malalignment and muscle weakness such as the quadriceps (p. 3).

 

After rehabilitation, the AAOS provided suggestions for mechanical intervention for patients with symptomatic OA of the knee. The AAOS guidelines suggested, "patients with symptomatic OA of the knee use patellar taping for short term relief of pain and improvement in function" (AAOS, 2008, p, iii). The next AAOS guidelines suggested that "lateral heel wedges not be prescribed for patients with symptomatic medial compartmental OA of the knee" (AAOS, 2008, p. iii). According to the research completed by 2008, the AAOS were "unable to recommend for or against the use of a brace with valgus directing force for patients with medial uni-compartmental OA of the knee" as well as "unable to recommend for or against the use of a brace with a varus directing force for patients with lateral uni-compartmental OA of the knee" (AAOS, 2008, p. iii).

 

The fourth category of AAOS clinical practice guidelines was complementary and alternative therapy. The AAOS addressed the topics of acupuncture and glucosamine and/or chondroitin sulfate use. The AAOS stated, "we are unable to recommend for or against the use of acupuncture as an adjunctive therapy for pain relief in patients with symptomatic OA of the knee" (AAOS, 2008, p. iv). Manheimer, Linde, Lao, Bouter, and Berman (2007) developed a meta-analysis on acupuncture for OA of the knee (p. 868). In the review, the authors concluded, "it is too soon to recommend acupuncture as routine part of care for patients with osteoarthritis" (Manheimer et al., 2007, p. 875). However, Manheimer et al. (2007) stated, "because acupuncture may have small short-term effects, some clinicians and patients may consider acupuncture as 1 treatment option in a multidisciplinary approach to treating knee osteoarthritis" (p. 875). For this reason, recommendation 16 has been modified for a nurse practitioner to refer patients for acupuncture therapy as a complement to traditional pain management measures for symptomatic OA of the knee.

 

The AAOS recommendation 12 stated, "glucosamine and/or chondroitin sulfate or hydrochloride not be prescribed for patients with symptomatic OA of the knee" (AAOS, 2008, p. iv). The use of glucosamine and chondroitin has been thoroughly discussed throughout this article and the recommendation was modified for the nurse practitioner to recommend glucosamine and chondroitin use in treating a patient with symptomatic OA of the knee.

 

Pain relievers are the fifth category addressed in the AAOS clinical practice guidelines. Pharmacotherapeutics may be used in conjunction with, before, or after the use of other treatments. The AAOS had two suggestions in regard to pain medications for patients with symptomatic OA of the knee. First, the AAOS (2008) suggested, "patients with symptomatic OA of the knee receive one of the following analgesics for pain unless there are contraindications to this treatment: acetaminophen (not to exceed 4 grams per day), non-steroidal anti-inflammatory drugs (NSAIDs)" (p. iv). Their second suggestion for pain medication was "patients with symptomatic OA of the knee and increased GI [gastrointestinal] risk (age >= 60 years, comorbid medical conditions, history of peptic ulcer disease, history of GI bleeding, concurrent corticosteroids and/or concomitant use of anticoagulants) receive one of the following analgesics for pain: acetaminophen (not to exceed 4 grams per day), topical NSAIDs, nonselective oral NSAIDs plus gastro-protective agent, cyclooxygenase-2 inhibitors" (AAOS, 2008, p. iv).

 

After the initiation of alternative therapy as well as pharmacotherapeutics, the appropriately trained and certified nurse practitioner or other clinical provider may use intra-articular injections. The AAOS made two intra-articular injection recommendations including (a) "we suggest intra-articular corticosteroids for short-term pain relief for patients with symptomatic OA of the knee" (AAOS, 2008, p. v) and (b) "we cannot recommend for or against the use of intra-articular hyaluronic acid for patients with mild to moderate symptomatic OA of the knee" (AAOS, 2008, p. v).

 

The seventeenth AAOS recommendation stated, "we suggest that needle lavage not be used for patients with symptomatic OA of the knee" (AAOS, 2008, p. v). The final five AAOS recommendations involved surgical interventions, which are not included in the scope of practice for a nurse practitioner and therefore not included in this article.

 

Recommendations

Recommendations for a nurse practitioner in the treatment of symptomatic OA of the knee include a modification of the 2008 physician-accepted AAOS clinical practice guidelines. The modification has included a corresponding algorithm titled, "Nurse Practitioner's Algorithm for Treatment of Symptomatic Osteoarthritis of the Adult Knee." The nurse practitioner can safely and effectively utilize recommendations 1-3 as well as 13-14 and 17 of the AAOS clinical practice guideline for OA of the knee.

 

The AAOS recommendations 4-10 are modified to nurse practitioner scope of practice to include the appropriate referral to physical therapy as well as medical supply salesperson as needed for therapy and/or fitting for a brace. Recommendation 11 has been modified for the nurse practitioner to refer a patient to an acupuncture specialist as a means of alternative therapy for symptomatic OA of the knee.

 

The AAOS recommendation 12 was modified to recommend the use of a daily glucosamine and chondroitin sulfate supplement to complement treatment of symptomatic OA of the knee. Seven research studies evaluated show-supporting evidence that glucosamine and/or chondroitin supplement therapy is not more harmful than beneficial. The Cochrane review titled "Glucosamine Therapy for Treating Osteoarthritis" supports the utilization of glucosamine and chondroitin for symptomatic OA of the knee (Towheed et al., 2009). Based on this supporting evidence, this professional article recommends that a nurse practitioner add glucosamine 1,500 mg and/or chondroitin 1,200 mg daily supplement therapy to their current treatment regimen for patients with symptomatic OA of the knee.

 

The AAOS recommendations 15 and 16 were modified to include the appropriate education and certification by nurse practitioners to safely and effectively administer intra-articular injections for patients with symptomatic OA of the knee. The final recommendations, 18-22, are modified for the nurse practitioner to refer the patient to an orthopaedic surgeon for determination of surgical intervention.

 

Discussion

In summary, despite conflicting results on the degree of efficacy, glucosamine (hydrochloride or sulfate) and chondroitin sulfate have not been proven to be more harmful than beneficial. For this reason, on the basis of the research, it is not advisable to recommend against the use of glucosamine and/or chondroitin sulfate. Recommendations for the nurse practitioner suggest that glucosamine 1,500 mg and/or chondroitin sulfate 1,200-mg vitamin supplement be used daily in the symptomatic relief of pain in patients with OA of the knee.

 

It is of continued importance to update research to improve patient quality of life. Implications for future research suggest that glucosamine and chondroitin supplements be studied further to reveal structural benefits to the knee, specifically joint space narrowing, over a minimum of 3 years of daily therapy. In addition, further research should be conducted on comparing the pain-relieving benefits and structural benefits of glucosamine sulfate versus glucosamine hydrochloride. It would be beneficial to research the efficacies of glucosamine and chondroitin as a tablet versus powdered mix or liquid versus topical cream.

 

Patients with symptomatic OA of the knee should be educated that glucosamine and chondroitin sulfate have been shown to have pain-relieving benefits as well as possibly retarding joint space narrowing indicative of OA. The supplementary use of glucosamine and chondroitin sulfate is ultimately a decision made by the patient suffering from OA of the knee following informative patient education. On the basis of the research evidence, the nurse practitioner may advise the patient to use the glucosamine 1,500 mg a day and chondroitin 1,200 mg a day on a 60-day trial to determine the patients' ability to tolerate the supplement as well as provide pain relief. Caution should be advised in patients receiving warfarin or other anticoagulant therapy. Those patients with asthma, diabetes, or allergy to shellfish should also be cautioned in their use of glucosamine and chondroitin sulfate.

 

The nurse practitioner plays a major role in patient education. To effectively facilitate patient education, the nurse practitioner must be knowledgeable regarding the current evidence-based, best practice guidelines. To facilitate the nurse practitioner's evidence-based practice, a nurse practitioner algorithm for treating an adult patient with symptomatic OA of the knee was created incorporating the AAOS 2008 clinical practice guidelines for treatment of symptomatic OA of the knee with the modification of recommendations 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, and 16. The "Nurse Practitioner's Algorithm for Treatment of Symptomatic Osteoarthritis of the Adult Knee" provides an evidence-based best practice reference for nurse practitioners for the treatment of adult patients with symptomatic OA of the knee.

 

References

 

American Academy of Orthopaedic Surgeons. (2008). Clinical practice guideline on the treatment of osteoarthritis of the knee (non-arthroplasty). Rosemont, IL: Author. Retrieved from http://www.aaos.org/research/guidelines/GuidelineOAKnee.asp[Context Link]

 

Centers for Disease Control and Prevention. (2010). Osteoarthritis. Retrieved from http://www.cdc.gov/arthritis/basics/osteoarthritis.htm[Context Link]

 

Clegg D. O., Reda D. J., Harris L., et al. (2006). Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis. New Engl J Med, 354, 795-808.

 

Dahmer S., Schiller R. M. (2008). Glucosamine. American Family Physician, 78(4), 471-476. [Context Link]

 

Kirkham S. G., Samarasinghe R. K. (2009). Review article: Glucosamine. Journal of Orthopaedic Surgery, 17(1), 72-76. [Context Link]

 

Lee Y. H., Woo J., Choi S. J., Ji J. D., Song G. G. (2010). Effect of glucosamine or chondroitin sulfate on the osteoarthritis progression: A meta-analysis. Rheumatology International, 30(3), 357-363. [Context Link]

 

Manheimer E., Linde K., Lao L., Bouter L. M., Berman B. M. (2007). Meta-analysis: Acupuncture for osteoarthritis of the knee. Annals of Internal Medicine, 146(12), 868-877. [Context Link]

 

Nandhakumar J., Sengottuvelu S., Tyagi M. G., Sethumathi P. P., Karthikeyan D., Vasudevan M., Narmadha S., Sivakumar T. (2009). Efficacy, tolerability, and safety of a multicomponent antiinflammatory with glucosamine hydrochloride vs glucosamine sulfate vs an NSAID in the treatment of knee osteoarthritis-a randomized, prospective, double-blind, comparative study. Integrative Medicine: A Clinician's Journal, 8(3), 32-38. [Context Link]

 

National Collaborating Centre for Chronic Conditions. (2008). Osteoarthritis. The care and management of osteoarthritis in adults. London, UK: National Institute for Health and Clinical Excellence; Clinical guideline; no. 59. Retrieved from http://guidelines.gov/content.aspx?id=14322&search=osteoarthritis+of+the+knee[Context Link]

 

National Institutes of Health. (2010). Fact sheet-osteoarthritis. Retrieved from http://report.nih.gov/NIHfactsheets/ViewFactSheet.aspx?csid=55&key=O#O[Context Link]

 

Towheed T., Maxwell L., Anastassiades T. P., Shea B., Houpt J. B., Welch V., Wells G. (2009). Glucosamine therapy for treating osteoarthritis (review). The Cochrane Library, 4. [Context Link]

 

Uitterlinden E. J., Koevoet J. L. M., Verkoelen C. F., Bierma-Zeinstra S., Jahr H., Weinans H., van Osch G. J. V. M. (2008). Glucosamine increases hyaluronic acid production in human osteoarthritic synovium explants. BMC Musculoskeletal Disorders, 9, 120. [Context Link]

 

Zhang W., Nuki G., Moskowitz R. W., Abramson S., Altman R. D., Arden N. K., Tugwell P. (2010). OARSI recommendations for the management of hip and knee osteoarthritis, Part III: changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis and Cartilage, 18, 476-499. [Context Link]

 

For 31 additional continuing nursing education articles on drug therapy, go to http://nursingcenter.com/ce.