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Management of Osteoarthritis with Avocado/Soybean Unsaponifiables

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Abstract and Figures

Osteoarthritis (OA) is a painful and life-altering disease that severely limits the daily activity of millions of Americans, and is one of the most common causes of disability in the world. With obesity on the rise and the world's population living longer, the prevalence of OA is expected to increase dramatically in the coming decades, generating burdensome socioeconomic costs. This review summarizes current pharmaceutical, non-pharmaceutical, and prospective new treatments for OA, with primary focus on the dietary supplement Avocado/Soybean Unsaponifiables (ASU). ASU modulates OA pathogenesis by inhibiting a number of molecules and pathways implicated in OA. Anticatabolic properties prevent cartilage degradation by inhibiting the release and activity of matrix metalloproteinases (MMP-2,3,13) and increasing tissue inhibitors of these catabolic enzymes (TIMP-1). ASU also inhibits fibrinolysis by stimulating the expression of plasminogen activator inhibitor (PAI-1). Anabolic properties promote cartilage repair by stimulating collagen and aggrecan synthesis via inhibition of inflammatory cytokines such as IL1, IL6, IL8, TNF, ERK, and PGE2. Chondroprotective effects are mediated by correcting growth factor abnormalities, increasing TGFβ while decreasing vascular endothelial growth factor (VEGF) in synovial fluid. ASU also inhibits cholesterol absorption and endogenous cholesterol biosynthesis, which mediate reactive oxygen species pathology in chondrocytes. At the clinical level, ASU reduces pain and stiffness while improving joint function, resulting in decreased dependence on analgesics.
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2015, Vol. 6(1) 30 –44
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DOI: 10.1177/1947603514554992
Osteoarthritis (OA) is a chronic synovial joint disease, char-
acterized by two main features: (1) progressive damage of
articular cartilage, bone remodeling, and new bone forma-
tion (osteophytes and subchondral bone sclerosis) and (2)
synovial inflammation and fibrosis of ligaments, tendons,
menisci, and capsules. All joints may be affected, but the
most commonly involved are knees, hands, and hips (Fig.
1). While chronic OA used to be regarded as a “wear and
tear disease,” researchers now believe that low-grade
inflammation and growth of blood vessels and nerves from
the subchondral bone into articular cartilage, as well as met-
abolic disorders, play a major role in disease pathology.1-4
Patients with OA suffer from pain, inflammation, and lim-
ited joint function. Pharmacological interventions are
mostly palliative, focusing on alleviation of symptoms or
slowing disease progression until damaged hip or knee
joints are eventually replaced.5-10 Women are more severely
affected than men by knee OA.11 Differences in knee anat-
omy (narrower femurs, thinner patellae, larger quadriceps
angles, and differences in tibial condylar size), previous
knee trauma, and genetic and hormonal influences may play
a role. Other factors such as age and obesity are also com-
mon factors. In general, women present for treatment in
more advanced stages of OA and have more debilitating
pain than men. Women also have less cartilage volume,
greater cartilage wear, and overall differences in mechani-
cal alignment.
Current Pharmacologic Therapies
Pain medications currently used to treat the symptoms of OA
include acetaminophen, topical capsaicin, topical and oral
nonsteroidal anti-inflammatory drugs (NSAIDs; i.e.,
naproxen and ibuprofen), and the synthetic opioids tramadol
554992CARXXX10.1177/1947603514554992CartilageChristiansen et al.
1Department of Orthopaedic Surgery, Lawrence J. Ellison
Musculoskeletal Research Center, University of California-Davis Health
System, Sacramento, CA, USA
2Formulation Technology Inc., Oakdale, CA, USA
3Pharmin USA, LLC, San Jose, CA, USA
4Independent scholar
Corresponding Author:
Dr. Shahin Emami.
Management of Osteoarthritis with
Avocado/Soybean Unsaponifiables
Blaine A. Christiansen1, Simrit Bhatti2, Ramin Goudarzi3,
and Shahin Emami4
Osteoarthritis (OA) is a painful and life-altering disease that severely limits the daily activities of millions of Americans, and it is
one of the most common causes of disability in the world. With obesity on the rise and the world’s population living longer,
the prevalence of OA is expected to increase dramatically in the coming decades, generating burdensome socioeconomic
costs. This review summarizes current pharmaceutical, nonpharmaceutical, and prospective new treatments for OA, with
primary focus on the dietary supplement avocado/soybean unsaponifiables (ASU). ASU modulates OA pathogenesis by
inhibiting a number of molecules and pathways implicated in OA. Anticatabolic properties prevent cartilage degradation by
inhibiting the release and activity of matrix metalloproteinases and increasing tissue inhibitors of these catabolic enzymes.
ASU also inhibits fibrinolysis by stimulating the expression of plasminogen activator inhibitor. Anabolic properties promote
cartilage repair by stimulating collagen and aggrecan synthesis via inhibition of inflammatory cytokines such as interleukin
(IL)-1, IL-6, IL-8, tumor necrosis factor, ERK, and prostaglandin E2. Chondroprotective effects are mediated by correcting
growth factor abnormalities, increasing TGF-β, and decreasing vascular endothelial growth factor (VEGF) in synovial fluid.
ASU also inhibits cholesterol absorption and endogenous cholesterol biosynthesis, which mediate reactive oxygen species
pathology in chondrocytes. At the clinical level, ASU reduces pain and stiffness while improving joint function, resulting in
decreased dependence on analgesics.
osteoarthritis, cartilage, dietary supplements, avocado soybean unsaponifiables (ASU), Arthrocen
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Christiansen et al. 31
and codeine. However, each of these therapies has potential
drawbacks that may limit their widespread use. Analgesics
can be addictive, whereas acetaminophen can have serious
side effects, such as kidney and liver damage.12 Patients who
do not respond to acetaminophen may be prescribed
NSAIDs. Treatment with NSAIDs, which inhibit cyclooxy-
genases (COX1 and COX2), thereby blocking prostaglandin
synthesis, improves quality of life and decreases pro-inflam-
matory cytokines including interleukin-6 (IL-6), vascular
endothelial growth factor (VEGF), and tumor necrosis
factor-α (TNF-α) in synovial fluid and mitogen-activated
protein kinases (MAPKs) in knee OA.13 However, NSAIDs
can also cause serious side effects, including upper gastroin-
testinal (GI) toxicity (dyspepsia, ulcers, perforation, obstruc-
tions, and bleeding) and liver dysfunction. As such, they are
typically prescribed for the shortest possible duration at the
lowest effective dose. To reduce the risk of these upper GI
complications, the US FDA has approved the use of the
NSAID HZT501 (Duexis), a drug containing 800 mg ibu-
profen, in combination with 26.6 mg famotidine, a histamine
H2-receptor antagonist.14 Alternatively the NSAID cele-
coxib has less risk of upper GI complications by selectively
inhibiting the isoenzyme COX-2, which is specific to
inflamed tissue, versus COX-1, which is constitutive in
many tissues including the GI tract. It should be noted that
daily treatment with celecoxib is more effective in patients
with normal body mass index (BMI) than obese patients.15
Intra-articular injection of corticosteroids (GC) is rec-
ommended to relieve inflammation and pain in OA joints.
However, GC injections are short acting, prone to adverse
side effects, and have limited disease-modifying effects.
For patients with knee OA, viscosupplementation with
hyularonin may be used to replaces shock absorbing and
lubricant material in the joint fluid, but the effects are simi-
larly short-lived.
Current Nonpharmacologic Therapies
Currently, guidelines for OA management are available from
numerous organizations, including the American Academy of
Orthopedic Surgeons (AAOS), the American College of
Rheumatology (ACR), the American Geriatrics Society
(AGS), the American Pain Society (APS), and the
Osteoarthritis Research Society International (OARSI) in the
United States and the European League Against Rheumatism
(EULAR) and the United Kingdom’s National Institute for
Health and Clinical Excellence (NICE) in Europe. Collectively,
these guidelines reflect the experience of physicians across a
variety of medical disciplines. Whereas all generally use the
same data sources (i.e., evidence-based research, expert opin-
ion, patient experience, and cost-effectiveness analysis), they
differ in focus. For instance, the AAOS and AGS guidelines
reflect the perspective of specialists in orthopedic surgery,
geriatrics, and pain management, whereas the EULAR and
OARSI guidelines primarily emphasize the findings of experts
in rheumatology. The NICE guidelines are developed jointly
by physicians and other health care professionals working in
conjunction with a range of clinical researchers. In addition,
the scope varies, with some guidelines (e.g., AAOS, ACR,
EULAR, and OARSI) addressing specific types of OA (i.e.,
knee, hip, or hand) and others (e.g., AGS, APS, and NICE)
addressing OA more generally. As such, recommendations
can vary widely, for instance, guidelines for use of
NSAIDs.10,16-19 Recommended nonpharmacologic interven-
tions range between therapeutic exercises, patient education,
transcutaneous electrical nerve stimulation, acupuncture,
Figure 1. Anteroposteriorand cross-table lateralof knee
osteoarthritis (OA). Symptomatic knee OA typically presents
with narrowing of the joint space and bone spurs (arrows).
(A and B) During the development of OA, articular cartilage
breaks down over time and becomes thin. As a result, the bone
surfaces rub against each other, further damaging the cartilage
and bone and causing pain. (C and D) Joints with late-stage OA
are often painful, warm to the touch, possibly red, swollen, have
subchondral cysts, andnotable loss of function.
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32 Cartilage 6(1)
orthotics and insoles, heat and cryotherapy, patellar tapping,
and weight control. In an effort to evaluate these varying
guidelines, the Appraisal of Guidelines Research and
Evaluation (AGREE II) scored 17 clinical practice guidelines
(CPGs) including EULAR, NICE, OARSI, AAOS, and ACR,
on six different measures: D1, scope and purpose; D2, stake-
holder involvement; D3, rigor of development; D4, clarity
and presentation; D5, applicability; and D6, editorial indepen-
dence.20 The general clinical management recommendations
tended to be similar among high-quality CPGs, although
interventions addressed varied. Nonpharmacological man-
agement interventions were superficially addressed in more
than half of the selected CPGs.
Prospective New Treatments
New noninvasive, disease-modifying therapies for OA are
lacking and needed by millions of patients. A number of
prospective new treatments targeting pro-inflammatory
mediators, cytokines, bone turnover, and angiogenic and
neurogenic factors are being investigated, with varying suc-
cess in clinical trials and clinical use.21
Interleukin-1 (IL-1) may prove an effective target, as
IL-1 induces matrix metalloproteinase (MMP) production,
resulting in the degradation of aggrecan and other matrix
constituents. IL-1 also induces high levels of COX2 and
prostaglandin E2 (PGE2), which may explain the pain asso-
ciated with OA degeneration.22 The drug diacerein, an
inhibitor of IL-1, may modify both disease symptoms and
disease structure in OA. Oral diacerein has proven effective
in reducing pain, although evidence from clinical trials and
scientific literature suggest that the effectiveness in OA is
weak. It can be used in conjunction with NSAIDs or visco-
supplementation therapies for additive effects due to its
alternative mechanism of action. The most common side
effects of diacerein are gastrointestinal, such as diarrhea,
and changes in the color of urine. Meanwhile, the IL-1-
receptor antagonists anakinra and orthokin are reported to
improve Western Ontario and McMaster Universities
Arthritis Index (WOMAC) scores.23-25 In addition, the
IL-1β antibody “gevokizumab” is in phase II clinical trials
for safety and biological activity in the treatment of hand
Nerve growth factor (NGF) has also been recognized as
an important mediator of chronic pain in OA. Tanezumab, a
monoclonal antibody against β-NGF receptor tyrosine
kinase (TrkA), inhibits NGF action and reduces pain in
patients.28 Two randomized phase III clinical trials indicate
that tanezumab provides superior pain relief while improv-
ing physical function and global disease assessment scores
in patients with painful hip OA.27,29-33 Although in most
cases tanezumab is well tolerated, the unexpected occur-
rence of rapid destructive arthropathies suggests there may
be safety issues. Alternatively, using the drug adalimumab
to inhibit TNF-α, which upregulates β-NGF, does not
improve global disease assessment scores in OA of the
Several studies have explored therapies aimed at modi-
fying bone turnover for treatment of OA. Strontium ranelate
(SrRa), an element similar to calcium, is easily taken up by
the body and incorporated into bones in place of calcium.
SrRa is currently indicated for the prevention of fracture in
severe osteoporosis. The SEKOIA (SrRa Efficacy in Knee
OsteoarthrItis triAl) trial, a 3-year randomized, double-
blind, placebo-controlled trial, evaluated the efficacy,
safety, and disease-modifying effects of SrRa given at 1 to
2 g/day in patients with knee OA. Magnetic resonance
imaging (MRI) data indicate that SrRa significantly reduced
cartilage volume loss and bone marrow lesion progression.
Symptoms also improved in terms of pain and physical
function after 6 and 12 months, respectively,35 although
treatment was deemed safe and well tolerated. These data
indicate that SrRa could be a promising new symptom and
disease-modifying treatment for OA. Additionally, there is
a need for further investigations to establish the optimal
dosage and to better clarify the mechanism of action of
SrRa in OA.35-37 Several clinical studies have investigated
the effects of anti-resorptive therapies such as bisphospho-
nates on OA symptoms. A study by Carbone et al. found
that alendronate (ALN) use in OA patients decreased bone
abnormalities and attenuated knee pain, yet cartilage degen-
eration was still present in the MRI scans of treated
patients.38 Spector et al. determined that risedronate use led
to significant improvements in WOMAC scores and preser-
vation of knee joint space compared with placebo in a
1-year randomized control trial involving patients with
moderate OA.39 However, a 2-year randomized control trial
of risedronate treatment revealed contradictory results, with
no significant improvement of WOMAC score or joint
space retention in the knee.40 Similarly, Nishii et al.
observed no inhibition of OA progression in treated hip OA
patients after 2 years of ALN treatment.41 Therefore, in
spite of the growing body of clinical work investigating the
subject, no definitive conclusion can be reached on the
practicality of using bisphosphonates to treat patients with
Antidepressants have shown promising preliminary
results for treatment of pain associated with OA by increas-
ing serotonin levels in the brain. Serotonin-norepinephrine
reuptake inhibitors duloxetine (Cymbalta) and milnacipran
significantly improve pain in OA.27,42 An open-label trial
also suggested analgesic effectiveness of methotrexate, an
anti-inflammatory drug that acts by inhibiting the metabo-
lism of folic acid, demonstrating that up to 20 mg/week for
6 months achieved OARSI responder criteria in knee OA
and warranted a randomized controlled trial.43
Other treatments are aimed at improving disease pathol-
ogy by building cartilage. The small molecule kartogenin
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Christiansen et al. 33
was identified in an image-based high-throughput screen to
promote chondrocyte differentiation. It shows chondropro-
tective effects in vitro and is efficacious in two animal mod-
els of OA. Kartogenin induces chondrogenesis by disrupting
the interaction between filamin A and the transcription fac-
tor core-binding factor b subunit (CBFβ), thereby altering
CBFβ-RUNX1 and possibly RUNX2 transcriptional pro-
grams.44 Autologous injection of platelet-rich plasma (PRP)
has been used to stimulate cartilage repair and healing in
OA patients,27,45,46 but the presence of other growth factors
in PRP may be problematic. Furthermore, bone morpho-
genic protein 7 (BMP7), FGF-8, and botulium toxin A
(BoNT-A) are used in the treatment of knee OA.47 BoNT-A
has an analgesic effect by temporarily suppressing acetyl-
choline secretion at presynaptic nueuromuscular junctions
and appears to be effective and safe for the management of
advanced knee OA. However, these results cannot be gener-
alized to patients with mild knee joint pain or nonspecific
soft tissue pain in the knee joint region. Further research is
necessary to investigate possible complications such as
aggravation of infection, effect on muscle strength, and
neuropathic joint degeneration.
Current nonsurgical and reconstructive surgical thera-
pies are unsuccessful in reversing OA. Recently, a phase I
trial was reported in which chondrocytes were modified via
intra-articular DNA injection to produce TGF-β1 in patients
with advanced knee OA.48 Intra-articular injection of adi-
pose-derived stem cell (ADSC) therapy in a new European
program is also under investigation.49 ADSC induced the
release of trophic factors that exerted anti-inflammatory
effects on both synoviocytes and chondrocytes, with no
MMP1, MMP3, or MMP13 production, suggesting safe and
effective use of ADSCs for clinical applications. However,
both treatments need proof-of-concept studies in larger
patient populations. Alternatively, intra-articular injection
of human mesenchymal stem cells can lead to articular car-
tilage protection through the SDF-1/CXCR4 axis.50-54
Dietary Supplements
Natural products can be safer than prescription medications
with less undesirable side effects. Dietary supplements
including avocado soybean unsaponifiables (ASU), chon-
droitin sulfate, hyaluronan, and glucosamine sulfate have
been reported to modify EULAR symptoms for the treat-
ment of OA.55,56 They are used to treat mild to moderate
pain and alleviate symptoms to reduce the consumption of
Several trials for chondroitin sulfate, glucosamine sul-
fate, and hyaluronan (C14H21NO11)n are in process.56,57
Chondroitin sulfate, glucosamine sulfate, and hyaluronan
are building blocks for proteoglycan synthesis, and major
constituents of the extracellular matrix in cartilage and
synovial fluid.58 They are produced by chondrocytes and
syonivocytes or obtained through diet.59-65 Hyaluronan and
hyaluronic acid (Hyalgan hylan-GF20/Synvisc) can be
injected into the knee joint of patients with OA who cannot
tolerate NSAIDs or are awaiting joint surgery.66 A recent
report indicates that viscosupplementation with Hylan-GF20
slows type II collagen degradation and joint inflammation
in patients with OA.67 However, Hylan-GF20 was not pres-
ent in granulomas, an indicator of inflammation, raising the
question of clinical significance in pain reduction.68 Also,
viscosupplementation with hyaluronic acid itself does not
significantly improve disease outcome, and little is known
about long-term effects.
The efficacy of glucosamine and/or chondroitin in treat-
ing knee OA pain was evaluated in the Glucosamine/
Chondroitin Arthritis Intervention Trial, funded by the
National Center for Complementary and Alternative
Medicine and the National Institute of Arthritis and
Musculoskeletal and Skin Diseases. Patients were treated
daily for 24 weeks with glucosamine alone (1,500 mg),
chondroitin sulfate alone (1,200 mg), glucosamine and
chondroitin sulfate combined (same doses), a placebo, or
celecoxib (200 mg), which served as a positive control.
Although there were no statistically significant differences
between any of the experimental treatments and the placebo
overall, patients with moderate-to-severe pain given both
glucosamine and chondroitin sulfate did show improvement
(79% experienced pain reduction vs. 54% for placebo).
Because of the small size of this subgroup, these findings
should be considered preliminary and need to be confirmed
in further studies.61,69-71
Glucosamine does not appear to slow arthritis progres-
sion over the long term and has many potential complica-
tions. The most common adverse effects are epigastric pain
or tenderness, heartburn, diarrhea, and nausea. Glucosamine
also may cause allergic reactions in patients with seafood
allergies, as a product of lobster, crab, and shrimp shells.
Glucosamine may interact with various pharmaceuticals,
such as warfarin (Coumadin) and diabetes medications,
dangerously modifying their efficacy.
Similarly, chondroitin sulfate appears not to provide
meaningful benefit for patients with OA, and their combi-
nation has not proven effective for either pain management
or functional improvement. OARSI and NICE no longer
recommend the use of glucosamine or chondroitin sulfate
alone, or in combination, if no effects are observed after 6
months or radiographic changes are marginal.55,61,62,72
A network meta-analysis of 10 trials in 3,803 patients by
Juni and collaborators in 2012 found no clinically signifi-
cant improvements in OA pain alleviation or JSN parame-
ters with glucosamine, chondroitin, or combined treatment
compared with placebo. Despite these results, many patients
believe otherwise, potentially due to the natural course of
disease, regression to the mean, or the placebo effect. The
authors conclude that such patients should be permitted to
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34 Cartilage 6(1)
use these supplements if they cover the cost themselves,
since neither of these preparations was found to be
SierraSil is a dietary supplement marketed for joint pain
relief that is derived from the mineral-rich clay found in the
high Sierra Mountains in the United States. Clinical trial
testing short-term efficacy of SierraSil at doses of 2 and 3 g
per day failed to show sustained benefits over placebo, and
iron toxicity has been reported.74
Some OA patients experience pain relief from topical
creams containing capsaicin, the active component of chili
peppers. However, use of these creams may introduce side
effects such as burning, stinging, and redness of the skin
and eyes.10
Avocado and Soybean Unsaponifiables
Avocado/soybean unsaponifiables are natural vegetable
extracts made from avocado and soybean oils, consisting of
the leftover fraction (approximately 1%) that cannot be
made into soap after saponification. ASU is composed of
one third avocado and two thirds soybean unsaponifiables
(A1S2U). The major components of ASU are phytosterols
β-sitosterol, campesterol, and stigmasterol, which are rap-
idly incorporated into cells. ASU is a complex mixture of
many compounds including fat-soluble vitamins, sterols,
triterpene alcohols, and possibly furan fatty acids. The iden-
tity of the active component(s) remains unknown. The ste-
rol contents of ASU preparations are the primary contributors
to biological activity in articular chondrocytes.75 Preclinical
in vitro and in vivo studies have demonstrated that ASUs
have beneficial effects on OA.76-90
ASU possesses chondroprotective, anabolic, and anti-
catabolic properties. It inhibits the breakdown of cartilage
and promotes cartilage repair by inhibiting a number of
molecules and pathways implicated in OA (Tables 1 and 2).
ASU stimulates the synthesis of collagen and aggrecan by
inhibiting inflammatory cytokines such as IL-1, IL-6, IL-8,
TNF, and PGE2 through modulation of NF-kappaB.91-94
The combination of ASU and epigallocatechin gallate
(EGCG; a major component of green tea catechins) affects
an array of inflammatory molecules including expression of
COX-2 and production of PGE2 in chondrocytes.95 COX-2
regulates the production of PGE2; both are mediators
involved in the process of cartilage breakdown. ASU also
inhibits the release and activity of collagenase (MMP2) and
stromelysin 1 (MMP3) in cultured chondrocytes,77,96
increases tissue inhibitors of metalloproteinases (TIMP-
1),79,97 and inhibits IL1-induced ERK but not p38 or JNK in
chondrocytes in vitro.86
In vitro studies show that ASU inhibits fibrinolysis by
stimulating the expression of plasminogen activator inhibi-
tor (PAI-1).98 PAI-1 inhibits tissue plasminogen activator
and urokinase (uPA), thereby blocking plasminogen activa-
tion and inhibiting fibrinolysis (the physiological break-
down of blood clots). This fibrinolytic and tissue destructive
proteinase cascade may play a role in OA joint inflamma-
tion via altered expression of uPA receptors.99
ASUs alter growth factor levels implicated in OA patho-
genesis, increasing TGF-β1 and TGF-β2 in the canine knee
joint fluid,100 to repair cartilage and decreasing VEGF,
which is markedly elevated in synovial fluid of patients.13,97
In a study of implant osseointegration in rat tibiae, ASU
administration improved markers of bone growth, including
Table 1. Stimulatory Effects of Avocado Soybean Unsaponifiable on Anti-Inflammatory, Anabolic Mediators That Protect Against
Molecular Mediator Target Tissue/Organ Organism Assay References
Collagen synthesis Articular synoviocytes,
chondrocytes, skin
Rabbit, bovine,
In vitro 81, 84, 93
Collagen II mRNA Chondrocytes +
subchondral bone
osteoblasts (SBO)
Human In vitro 84
Agreecan proteoglycan Chondrocytes, SBO Equine, human In vitro 84, 94
TGF-β1 Knee joint fluid,
osseointegration in tibiae
Rat, canine In vivo, in vitro 84, 98, 100, 101
TGF-β2 Knee joint fluid Canine In vitro, in vivo 98, 100
TGF-β3 Chondrocytes + SBO Human In vitro 84
BMP-2 Osseointegration in tibiae Rat In vivo 101
Osteocalcin Chondrocytes + SBO Human In vitro 84
Chondroprotector Bone implant Rat In vivo 96
Delayed destruction of the
Radiological evaluation Human In vivo 81
Plasminogen activator
inhibitor 1 (PAI-1)
Chondrocytes, osteoblasts Bovine In vitro 98
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Christiansen et al. 35
bone morphogenic protein 2 (BMP-2) and transforming
growth factor beta 1 (TGF-β1), though histomorphometric
analysis of implant osseointegration was only slightly
improved.101 ASU also inhibits cholesterol absorption and
endogenous cholesterol biosynthesis.102 Sixty percent of
patients with OA exhibit high levels of oxidized low-den-
sity lipoproteins (oLDL) in serum, which mediates reactive
oxygen species (ROS) activity in chondrocytes and OA
pathology.103,104 Treating patients with a daily dose of 300
mg ASU for 3 months decreased oLDL levels.105
At the clinical level, ASU reduces pain and stiffness while
improving function in joints, resulting in decreased depen-
dence on analgesics. ASU efficacy and safety during and
after treatment have been assessed in various randomized,
double-blind, multicenter trials in patients with symptomatic
knee or hip OA. Two studies conducted over a 3-month
period report that standard treatment with 300 mg/day of
ASU improved indices of pain, stiffness, and physical func-
tion, as measured by WOMAC, and decreased analgesic drug
demanded in patients with OA.106-109 A third trial conducted
over 6 months reports similarly improved function compared
with placebo, measured by the Lequense Functional Index,
with persistent effects after termination of treatment.108 In a
6-month trial on patients with femorotibial gonarthrosis,
ASU was as effective as 400 mg of chondroitin sulfate three
times per day, as measured by WOMAC.110 Most recently, a
3-year randomized trial on patients with hip OA, performed
under the ACR criteria (minimum of 1-4 mm hip JSW on the
pelvic radiographs), reports excellent safety, but no signifi-
cant reduction in the mean rate of JSN after 1 year. However,
analyzing the results under different parameters reveals a sig-
nificant 20% reduction in the rate of progression in patients
with severe hip OA (P = 0.04), indicating a potential structure
modifying effect of ASU,111 as confirmed in the ERADIAS
Table 2. Inhibitory Effects of Avocado Soybean Unsaponifiable on Inflammatory and Catabolic Mediators of Osteoarthritis.
Molecular Mediator Target Tissue/Organ Organism Assay References
Interleukin-1 beta (IL-1β) Synoviocytes,
Mice, rabbit,
In vitro 77, 81, 116
Interleukin-4 (IL-4) Chondrocyte In vitro
Interleukin-6 (IL-6) Chondrocyte Human In vitro 81, 92
Interleukin-8 (IL-8) Chondrocyte Human In vitro 92
Macrophage inhibitory
protein-1beta (MIP-1β)
Chondrocyte Human In vitro 87, 116
MMP-2 (also known
as collagenase, or
Fibroblasts, chondrocyte Human In vitro 79, 81, 92
MMP-3 (also known as
Fibroblasts chondrocyte
+ subchondral bone
osteoblasts (SBO)
Mice, human In vitro 79, 81, 84, 86, 92, 101
MMP-13, collagenase-3 Chondrocytes,
chondrocytes + SBO
Mice, human In vivo 84, 86
Tissue inhibitors of MMP
Fibroblasts + SBO Human In vitro 79, 84
COX2 Chondrocytes, monocyte/
Macrophage-like cells,
chondrocytes + SBO
In vitro 84, 116, 115
Prostagladine-2 (PGE2) Hyalin chondrocytes,
like cells
Mice, equine,
In vitro 86, 92, 116
NF-κB Hyalin chondrocytes,
nuclear translocation
of p65
Mice, equine,
In vitro 86, 115
ERK1/2 Hyalin chondrocytes Mice, human In vitro 86
TNF-αChondrocytes Human In vitro 84
iNOS Chondrocytes, monocyte/
macrophage-like cells
Human In vitro 84, 116
NO Chondrocytes, monocyte/
macrophage-like cells
Human In vitro 116
oLDL Osteoblasts Human Serum 104
Fibronectin Chondrocytes Human In vitro 81
Alkaline phosphatase Osteoblasts Human In vitro
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36 Cartilage 6(1)
study. In a clinical trial of patients with hip OA, the effects of
ASU treatment over 3 years were evaluated by radiography
to identify joint pathology and disease progression on the
structural level. Although JSN was not statistically signifi-
cant between ASU and placebo treatment, secondary analysis
of disease progression, measured by JSN (0.5 mm) or total
hip replacements, indicated 20% improvement with ASU
(42.2% vs. 51.4% of placebo group, P = 0.054). Computerized
image analysis also showed significant histological differ-
ences not detectable by traditional scoring methods.112 In
sheep, ASU treatment following cartilage insult improved
articular integrity, as measured by toluidine blue staining,
after 6 months compared with untreated animals. These
improvements were the result of decreased catabolism and
increased anabolism of cartilage by ASU.78 Indeed, ASU
reduces inflammation-mediated cartilage degradation by
reducing IL-1, PGE2, and MMP-3 production, while also
inducing proteoglycan, noncollagenous protein (NCP), and
collagen synthesis within 72 hours of administration to
bovine cells in culture.75 A recent study in patients with non-
specific dorsalgia demonstrated analgesic effect of
Piascledine with positive outcome after 1 month.113 However,
a randomized, double-blind, placebo-controlled clinical trial
carried out in 14 obese adult volunteers over 3 months reports
no significant effect on these parameters, as measured by
hyperglycemic–hyperinsulinemic clamp technique.114
Four double-blind placebo-controlled randomized human
clinical trials (RCTs) evaluate ASU’s impact on knee and hip
OA.109 Two of these indicated that ASU treatment decreased
NSAID intake over 3 months.106,107 Another found that ASU
improves LFI compared with placebo over the course of 6
months, and also that improvements took 2 months to take
effect, and subside after treatment ended.108 Alternatively, a
long-term study indicated no significant difference in JSN,
or other parameters of disease, after 2 years of ASU treat-
ment,80 indicating that the beneficial impact of ASU on OA
may be limited to short-term effects. However, this study
also focused on identifying structure-modifying effects, ver-
sus symptom-modifying effects; although these two differ-
ent measures of OA severity often correlate, ASU may affect
each uniquely. Evidence for symptom-modifying effects of
ASU is much stronger, and thus an alternative explanation
for these contradictory findings is that while ASU does not
improve structural damage of OA, as measured in this study,
it does improve symptoms such as pain and mobility, as
measured in previous studies.82 In a study of chronic nonspe-
cific back pain, treatment with ASU (piascledine) combined
with the NSAID artrosiline (320 mg/day) showed significant
analgesic effect over NSAID treatment alone. The positive
effect of ASU was demonstrated after 1 month of treatment.
The authors suggest that further RCTs are needed to confirm
results. To this end, the ERADIAS trial determined whether
ASU Expanscience treatment slowed the radiological pro-
gression of hip OA.113 As for safety, none of the four RCTs
reported significant differences in adverse effects between
ASU and placebo.
Factors like BMI, severity of disease, and activity level
may influence the effect of ASU, as these conditions exac-
erbate inflammatory conditions and mechanical stresses
that contribute to OA. Adipose tissue plays an important
role by producing metabolic factors with catabolic and
pro-inflammatory properties, including cytokines, chemo-
kines, and adipokines (IL-6 and TNF-α, IL-8, IFN-γ),
which orchestrate pathophysiological processes in OA.
Soluble mediators produced by adipocytes may also mod-
ulate chondrocyte metabolism and contribute to cartilage
degradation. ASU may counteract these inflammatory
processes by inhibiting the translocation of the transcrip-
tion factor NF-κB from the cytoplasm to the nucleus,
which controls transcription of many pro-inflammatory
factors (Table 2).86,115 As such, ASU acts as an anabolic
agent in vitro, reducing the production of pro-inflamma-
tory mediators, including IL-1, IL-6, IL-8, macrophage
inflammatory protein-1, NO, MMP-13, TNF-α, and
COX2/PGE288,94,115,116 from various cell types (Table 1).
In mice, ASU decreases pro-inflammatory interferon-γ
(IFN-γ) and IL-4 production, in the context of parasitic
diseases.117,118 Although more studies need to be con-
ducted to show the effects of ASU in patients with varying
BMI, the anti-inflammatory effects of ASU are likely to
protect cartilage from obesity-associated inflammatory
degradation and improve OA symptoms. Indeed, ASU sig-
nificantly decreased the rate of OA progression to 40%
compared with 50% in the placebo group in one study.111
However, this study showed that ASU did not influence
the rate of OA progression in the obese subset of patients
with mean symptom duration 4 and BMI of 27 kg/m2.
However, excessive inflammation associated with obe-
sity may also impede efficacy, as it does with celecoxib
(NSAID) treatment, which is not as effective in obese
patients (BMI in excess of 30 kg/m2).119 The influence of
obesity, and how it influences ASU efficacy, may also
depend on the parameters used to measure and define dis-
ease. In a study examining the relationship between BMI
and OA in patients scheduled to undergo hip replacement,
increasing BMI was associated with increasing levels of
pain and functional disability, but not radiographic joint
damage. Thus, obesity might influence some aspects of
disease and treatment but not others. This should be taken
into account when designing and assessing studies intended
to examine the impact of obesity on treatment efficacy.119
ASU has anti-inflammatory effects in mice when admin-
istered in conjunction with the anti-parasitic drug
Praziquantel, reducing inflammatory cytokines IFN-γ and
IL-4, as well as granuloma size, while increasing cidal
activity.117,118 ASU also protects gingival elastic fibers from
degradation by human leukocyte elastase,120 hypodermati-
tis,121 and ischemic damage.122
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Christiansen et al. 37
A recent electronic database analysis demonstrated the
benefits and harms of oral medicinal plant products in treat-
ing OA. The authors used standard methods for trial selection
and data extraction, and they assessed the quality of the body
of evidence using the GRADE approach for major outcomes
such as pain, function, radiographic joint changes, quality of
life, withdrawals due to adverse events, total adverse events,
and serious adverse events. The ASU product Piasclidine
formed a small and clinically questionable improvement in
symptoms, compared with placebo after 3 to 12 months treat-
ment. Radiographic joint changes, as change in joint space
width (JSW), did not differ between ASU 300 mg treatment
and placebo. Moderate-quality evidence from a single study
confirmed possible benefits of ASU 600 mg over placebo.
There is no evidence that Piasclidine significantly improves
joint structure, and limited evidence that it prevents joint
space narrowing. The authors suggest further investigations
are required to determine optimum daily doses producing
clinical benefits without adverse events.123
ASU is considered as drug in most countries and is there-
fore prescribed by physicians. However, in the United
States it is classified as dietary supplement and can be pur-
chased as over-the-counter supplements, Avoca ASU (ASU-
NMX1000, Nutramax Laboratories Inc., Edgewood, MD)
and Maximize ASU 300/SierraSil (Maximum International
Inc., Pompano Beach, FL). Avoca ASU, a combination of
ASU and glucosamine sulfate, has been shown to suppress
TNF-α, IL-1β, COX2, iNOS, PGE2, NF-κB activation and
nitrite production in articular chondrocytes and monocytes/
macrophages, reducing pain and inflammation in OA
patients.115,116,124 However, conflicting reports indicate the
complete absence of specific ASU molecules in Avoca ASU
when compared with Piascledine.75,125-127
Questions remain about the efficacy and safety of ASUs
for treatment of OA (Table 4). Macaigne and colleagues
published a case report in 2004 describing a female with
lymphatic colitis associated with Piascledine treatment.128
Further prospective multicenter studies are warranted to
investigate whether other microscopic colitis cases129 are
observed in patients treated with Piascledine. Avoca ASU
that contains glucosamine can induce allergic reaction in
people with shellfish allergy. Even in very small quantities,
these people may experience mild symptoms, such as hives
or nasal congestion, or more severe, even life-threatening,
An alternative ASU formulation is Arthrocen (Pharmin,
USA, LLC, San Jose, CA). Arthrocen is an extract from
avocado and soybean oils that does not contain any ingredi-
ents of animal origin, artificial flavor, sweetener, preserva-
tive, or color. Each capsule contains 100 mg unsaponifiable
persea gratissima unsaponifiable (avocado) and 200 mg
unsaponifiable glycine max (soybean) extracts, silica, mag-
nesium stearate (E470b—manufactured from vegetable
oil), and gelatin fines.
In general, the FDA does not hold dietary supplements to
the stringent standards of pharmaceutical manufacture. If
ASU is to be widely used for the treatment of OA, serious
consideration should be given to their current regulatory sta-
tus in order to ensure potency, purity, and as well as the
excipients. Many studies have demonstrated substantial
variation between the content listed on the labels of these
products and the actual content. The sterols content of ASU
have been demonstrated to have biological activities in cul-
ture and in animal models. This approach allowed us to com-
pare the contents of three commercial supplements (Fig. 2).
We found multiple peaks were present in the Piascledine-300
(Expanscience) mass spectrometry analysis (Agilent 7890
GC System, 7693 Auto Sampler, Agilent VL MSD with tri-
ple Axis Detector, Brea, CA), compared to the Arthrocen
300 mg (PharminUSA) or ASU300-Avocado Soy
Unsaponifiable with Sierra 600 mg (Maximize, Maximum
Int.) preparations (Fig. 2, Table 3). Similar results were
found for Piascledine-300,75 with mass spectra sterol content
Figure 2. Gas chromatography–mass spectrometry analysis of
major sterol components of Piascledine 300, Avocado 300 Soy
Unsaponifiable with Sierra 600 mg, and Arthrocen 300. Control
sample exhibited characteristic peaks corresponding to 1 =
Dihydrocholesterol (5α-Cholestan-3β-ol; internal control; Sigma
Aldrich), 2 = Brass (Brassicasterol), 3 = Camp (Campesterol),
4 = Stigmn (Stigmastanol), 5 = β-Sito (β-sitosterol), 6 = Stigma
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38 Cartilage 6(1)
of C20H30O2, C20H28O2, sitosterol, stigmasterol, campesterol,
squalene, β-tocopherol, desmethyl tocopherol, oleic acid
docosane, α-amyrin, and cholesterol. In two letters to the
editor, Msika et al.126 and Henroitin125 claimed that the exact
Table 3. Content Analysis of Supplements Containing Avocado Soybean Unsaponifiable.
Company/Manufacturer Brand Name Dosage Form Other Ingredients Excipients on the Label
Nuramax Laboratories, Inc. Avoca ASU Avocado/Soybean
Unsaponifiables, non-
shellfish glucosamine,
Green tea extract
Helseudsalg Faaborg Denmark AvoSol Avocado 100 mg/Soy 200
mg Unsaponifiables
Vitamin C 30 mg Glucose syrup, ox gelatin,
soy protein isolate, extract
rich in tocopherol, silicon
dioxide, magnesium salts
from fatty acids
Dr. Theos Official, USA Avosoy Avocado-Soybean
Vitamin C 60 mg Cellulose, dicalcium
phosphate, sodium
croscarmellose, silicon
dioxide, gum acacia,
vegetable stearic acid, film
coating, magnesium stearate
Vitamin E 30 U
Manganese 2 mg
Dr. Theos Official, USA AvosoyComplete Avocado-Soybean
Unsaponifiables 300 mg
Vitamin C 60 mg
Glucosamine 1,500 mg Vitamin E 30 U
Porcine chondroitin 800 mg Manganese 2 mg
Swanson Health Products,
Fargo, ND, USA
AvoVida 100 mg Unsaponifiables
Persea gratissima
30% β-sitosterol,
Soy protein isolate, mixed
tocopherols, silica
Glycine max Microcrystalline cellulose
(plant fiber), gelatin,
magnesium stearate
Pharmin, USA, LLC,
Formulation Technology,
Arthrocen 300 mg Avocado 100 mg/Soy 200
mg Unsaponifiables
Persea gratissima Silica, magnesium stearate
(E470b manufactured from
vegetable oil), and gelatin
Glycine max
Nuramax Laboratories, Inc. Cosamin ASU Avocado/Soybean
Glucosamine Sulfate
Chondoitine Sulfate
Maximum International, USA Maximize ASU300-Avocado Soy
Iron: 1.1 mg (from
cellulose, maltodextrin,
croscarmellose sodium,
silicon dioxide, stearic
acid, hydroxypropylm
magnesium stearate,
polyethylene glycol
SierraSil: 600 mg Iron toxicity
recommendation on the
Expanscience Lab,
Courbevoie, France;
Pharmascience, Montreal,
Canada; Pharma Inv., Chile
SA, Santiago; Solvay Ins.;
Biol. Chenioterapicosells;
Microsules y Bernabo
Siegfried, Rhein
Piascledine 300 Avocado/Soybean
Not described Butylated hydroxytoluene
(BHT) 0.05 mg/capsule
Colloidal anhydrous silica
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Christiansen et al. 39
ingredients and preparation of ASU-Expanscience was an
intellectual proprietary, protected by patent. Msika further
emphasized that the tocopherols, sterols, and patented spe-
cific molecules from avocado contribute to the originality of
the product, different from natural avocado unsaponifiables.
In contrast, they analyzed Dasuquin with MSM, Dasuquin,
and Avoca ASU (Nutramax), and compared them with ASU
Expanscience. The analyses revealed content of products
were significantly different from those indicated on the
Nutramax labels—with no citrostadienol, and brassicasterol
present in ASU Expanscience. Contrary to that they found
contents included high level of rapeseed oil and unsaponifi-
ables products with very low tocopherol, and without
respected ratio of 1:2 for avocado to soybean unsaponifi-
ables. The original ASU Piascledine 300 pills contains 100
mg of avocado unsaponifiables and 200 mg of soybean
unsaponifiables. The difference in sterol content is based on
the A/S ratio and avocado-specific modified unsaponifiables
obtained by a patented process. Henrotin et al. have shown
ASU effects are best when the ASU ratio is 2:1.92 In support,
Henroitin et al. recommended additional studies to ensure
efficacy of Nutramax products.125 These issues and reported
adverse effects of ASU (Table 4)128,130 raises concerns about
the content and purity of ASU supplements on the market,
with implications for patient safety.
Osteoarthritis inflicts pain and physical limitation on millions
of people. Improving joint function and patient activity is a cen-
tral public health concern to improve quality and length of life.
The aim is not only to treat pain but also to prevent the onset of
disease. There is no cure for OA, and even symptomatic treat-
ment options are scarce, dominated by pain management and
surgical intervention. ASUs may prove to be an effective treat-
ment option for symptomatic OA, as they have been shown to
possess chondroprotective, anabolic, and anticatabolic proper-
ties, as well as anti-inflammatory properties. At the clinical
level, ASUs reduce pain and stiffness while improving joint
function. Importantly, ASUs are a natural, slow-acting agent
that do not merely address acute pain but actively prevent pro-
gression of OA symptoms. Further studies are required to deter-
mine the specific mechanisms and target molecules of ASU
function on OA at the cellular and metabolic level.
Acknowledgement and Funding
We are grateful to Susan Eastman, health librarian at Stanford
Hospital Health Library. We are grateful to many authors for their
generous contributions while writing this review. We also apolo-
gize to authors of many relevant articles whose works are not cited
due to space constraints. Weacknowledge PL for providing us
photos and X-ray images of his hands and knees. Dr. Christiansen
is funded by the National Institute of Arthritis and Musculoskeletal
and Skin Diseases, part of the National Institutes of Health, under
Award Number AR062603, and by the Department of Defense–
Congressionally Directed Medical Research Programs, under
Award Number PR110178.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest
with respect to the research, authorship, and/or publication of this
article: SimritBhatti and Dr. Ramin Goudarzi are employees of
Formulation Technology Inc. and Pharmin USA, LLC,
Table 4. Adverse Effects of Avocado Soybean Unsaponifiable.
Organ Side Effects Frequencies Drug Withdrawal References
Skin Eczema 32.5% 130
Liver Liver injury 16.2% Return to normal 130
Gastrointestinal Regurgitation 12% Return to normal 106, 129, 130
Epigastric pain
Microscopic colitis
Coagulation Platelets 6.8% 130
ALKP = alkaline phosphatase; GGTP = gamma-glutamyl transpeptidase.
at UNIV CALIFORNIA DAVIS on June 11, 2015car.sagepub.comDownloaded from
40 Cartilage 6(1)
respectively. However, neither Formulation Technology nor
Pharmin USA contributed funds or resources to this study or to the
Ethical Approval
This review does not include previously unpublished research
involving human subjects, and therefore no institutional approval
was necessary. Images in Figure 1 were provided directly by PL,
and are used with his full knowledge and approval.
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... The oil enhances the synthesis of collagen and proteoglycan and decreases the synthesis of fibronectin. Another mechanism of action is the inhibition of the release and activity of metalloproteinases and proinflammatory cytokines such as IL-1, IL-8, and PGE2 [57][58][59]. Additionally, in vitro studies have shown that the oil mixture stimulates aggrecan and matrix component synthesis, reduces catabolic and proinflammatory mediator production, and appears to prevent the osteoarthritic osteoblastinduced inhibition of matrix molecule production, suggesting that this compound may promote osteoarthritis cartilage repair by acting on subchondral bone osteoblasts [57]. ...
... The clinical data suggest that unsaponifiable oil from avocado and soybean can efficiently supplement long-term treatments of knee and hip osteoarthritis [57,59,60]. ...
Full-text available
Mexico, a megadiverse country, hosts approximately 10–12% of the world’s biodiversity and at least 21,989–23,424 vascular plants, 3350 of which are traditional medicinal flora. The Mexican Regulation categorizes herbal medicinal products into two groups: herbal medicines products and herbal remedies products. To date, there is no available information that describes and includes analyzed data about these two types of herbal medicinal products registered in Mexico. The purpose of the study was to analyze national sanitary registries of herbal products from 2001 to 2020 and identify native Mexican plants that are most used in herbal products. Further, the study aims to highlight the impact and relevance of this large number of medicinal plants, which represent a great source of information, genetic resources, bioactive compounds, and potential use in subsequent therapies based on scientific evidence. The future of medicines and herbal remedies is underestimated; thus, the significance of evaluating the great potential in studying plants for medicinal use must be taken into account.
... While inflammation plays a major role in the pathology of OA, the effects of ASU on molecules implicated in inflammation are still poorly explained in patients with OA. There are several reports of the stimulatory effects of ASU on anti-inflammatory and anabolic mediators as well as its inhibitory effects on inflammatory and catabolic mediators [10,[16][17][18]. Previous reports have shown that ASU can reduce the production of pro-inflammatory mediators such as IL-1, IL-6, IL-8, and TNFα in various cell types [16,19,20]. ...
... There are several reports of the stimulatory effects of ASU on anti-inflammatory and anabolic mediators as well as its inhibitory effects on inflammatory and catabolic mediators [10,[16][17][18]. Previous reports have shown that ASU can reduce the production of pro-inflammatory mediators such as IL-1, IL-6, IL-8, and TNFα in various cell types [16,19,20]. Moreover, many of these cytokines are involved in the pathogenesis of OA [21]. ...
Full-text available
Background and objectives: Many mediators and cytokines are involved in the pathogenesis of osteoarthritis (OA). Some of these cytokines are spontaneously expressed by cultured fibroblast-like synoviocytes. Therefore, using serum samples, the efficacy and the effects of avocado/soy unsaponifiables, ASU, (Arthrocen) on cytokine changes were assessed in patients with knee OA (KOA). Materials and Methods: Experimental procedure: A randomized, double-blind, placebo-controlled clinical trial was conducted on patients with a diagnosis of mild to moderate OA who received either Arthrocen 300 mg/day (n = 61) or placebo (n = 58) for 3 months. Data collection was performed using questionnaires including the Western Ontario and McMaster Universities osteoarthritis index (WOMAC), 20-item short form survey (SF-20), Lequesne index of severity for osteoarthritis of the knee (LISOK), and three visual analog scales (VASs) as pain quality indices. The serum levels of interleukins 2 (IL-2), IL-4, IL-10, IL-17α, and TNF-α were measured using an ELISA reader. Results: Both quality of life indices, pain sensation and scored by specialists (as VASs), respectively, including WOMAC and SF-20, as well as joint dysfunctionality symptoms assessed by physicians were significantly improved (p < 0.05) in OA patients receiving Arthrocen. The serum levels of anti-inflammatory interleukins 4 and 10 were also augmented, while levels of inflammatory IL-17 and TNF-ɑ cytokines were decreased significantly (p < 0.05) compared with the control groups during the 3- and 6-month treatment. Conclusions: Arthrocen consumption may increase the quality of life in OA patients through amelioration of inflammation and improvement of functional activities without any adverse effects in the long term.
... The identity of the active component(s) remains unknown. The sterol contents of ASU preparations are the primary contributors to biological activity in articular chondrocytes (5). Preclinical in-vitro and in-vivo studies have demonstrated that ASUs have beneficial effects on OA (6,7). ...
Full-text available
Due to the lack of suitable therapeutic approaches to cartilage defect, the objective of this study was to determine the effect of Transforming growth factor-β3 (TGF-β3), avocado/soybean (ASU) and Kartogenin (KGN) on chondrogenic differentiation in human adipose-derived stem cells (hADSCs) on fibrin scaffold. hADSCs seeded in fibrin scaffold and cultured in chondrogenic media. These cells were divided into 4 groups (control, TGF-β3, ASU and KGN). Cell viability was estimated by MTT assay. Differentiated cells were evaluated by histological and immunohistochemical (IHC) techniques. Expression genes [sex determining region Y-box 9 (SOX9), Aggrecan (AGG), type II collagen (Coll II) and type X collagen (Coll X)] were assessed by real-time PCR. For a study on an animal model, differentiated cells in fibrin scaffolds were subcutaneously transplanted in rats. Histological and immunohistochemistry were done in the animal model. The results of the real-time PCR indicated that SOX9, AGG and Col II genes expression in TGF-β3, KGN and ASU groups were significantly higher (p < 0.01) compared to the control group, Col X gene expression only in the TGF-β3 group was significantly higher (p < 0.01) compared to the control group. The glycosaminoglycan (GAG) deposition was higher in TGF-β3, KGN and ASU groups compared to the control group. The immunohistological analysis showed the distribution of collagen type X in the extracellular matrix in the fibrin scaffold TGF-β3 group was significantly higher in control, KGN and ASU groups, and (p < 0.001). ASU, particularly KGN, was suitable for successful chondrogenic differentiation of hADSCs and a suppressor of the consequent hypertrophy.
... Zu einer Kombination beider Präparate (Chrondroitinsulfat und Glucosaminsulfat) gibt es keine ausreichende Evidenz [29]. Andere Produkte wie Diacerein, Kollagenhydrolysat, Avocado/Sojabohnen, Boswellia serrata, Myrobalan, Grapefruit, Methylsulfonylmethan oder orale Hyalurongabe haben sich im klinischen Alltag aufgrund ihrer Nebenwirkungsrate oder schlicht fehlender oder unklarer Evidenz nicht etabliert [26,30,31,32,33,34]. Auch bei verschiedenen Vitaminpräparaten, vor allem Vitamin D3 und C, ist keine klare Evidenz im Hinblick auf eine Besserung der Arthrosebeschwerden zu erkennen [33]. ...
Osteoarthritis (OA) is a degenerative joint disease, a leading cause of bone‐related disabilities affecting the life quality of a huge segment of the global population. To eradicate this problem, non‐pharmacological treatments like diet and lifestyle modification (weight loss, Tai chi, cupping therapy, kinesio taping, ultrasound and whole‐body vibration, low‐level laser therapy, manual therapy, electrotherapy, mudpack therapy, and moxibustion) are effective along with medical treatments. Nowadays, these preventive and therapeutic remedies are getting more attention as adjuvant measures due to enhanced awareness amongst the common people. In most OA management guidelines, dietary modifications along with effective exercises and therapies are preferred over other existing treatments owing to their safe nature and significant positive effects on reverting the OA symptoms. Scientific evidence has shown that food components like phytochemicals, polyphenols, flavonoids, epigallocatechin 3‐gallate, ellagic acid (EA), vitamins, minerals, extracellular vesicles, glucosamine, and chondroitin sulfate have a promising effect on relieving the OA symptoms and slowing down its progression due to their antioxidant and anti‐inflammatory activities. This review summarizes the evidence‐based dietary and lifestyle modifications for improved bone health with special reference to OA.
Purpose: To assess the importance of home nursing care on the functional outcome, quality of life, and length of stay of patients who underwent total hip arthroplasty. Methods: This was a retrospective cross-sectional study including patients who underwent surgery from February 2011 to December 2016. Patients were analyzed in two groups: with home care (received nursing care) and without home care. The analyzed outcomes were quality of life, functional outcome, and length of hospital stay. Total follow-up with questionnaires was 24 months. Results: A total of 244 patients (143 with home care and 101 without home care) were analyzed. No significant differences were found regarding the mean age (p = 0.125), gender distribution (p = 0.449) and BMI (p = 0.548) between the two groups. There was also no significant difference regarding functional outcome (p = 0.107) and quality of life (p = 0.848), measured by validated tools. However, the median of length of hospital stays in the home care group was lower in 1 day compared to without home care group (p < 0.001). Conclusion: The home nursing care did not influence the functional outcome or quality of life of the patients, but there was a decrease in the length of hospital stay in the group that received preoperative nursing care.
Owners often reach for over-the-counter supplements for the management of canine osteoarthritis, believing them to be natural, side effect-free options. Some may ask for your opinion as a veterinary professional, whereas others will come to you already using certain products. It is imperative to be aware of the evidence for the relevant products and to encourage the use of good quality products as the first option. The aim should be to help prevent owners of arthritic dogs wasting their money buying multiple products with little or no evidence to back up their use, to be wary of bold unsubstantiated claims for improvements or health benefits, and to ensure that supplements are not used as a sole intervention for the management of arthritic pain, as they are unlikely to have the evidence base to support this claim.
One of the highest priorities of the aging adult is the ability to remain active and mobile [Akishita et al., J Am Med Dir Assoc. 14:479–84, 2013]. Unfortunately, with age often comes the physical breakdown of the components of the musculoskeletal system putting this goal in jeopardy. The aging adult feels the effects of decades of activity on their muscles and joints with pain and stiffness and the inability to comfortably enjoy the quality of life that they envision. In addition, the effects of a lifetime of chronic inflammation and undernutrition escalate as metabolic derangement in metabolism that can lead to conditions such as sarcopenia, anorexia of aging, and osteoporosis. Strategic nutritional interventions can significantly improve the physical function of the aging adult by decreasing chronic inflammation, supplying ample nutrients and phytonutrients, and eliminating a common repetitive source of inflammation – poor dietary choices.
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Objective: To assess the ability of avocado-soybean unsaponifiable- Expanscience (ASU-E) to slow radiographic progression in symptomatic hip osteoarthritis (OA). Methods: Prospective, randomised, double blind, parallel group, placebo controlled 3 year trial. Patients with symptomatic (painful 1 year, Lequesne Index between 3 and 10) hip OA (American College of Rheumatology criteria) and a minimum joint space width (JSW) of the target hip between 1 and 4 mm on a pelvic radiograph were randomly assigned to 300 mg/day ASU-E or placebo. Standing pelvis, target hip anteroposterior (AP) and oblique views were taken annually. The primary outcome was JSW change at year 3, measured at the narrowest point on pelvic or target hip AP view (manual measure using a 0.1 mm graduated magnifying glass). The full analysis dataset (FAS) included all patients having at least two successive radiographs. An analysis of covariance Mixed Model for Repeated Measurements with Missing at Random (for missing data) was performed to compare adjusted 3 year JSW changes (primary outcome) and the percentages of 'progressors∗ (JSW losse 0.5 mm) between groups. Results: 399 patients were randomised (345 kept in the FAS), aged 62 (35 - 84) years, 54 % women, mean body mass index 27 (SD 4) kg/m2, mean symptom duration 4 (SD 5) years, 0-100 normalised Lequesne Index 30 (SD 9) and global pain visual analogue scale 37 (SD 23) mm. Mean baseline JSW was 2.8 (0.9) mm. There was no significant difference on mean JSW loss (-0.638 mm vs -0.672 mm, p = 0.72, in the ASU-E and placebo groups, respectively) but there were 20 % less progressors in the ASU-E than in the placebo group (40 % vs 50 %, respectively, p = 0.040). No difference was observed on clinical outco-mes. Safety was excellent Conclusions: 3 year treatment with ASU-E reduces the percentage of JSW progressors, indicating a potential structure modifying effect in hip OA to be confirmed, and the clinical relevance requires further assessment. Trial registration number on NCT01062737.
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Purpose: To evaluate the influence of administration of avocado/soybean unsaponifiables (ASU) on implant osseointegration in rat tibiae. Materials and methods: Thirty rats were randomly assigned into one of three equal-sized groups: (1) ASU1: administration of ASU starting 7 days prior to implant placement; (2) ASU2: administration of ASU starting on the day of implant placement, and (3) CTL: administration of saline solution. In all animals, one titanium implant was placed in each tibia. All animals received ASU or saline solution by gavage daily until sacrifice 60 days postoperatively. Implant osseointegration and bone maturation were assessed by biomechanical and radiographic bone density analysis; descriptive histology; immunohistochemistry for bone morphogenetic protein 2 (BMP-2), transforming growth factor beta 1 (TGF-β1), and osteocalcin; and histomorphometric evaluation of bone-to-implant contact (BIC) and mineralized bone area fraction within the threads of the implant. Results: ASU1 and ASU2 showed three times higher expression of BMP-2 and nine times higher expression of TGF-β1 compared with CTL (P < .05). Histomorphometric analysis, however, showed that both ASU1 and ASU2 groups presented significantly higher BIC values only in the cortical bone compartment when compared to CTL (P < .05). Conclusion: ASU consumption seems to exert only a subtle effect on implant osseointegration.
Objective: To evaluate the effects of avocado soybean unsaponifiables (ASU) on proinflammatory mediators in chondrocytes and monocyte/ macrophage-like cells. Design: To determine the dose response of ASU, chondrocytes (5 x 10(5) cells/well) were incubated at 5% CO2, 37 degrees C for 72 h with (1) control media alone or (2) ASU at concentrations of 0.3, 0.9, 2.7, 8.3, and 25 mu g/ml. Cells were activated with 20 ng/ml lipopolysaccharide (LPS) for 24 h and cell supernatants were analyzed for prostaglandin E-2 (PGE(2)) and nitrite content. Chondrocytes and THP-1 monocyte/macrophages (5 x 105 cells/well) were incubated at 5% CO2, 37 degrees C for 72 h with (1) control media alone or (2) ASU (25 mu g/ml). One set of cells was activated for I h with LPS (20 ng/ml) for both reverse-transcriptase PCR and real-time PCR analysis of tumor necrosis factor-alpha (TNF-alpha), interleukin-1 -beta (IL-1 beta), cyclooxygenase-2 (COX-2), and inducible nitric oxide synthase (NOS) expression. One set of cells was activated for 24 h to analyze secreted PGE2 and nitrite levels in the cellular supernatant. Results: ASU reduced TNF-alpha, IL-1 beta, COX-2, and NOS expression in LPS-activated chondrocytes to levels similar to nonactivated control levels. The suppression of COX-2 and NOS expression was paralleled by a significant reduction in PGE(2) and nitrite, respectively, in the cellular supernatant. ASU also reduced TNF-a and IL-1 expression in LPS-activated monocyte/macrophage-like cells. Conclusion: The present study demonstrates that the anti-inflammatory activity of ASU is not restricted to chondrocytes, but also affects monocyte/macrophage-like cells that serve as a prototype for macrophages in the synovial membrane. These observations provide a scientific rationale for the pain-reducing and anti-inflammatory effects of ASU observed in osteoarthritis patients. (c) 2007 OsteoArthritis Research Society International. Published by Elsevier Ltd. All rights reserved.
The authors used immunoenzyme method to assess level of oxydated low density lipoproteins (o-LDL) in 130 patients with osteoarthrosis. High serum level of o-LDL was seen in 60% of the patients with osteoarthrosis. 40 patients with osteoarthrosis were treated by unsaponifiable compounds of soya beans and avocado (Piaskledin, Expanscience, France)--dose of 300 mg daily, over 3 months. The treatment resulted in good effect in the patients with high level of o-LDL (over 168 ng/ml).
In this work, the authors have studied the effect of avocado/soy-bean extracts (Piascledine) on the collagenolytic activity of cultured rabbit articular chondrocytes and human rheumatoid synovial cells. Incubation of these cells for 48 h with 10 μg/ml of Piascledine show that this drug slightly increases collagenase production. As expected, incubation of these cells with interleukin-1 (100 pg/ml) induces an important release of collagenase. Piascledine partially reverses the effet of interleukin-1 on synovial cells and totally abolishes its action on chondrocytes. Moreover, incubation of the two cell types for 5 days with Piascledine prior to a 48 h-exposure to interleukin-1 prevents partially the effect of interleukin-1. These data suggest a potential role for Piascledine to limit the deleterious effects of interleukin-1 in osteoarticular diseases by reducing the capacity of this cytokine to stimulate collagenase production by synoviocytes and chondrocytes.
Americans continue to spend millions of dollars annually on glucosamine and chondroitin for symptoms of osteoarthritis. These agents are classified as dietary supplements, not as drugs, per se. Therefore, they do not meet the requirements of the FDA to be classified as drugs. This study was designed to determine if glucosamine and chondroitin are effective for osteoarthritis pain. This report was adapted from an online publication by the National Center for Complimentary and Alternative Medicine of the National Institutes of Health to inform the general public about the GAIT trial and its findings. Participants taking the positive control, celecoxib, experienced statistically significant pain relief versus placebo, about 70% of those taking celecoxib had a 20% or greater reduction in pain versus about 60% for placebo. Overall, there were no significant differences between the other treatments tested and placebo. For a subset of participants with moderate-to-severe pain, glucosamine combined with chondroitin sulfate provided statistically significant pain relief compared with placebo, about 79% had a 20% or greater reduction in pain versus about 54% for placebo. According to the researchers, because of the small size of this subgroup these findings should be considered preliminary and need to be confirmed in further studies. For participants in the mild pain subset, glucosamine and chondroitin sulfate together or alone did not provide statistically significant pain relief.