Efficacy and tolerability of an undenatured type II collagen supplement in modulating knee osteoarthritis symptoms: A multicenter randomized, double-blind, placebo-controlled study

Abstract

Background
Undenatured type II collagen (UC-II) is a nutritional supplement derived from chicken sternum cartilage. The purpose of this study was to evaluate the efficacy and tolerability of UC-II for knee osteoarthritis (OA) pain and associated symptoms compared to placebo and to glucosamine hydrochloride plus chondroitin sulfate (GC). Methods
One hundred ninety one volunteers were randomized into three groups receiving a daily dose of UC-II (40 mg), GC (1500 mg G & 1200 mg C), or placebo for a 180-day period. The primary endpoint was the change in total Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) from baseline through day 180 for the UC-II group versus placebo and GC. Secondary endpoints included the Lequesne Functional Index (LFI), the Visual Analog Scale (VAS) for pain and the WOMAC subscales. Modified intent-to-treat analysis were performed for all endpoints using analysis of covariance and mixed model repeated measures, while incremental area under the curve was calculated by the intent-to-treat method. ResultsAt day 180, the UC-II group demonstrated a significant reduction in overall WOMAC score compared to placebo (p = 0.002) and GC (p = 0.04). Supplementation with UC-II also resulted in significant changes for all three WOMAC subscales: pain (p = 0.0003 vs. placebo; p = 0.016 vs. GC); stiffness (p = 0.004 vs. placebo; p = 0.044 vs. GC); physical function (p = 0.007 vs. placebo). Safety outcomes did not differ among the groups. ConclusionUC-II improved knee joint symptoms in knee OA subjects and was well-tolerated. Additional studies that elucidate the mechanism for this supplement’s actions are warranted. Trial registrationCTRI/2013/05/003663; CTRI/2013/02/003348.

Full text

R E S E A R C H Open Access
Efficacy and tolerability of an undenatured
type II collagen supplement in modulating
knee osteoarthritis symptoms: a
multicenter randomized, double-blind,
placebo-controlled study
James P. Lugo
1
, Zainulabedin M. Saiyed
1
and Nancy E. Lane
2*
Abstract
Background: Undenatured type II collagen (UC-II) is a nutritional supplement derived from chicken sternum
cartilage. The purpose of this study was to evaluate the efficacy and tolerability of UC-II for knee osteoarthritis
(OA) pain and associated symptoms compared to placebo and to glucosamine hydrochloride plus chondroitin
sulfate (GC).
Methods: One hundred ninety one volunteers were randomized into three groups receiving a daily dose of
UC-II (40 mg), GC (1500 mg G & 1200 mg C), or placebo for a 180-day period. The primary endpoint was the
change in total Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) from baseline through
day 180 for the UC-II group versus placebo and GC. Secondary endpoints included the Lequesne Functional
Index (LFI), the Visual Analog Scale (VAS) for pain and the WOMAC subscales. Modified intent-to-treat analysis
were performed for all endpoints using analysis of covariance and mixed model repeated measures, while
incremental area under the curve was calculated by the intent-to-treat method.
Results: At day 180, the UC-II group demonstrated a significant reduction in overall WOMAC score
compared to placebo (p= 0.002) and GC (p= 0.04). Supplementation with UC-II also resulted in significant
changes for all three WOMAC subscales: pain (p= 0.0003 vs. placebo; p= 0.016 vs. GC); stiffness (p= 0.004
vs. placebo; p=0.044vs.GC);physicalfunction(p= 0.007 vs. placebo). Safety outcomes did not differ
among the groups.
Conclusion: UC-II improved knee joint symptoms in knee OA subjects and was well-tolerated. Additional
studies that elucidate the mechanism for this supplement’s actions are warranted.
Trial registration: CTRI/2013/05/003663; CTRI/2013/02/003348.
Keywords: Knee function, Osteoarthritis, T regulatory cell, Undenatured type II collagen
* Correspondence: nelane@ucdavis.edu
2
Center for Musculoskeletal Health, University of California Davis Health
System, 4625 2nd Avenue, Suite 2006, Sacramento, CA 95817, USA
Full list of author information is available at the end of the article
© 2016 Lugo et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Lugo et al. Nutrition Journal (2016) 15:14
DOI 10.1186/s12937-016-0130-8
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Introduction
Osteoarthritis, which entails the destruction of joint car-
tilage and remodeling of the adjacent bone, is the most
common form of arthritis affecting more than 25 million
Americans [1]. Current therapies for OA include various
over the counter analgesics, a number of nonsteroidal
anti-inflammatory drugs (NSAIDs), intra-articular injec-
tions of corticosteroids or hyaluronic acid, plus tramadol
and other opioid analgesics to relieve severe pain [2, 3].
While these therapies can alleviate symptoms in the near
term, their ultimate impact on the pathophysiologic pro-
gression of OA is limited [4].
Previous studies reported UC-II to be efficacious for
the treatment of arthritis [5, 6]. More recently, a statisti-
cally significant improvement in knee joint function over
placebo was also reported in a clinical study comprising
a group of healthy individuals, supplemented with
UC-II, and who developed transient knee joint pain
upon strenuous exercise [7]. These same individuals
also took longer to experience pain after 120 days of
supplementation. Based on these observations, the
current study was designed to evaluate the efficacy of
UC-II in knee OA subjects compared to placebo and
to GC, which is a widely available supplement that is
used for reducing joint pain.
Materials and methods
Investigational products
The study product UC-II® (Lot 1204004) was derived
from chicken sternum. It was manufactured under
current good manufacturing practice (cGMP) conditions
using a patented process that preserved its native struc-
ture (Chick Cart Inc., Fort Smith, AR). Both glucosamine
hydrochloride (GH) and chondroitin sulfate (CS) were
purchased through Wilke Resources (Lenexa, KS). The
Wellable group (Shishi City, Fujian) manufactured GH
under cGMP and according to United States Pharmacopeia
26 specifications. Sioux Pharm (Sioux Center, IA)
manufactured bovine-derived CS under cGMP. UC-II
and GC were encapsulated in opaque, size “00”cap-
sules with sufficient amounts of excipients (microcrys-
talline cellulose and silicon dioxide) such that they
were sensory identical to placebo. InterHealth Nutra-
ceuticals provided all study materials. All American
Pharmaceutical (Billings, MT) verified the amount of
active ingredients in the study capsules. Study mate-
rials were kept in a secure cabinet with access
restricted to the site coordinator, the dispensing
pharmacist, and the principal investigator.
Study design
The objective of this randomized, double-blind, placebo-
controlled clinical study was to evaluate the ability of
UC-II to improve knee symptoms in OA subjects, as
measured by overall WOMAC score, compared to pla-
cebo and to GC. The trial was conducted at 13 centers
in southern India. Because of a limitation in synovial
fluid sampling procedures at multiple clinical sites, the
study was conducted under two separate study proto-
cols. Study protocols were approved by each center’s
Institutional Ethics Committee (IEC), and listed on the
clinical trial registry of India as study protocols 003663
and 003348. Enrollment, randomization, and follow-up
visits were identical for both protocols, and were carried
out at days 1 (baseline), 7, 30, 60, 90, 120, 150 and 180
(Table 1). All investigators attended the same investiga-
tor meetings, used identical intake and data reporting
forms, and were trained and monitored by the same
group of clinical research associates.
Efficacy measurements were assessed at all visits and
included WOMAC, VAS, and LFI indices. The knee
flexion range of motion (ROM) test was performed at
each visit. Subject diaries and study product were pro-
vided at all visits, except day 180 and were collected at
all follow-up visits. Subjects were instructed to record
daily the consumption of study product, use of rescue
medication, as well as concomitant medications in the
subject dairy for the entire duration of the study. Blood
and urine were collected at screening and day 180.
Pregnancy testing was done at screening and follow-up
visits. Adverse events (AEs) were recorded using each
subject’s diary inputs plus site visit questionnaires ad-
ministered by intake personnel at all study visits.
Clinical endpoints
The primary endpoint was defined as the change in total
WOMAC score from baseline through day 180 for the
UC-II group versus placebo and GC. Secondary clinical
endpoints for both protocols were similar and included
the change from baseline through day 180 versus pla-
cebo and GC for all endpoints including the following
scores: (1) mean VAS; (2) mean WOMAC subscales; (3)
LFI; and (4) knee flexion. Another endpoint included the
change from baseline to day 180 for the serum bio-
marker cartilage oligomeric matrix protein (COMP). In
protocol 003348, additional secondary endpoints in-
cluded the change in serum biomarker, C-reactive pro-
tein (CRP) plus synovial fluid biomarkers interleukin
(IL)-6, and matrix metalloproteinase (MMP)-3 from
baseline to day 180.
Study subjects
A total of 234 subjects were screened and 191 random-
ized (Fig. 1). Study inclusion criteria were 40–75 years-
old male and female subjects, a body-mass index (BMI)
of 18–30 kg/m
2
, moderate-to-severe OA by physical
examination (crepitus, bony enlargements, joint swelling,
etc.) in one or both knees, knee pain for at least
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3 months prior to the start of the study, an LFI score be-
tween 6 and 10 and a VAS score of 40–70 mm 7 days
after withdrawal from excluded medications, plus a knee
radiograph that was graded as Kellgren and Lawrence
(K-L) radiograph score of either 2 or 3 [8]. All OA diag-
noses were confirmed by each study site investigator and
noted in the subject’s case report form (CRF). In the case
of bilateral knee involvement, the index knee used for
the study was the one that presented with the most se-
vere OA symptoms at baseline. Detailed inclusion–ex-
clusion criteria are summarized in Table 2.
Ethics, consent and permissions
Subjects were recruited after they reviewed, understood
the study details, and then signed the IEC-approved
consent form. The study conformed to the Declaration
of Helsinki (version 1996).
Randomization & blinding
Block randomization, consisting of nine individuals
per block, was executed in a 1:1:1 ratio using random
numbers generated by an independent statistician
(SPSS version 16.0). Knowledge of the randomization
code was limited to the statistician plus one QA
monitor unrelated with the study. Each investigator
was given opaque, sealed envelopes denoting single
patient identity numbers, randomization codes, and
supplementation regimen to be opened in case of an
emergency. The code was broken after the clinical
database was locked.
Table 1 Protocol Schedule and Activities
Procedures common to both protocols Screening
(Visit 1)
Study period
Day 1 (Baseline
Visit 2)
Days 7, 30, 60, 90, 120, 150
(Visits 3, 4, 5, 6, 7, 8)
Day 180
(Visit 9)
Signed Informed Consent X
Inclusion/Exclusion Reviewed X X X
Medical/Surgical/Medication History X
Physical Examination X
Vital Signs X X X X
Height
a
, Weight, BMI X X
Clinical Assessment for Knee Pain & Swelling X X X X
Knee Flexion Range of Motion X X X
X-ray examination X
WOMAC Score X X X X
VAS Scale X X X X
LFI Score X X X X
Clinical Laboratory Tests (hematology, chemistry, urinalysis) X X
Urine Pregnancy Test (if applicable) X X X
Serum biomarker analysis-COMP X X
Randomization Number Assigned X
Investigational Product Administration X
Dispense Subject Diary X X
Collect/Review Subject Diary XX
Provide Directions for Concomitant Medication and
Rescue Medication Use
XX X
Dispense New Investigational Product X X
Review Product Accountability XX
Assess use of Concomitant Medications X X X
Adverse Events Assessed X X X
Procedures Confined to Protocol 003348
Synovial fluid biomarker—MMP-3 and IL-6 X X
Serum biomarker analysis—CRP X X
a
Height was measured only at Visit 1
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Dosing regimen
Subjects ingested two blue pills in the morning with
breakfast and two white capsules before bedtime. For
the UC-II cohort, the two morning capsules were pla-
cebo, while the evening capsules contained 20 mg each
of UC-II totaling 40 mg, which is identical to previously
used clinical dose levels [5, 7]. This dose delivered
1.2 mg of undenatured type II collagen as determined by a
newly developed and validated extraction-ELISA protocol
(AIBiotech, Richmond, VA & Chondrex, Redmond, WA).
For the GC group, the morning and evening doses
delivered 750 mg of GH plus 600 mg of CS each to-
taling a daily dose of 1,500 mg of GH plus 1,200 mg
of CS. The placebo group ingested identical numbers
of blue and white capsules containing excipients only.
Study bottles were labeled according to ICH-GCP and
applicable local regulatory guidelines.
Prior and concomitant therapies
Prior medications were documented at the screening
visit by the study investigator. At each visit, study
personnel reviewed subject diaries and questioned each
participant on the use of any concomitant medications
including those on the prohibited list. Prohibited medi-
cations included ibuprofen, aspirin, other NSAIDS, or
any other pain relievers (OTC or prescription), plus any
dietary supplements (excluding vitamins) that could sup-
port joint health. All concomitant medications used dur-
ing the study was documented in the subject’s medical
record by the study investigator then transcribed into
their CRF by study personnel.
Rescue medications
Acetaminophen was allowed at a dose of 500 mg
twice daily. Participants were instructed to not take
this medication within 48 h of an evaluation visit.
Usage levels and timing was entered at each visit into
the subject’s medical record by the study investigator.
Study personnel transcribed this information into the
subject’sCRF.
Compliance and safety
Subjects were instructed to bring their bottles to each
visit. Remaining capsules were counted and recorded in
the subject’s CRF and accountability log. As a secondary
measure of compliance, subjects completed a diary
indicating daily dosing of the study products. Safety as-
sessments were performed at all visits by the site investi-
gator and staff (see Table 9).
Study evaluations
WOMAC scores were determined using the WOMAC
VA3.1 questionnaire containing 24 items grouped into
three categories: pain, stiffness, and physical function
(score range 0–2400). Each respective WOMAC sub-
scale mean scores was determined by dividing the sub-
scale score by the number of questions (5, pain; 2,
stiffness; 17, physical function) it contained. The mean
VAS score was determined using a VAS questionnaire
containing 7 pain-related questions (score range 0–700),
and then dividing the overall score by seven. LFI score
was determined using an LFI questionnaire that assessed
pain, walking distance, and activities of daily living,
Fig. 1 Enrollment and randomization flow chart
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(score range 0–24). Knee flexion was measured using
goniometry with the subject lying in the prone position
and the leg to be tested positioned along the edge of the
table [9].
Synovial fluid biomarkers
Synovial fluid (~0.5 mL) was aspirated from the knee
joint using an appropriate sized needle (18–24 gauge,
depending on joint size). Harvested fluid was stored
frozen until tested. IL-6 and MMP-3 levels were deter-
mined using the corresponding Duoset ELISA kits (R&D
Systems, Minneapolis, MN).
Serum biomarkers
COMP levels (Quantikine ELISA, R&D Systems) were
determined in both study protocols. CRP levels (Latex
COBAS INTEGRA, Roche Diagnostics GmbH, Mannheim)
were assessed in protocol 003348. Serum was stored frozen
until analyzed. Interassay and intrassay coefficients of vari-
ation for COMP and CRP were <5 %.
Statistics
We verified, using 2-way analysis of variance (ANOVA),
that the results of the two protocols could be combined
into a single analysis by demonstrating there was no
group by study interaction and that the magnitude of
the efficacy observed under the two protocols was
similar.
A modified intent-to-treat (mITT) analysis was used
to assess the efficacy and safety outcomes that was
defined apriori. This included all subjects who were
randomized, consumed study product, and had at
least one completed post-baseline visit. An analysis of
covariance (ANCOVA), that included supplementation
as a fixed factor and the corresponding baseline value
of the variable being tested as a covariate, was used
for assessing the overall statistical significance of the
primary and secondary endpoints. Following
ANCOVA, the Tukey-Kramer multiple comparison
test was used for determining pairwise statistical sig-
nificance and calculating 95 % confidence intervals.
Also, a mixed model repeated measures (MMRM)
analysis of the primary endpoint was performed to ac-
count for the multiple assessments obtained during
this study. In addition, the method of trapezoids was
used to calculate incremental area under the curve (iAUC)
for all study groups. For iAUC estimation, missing values
were imputed using the expectation-maximization algo-
rithm in SAS. Rescue medication usage between groups
was compared using logistic regression followed by pair-
wise comparisons using the Tukey-Kramer test. In
addition, a stratified analysis of the primary endpoint was
performed according to baseline serum COMP levels
above and below the median value for this biomarker.
Table 2 Inclusion-exclusion criteria
Inclusion
•Ambulatory, 40–75 years of age, with a BMI of 18 to 30 kg/m
2
•Females of childbearing age must agree to use a medically approved
form of birth control and have a negative urine pregnancy test result
throughout the study
•Female subjects of limited to no childbearing potential must be
amenorrheic for at least 1 year or have had a hysterectomy, a
bilateral oophorectomy, or both
•Unilateral or bilateral OA of the knee for greater than 3 months plus a
Kellgren and Lawrence radiographic grade of 2 or 3
•VAS score during knee movement between 40–70 mm after 7 day
withdrawal of excluded medications
•LFI score between 6–10 points after 7 day withdrawal of excluded
medications
•Clinical laboratory results that are within normal range or considered
not clinically significant by the Principal Investigator
•Be willing to participate in all scheduled visits, tests, and other trial
procedures according to the clinical protocol
•Be willing to refrain from taking ibuprofen, aspirin or other NSAIDS, or
any other pain reliever (OTC or prescription) during the entire trial
other than acetaminophen (paracetamol) as rescue medication
•Provide a signed and dated informed consent indicating that the
subject has been informed of all pertinent aspects and possible risks
associated with participation in the trial
Exclusion
•History of hypersensitivity to the rescue medication or any of the
products used in the study
•History of hypersensitivity to eggs, chicken or fowl, or shellfish
•History of inflammatory arthropathy, severe RA, OA (VAS score greater
than 70), or Systemic Lupus Erythematosus
•Hyperuricemia (>440 μmol/L), past history of gout, or both
•Anticipation of surgery within the next 4 months
•Recent injury in the target knee (past 4 months)
•History of use for corticosteroid, indomethacin, glucosamine &
chondroitin within 3 months of Visit 2; intra-articular treatments,
including injections of corticosteroid or hyaluronic acid; consumption
of Omega 3 fatty acids dietary supplements within 6 months preceding
the treatment period (a 2-week washout period is allowed for subjects
taking omega 3 fatty acid supplements)
•History of congestive heart failure
•Anticipated problems with product consumption
•Evidence or history of clinically significant hematological, renal,
endocrine, pulmonary, gastrointestinal, cardiovascular, hepatic,
neurologic diseases, or malignancies within the last 5 years
•High alcohol intake (>2 standard drinks per day) or use of recreational
drugs (e.g., cocaine, methamphetamine, marijuana, etc.)
•Females who are pregnant or lactating or planning to become
pregnant
•History of any mental illness that might impair the ability of subjects
to provide a written informed consent
•Consumed acetaminophen (paracetamol), ibuprofen, aspirin or other
NSAIDS, or any other pain reliever (OTC or prescription), or any natural
health product, (excluding vitamins) within 7 days of first visit
•Participation in any clinical trials within 30 days prior to first visit
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Differences were considered significant if the resultant p-
value was ≤0.05. An independent statistician performed
the analyses and other calculations using SAS version 9.3
(Cary, NC).
Results
Demographics and baseline characteristics
Two hundred and thirty-four subjects were screened and
191 subjects who met the eligibility criteria were random-
ized to placebo (n=62), GC (n= 66), or UC-II (n=63)
(Fig. 1). Per mITT criteria, 5 subjects were excluded from
all analyses because they failed to present at any post-
randomization visits resulting in an absence of clinical
data. Table 3 summarizes the demographics of the
remaining 186 subjects that were eligible for efficacy and
safety analyses. Baseline subject characteristics, OA sever-
ity, serum CRP, COMP, IL-6 and other characteristics
were similar among the three groups.
Subject dropouts
One hundred and sixty four subjects completed the
study: 53, placebo; 57, GC; and 54, UC-II. The 27 drop-
outs, which included the five subjects mentioned previ-
ously, were allocated across the three cohorts as follows:
9, placebo; 9, GC; and 9, UC-II. The final dropout rate
was 14 %. Subjects’dropout reasons are summarized in
Fig. 1. No subject withdrew from the trial due to an ad-
verse event attributable to any study product.
Study product compliance
Compliance with daily dosing of study capsules exceeded
90 % for all cohorts (data not shown).
Total WOMAC score
The UC-II supplemented group had statistically signifi-
cant changes in the total WOMAC score compared to
placebo (−551 vs. −414; 95 % CI −232 to −42; p= 0.002)
and GC (−551 vs. −454; 95 % CI −190 to −3; p= 0.04) at
day180(Fig.2a,Table4).WhenthetotalWOMAC
results were analyzed, using MMRM, to account for
treatment by time interactions, there remained a sta-
tistically significant difference between the UC-II and
the placebo groups (−514 vs. −397; 95 % CI −210 to −24;
p= 0.0097; Table 4). An iAUC analysis also yielded
statistically significant differences between the UC-II
group versus placebo (−2042 vs. -1479; 95 % CI
−1012 to −113; p= 0.0098; Table 4). No significant
changes were observed between the GC and placebo
Table 3 Demographic and baseline characteristics of the trial subjects
Characteristics Placebo (n= 58) GC (n= 65) UC-II (n= 63)
Sex ((n) male + (n) female) 28M + 30F 28M + 37F 33M + 30F
Age (years) 53.1 ± 1.02 52.6 ± 1.02 53.5 ± 0.99
Height (cm) 162 ± 1.00 161 ± 1.12 161 ± 0.89
Body weight (kg) 64.5 ± 1.20 66.0 ± 1.13 65.5 ± 1.12
Body mass index (kg/m
2
) 24.7 ± 0.40 25.5 ± 0.40 25.2 ± 0.37
Kellgren Lawrence radiographic score
Grade 2 (n) 39 45 42
Grade 3 (n) 19 20 21
Lequesne's Functional Index 7.74 ± 0.12 8.02 ± 0.12 7.90 ± 0.13
Visual analog score (mm) 58.2 ± 0.97 59.1 ± 0.97 58.4 ± 0.99
Total WOMAC score 1382 ± 34.8 1396 ± 31.8 1398 ± 27.9
Mean WOMAC pain 56.9 ± 1.36 57.5 ± 1.33 58.1 ± 1.03
Mean WOMAC physical function 57.9 ± 1.51 58.5 ± 1.37 58.3 ± 1.24
Mean WOMAC stiffness 56.3 ± 1.63 57.3 ± 1.52 58.1 ± 1.32
Knee flexion ROM (°) 114 ± 1.62 114 ± 1.36 114 ± 1.57
Serum CRP (mg/L)
a
5.29 ± 1.47 8.15 ± 1.79 3.35 ± 0.58
Serum COMP (ng/mL)
b
325.2 ± 30.5 381.2 ± 44.1 334.6 ± 36.5
Synovial IL-6 (ng/mL)
c
13.3 ± 4.73 13.9 ± 5.57 15.3 ± 6.04
Synovial MMP-3 (μg/mL)
d
4.03 ± 1.20 2.54 ± 0.78 4.86 ± 1.74
Values presented as Mean ± SE
a
Number of subjects used for analyses: 27, placebo; 29, GC; 29, UC-II
b
Number of subjects used for analyses, 54, placebo; 58, GC; 55, UC-II
c
Number of subjects used for analyses, 23, placebo; 24, GC; 21, UC-II
d
Number of subjects used for analyses, 25, placebo; 27, GC; 23, UC-II
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cohorts regardless of the type of analytical model
used.
Total WOMAC score based on baseline COMP levels
We found that subjects supplemented with UC-II, and
presented with baseline COMP levels ≥285 ng/mL
(median), had a greater reduction in the total WOMAC
score than both placebo and GC groups with similar
COMP levels under all modeling conditions (Table 5).
For study participants with baseline COMP levels
<285 ng/mL, no significant differences between the study
groups were noted. Interestingly, we did observe a smaller
placebo effect among individuals with baseline COMP
levels ≥285 ng/mL as compared to those with <285 ng/mL
(28 % vs 32 %). Despite this, UC-II efficacy, as defined by a
reduction in overall WOMAC score, was higher in subjects
with COMP levels ≥285 ng/mL versus subjects with COMP
levels < 285 ng/mL (43 % vs 36 %).
WOMAC mean subscores—pain, stiffness and physical
function
At day 180, we observed significant reductions in all
three WOMAC subscales for UC-II group compared
to placebo (Table 6): pain (24.0 vs. 17.0; 95 % CI
−11.1 to −2.8; p= 0.0003), stiffness (23.8 vs. 17.8;
95 % CI −10.4 to −1.6; p= 0.004), and physical func-
tion (22.5 vs. 17.3; 95 % CI −9.3 to −1.3; p=0.007).
The UC-II cohort also had significant reductions in
WOMAC pain (24.0 vs. 19.2; 95 % CI −8.9 to −0.7;
p= 0.016) and stiffness (23.8 vs. 19.4; 95 % CI −8.7
to −0.1; p= 0.044) at day 180 compared to GC.
Mean VAS score
The UC-II supplemented group had a significant
decrease in mean VAS score at day 180 (Fig. 2b)
versus both placebo (22.6 vs. 17.0; 95 % CI −9.5 to −1.8;
p= 0.002) and GC (22.6 vs. 18.4; 95 % CI −8.0 to −0.4;
p= 0.025). In contrast, the GC group was not signifi-
cant compared to placebo at any time.
LFI score
A significant reduction was observed in the LFI score for
the UC-II group at day 180 versus placebo (2.9 vs. 2.1;
95 % CI −1.4 to −0.2; p= 0.009; Fig. 2c). UC-II supplemen-
tation also has a greater improvement in LFI score versus
GC (2.9 vs. 2.2; 95 % CI −1.4 to −0.2; p= 0.008). No sig-
nificant change was observed between the GC and pla-
cebo cohorts. Improvement in the total LFI score for the
UC-II group was attributed to a significant reduction in
the LFI subscale for daily activities at day 180 (p=0.004
vs. placebo; p= 0.013 vs. GC, data not shown).
Knee flexion
No significant differences were observed between the
study groups (data not shown).
Serum biomarkers
A significant increase in the final CRP levels versus base-
line occurred in all three cohorts (p= 0.001). However, no
statistical difference between the three cohorts (Table 7;
p> 0.05) was noted. The scientific reason behind this in-
crease is not well understood. A significant decrease in
serum COMP levels was seen in all groups versus baseline
(p= 0.04) with no significant changes between groups.
Synovial fluid biomarkers
Similar non-significant decreases in IL-6 and MMP-3
levels were noted for all cohorts (Table 7).
Rescue medication usage
The number of subjects that used rescue medication was
significantly lower in the UC-II group compared to
Fig. 2 Total WOMAC score (a), Mean VAS (b), Total LFI (c) in the UC-II, GC and placebo groups over the 180-day study period. Values are
presented as mean ± SE. *Significant difference between the UC-II (n= 54) and the placebo (n= 53) group, p< 0.05. †Significant difference
between the UC-II (n= 54) and the GC group (n= 57), p< 0.05
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Table 4 Change in total WOMAC score from baseline
Analytical
method
Type of
analysis
Time point
(Days)
Placebo
(n= 53)
GC
(n= 57)
UC-II
(n= 54)
pvalue (95 % CI)
Overall
a
GC vs PBO UC-II vs PBO
b
UC-II vs GC
ANCOVA mITT 180 −414 ± 28.5 −454 ± 27.5 −551 ± 28.2 0.002 0.56 (−134 to 53) 0.002 (−232 to −42) 0.04
c
(−190 to −3)
MMRM mITT 180 −397 ± 28.6 −452 ± 27.6 −514 ± 28.3 0.014 0.33 (−148 to 37) 0.0097 (−210 to −24) 0.25 (−153 to 30)
(n= 58) (n= 65) (n= 63)
iAUC ITT 1 to 180 −1479 ± 137 −1751 ± 130 −2042 ± 132 0.014 0.33 (−718 to 174) 0.0098 (−1012 to −113) 0.26 (−727 to 146)
Values presented as Mean ± SE
Abbreviations:PBO placebo
a
Overall p value was obtained by comparing the mean changes among the three groups using ANCOVA
b
Significant difference between the UC-II and the placebo groups using Tukey-Kramer test
c
Significant difference between the UC-II and the GC groups using Tukey-Kramer test
Lugo et al. Nutrition Journal (2016) 15:14 Page 8 of 15
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Table 5 Stratified analysis for change in total WOMAC score based on baseline COMP levels
COMP
(ng/mL)
Analytical
method
Type of
analysis
Time point
(Days)
Placebo
(n= 27)
GC
(n=28)
UC-II
(n= 27)
pvalue (95 % CI)
Overall
a
GC vs PBO UC-II vs PBO UC-II vs GC
≥285 ANCOVA mITT 180 −368 ± 41.7 −396 ± 40.9 −574 ± 41.6 0.002 0.88 (−168 to 112) 0.002
b
(−347 to −65) 0.009
c
(−317 to −38)
MMRM mITT 180 −351 ± 44.1 −398 ± 41.1 −540 ± 44.2 0.006 0.71 (−188 to 94) 0.006
b
(−330 to −48) 0.048
c
(−282 to −1)
iAUC
d
ITT 1 to 180 −1351 ± 212 −1582 ± 204 −2384 ± 207 0.003 0.72 (−934 to 473) 0.002
b
(−1741 to −325) 0.02
c
(−1498 to −107)
(n= 26) (n=29) (n= 26)
<285 ANCOVA mITT 180 −463 ± 38.8 −508 ± 36.6 −526 ± 38.7 0.48 0.67 (−173 to 82) 0.49 (−195 to 68) 0.94 (−145 to 109)
MMRM mITT 180 −442 ± 38.2 −493 ± 37.3 −521 ± 38.1 0.34 0.60 (−178 to 76) 0.32 (−208 to 50) 0.86 (−155 to 100)
iAUC
e
ITT 1 to 180 −1626 ± 185 −1908 ± 178 −1902 ± 185 0.49 0.52 (−896 to 333) 0.55 (−902 to 350) 0.99 (−607 to 618)
Values presented as Mean ± SE
a
Overall p value was obtained by comparing the mean changes among the three groups using ANCOVA
b
Significant difference between the UC-II and the placebo groups using Tukey-Kramer test
c
Significant difference between the UC-II and the GC groups using Tukey-Kramer test
d
Number of subjects used for analyses, 27, placebo; 29, GC; 28, UC-II
e
Number of subjects used for analyses, 27, placebo; 29, GC; 27, UC-II
Lugo et al. Nutrition Journal (2016) 15:14 Page 9 of 15
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placebo (Table 8; p= 0.001). Sixty individuals used
rescue medications, at least once, during the study.
Twenty-eight of these users were from the placebo
group, 21 and 11 were from the GC and UC-II cohorts,
respectively.
Safety assessments
No clinical or statistically significant changes were
reported for any of the hematologic, blood biochem-
istry or vital signs results (Table 9). No significant
changes were noted for the urinalyses results (data
not shown).
A total of 45 AEs were reported during the 180-day
study period: 9, placebo; 28, GC; and 8, UC-II (Table 10).
The majority (62 %) of these occurred in the GC group.
Fifteen of 45 events were classified as possibly related to
supplementation, 14 of which belonged to the GC group
and 1 to placebo. The 14 possible events linked to GC
supplementation were primarily gastrointestinal in na-
ture. The eight AEs noted for the UC-II cohort were
deemed not related to supplementation. One individual
in the GC group was removed from the study due to a
respiratory tract infection (cough & fever). This infection
was classified as an SAE. The event was investigated by
Table 6 Reduction in mean WOMAC subscores in placebo, GC and UC-II groups over 180 days
Parameter reduction Day Placebo (n= 53) GC (n= 57) UC-II (n= 54) pvalue
Overall
a
GC vs PBO UC-II vs PBO
b
UC-II vs GC
c
WOMAC pain 7 3.21 ± 0.58 4.57 ± 0.54 3.88 ± 0.55 - - - -
30 6.61 ± 1.04 7.89 ± 1.00 9.18 ± 1.01 - - - -
60 8.17 ± 1.10 10.1 ± 1.07 12.7 ± 1.09 0.0149 - 0.011 -
90 11.2 ± 1.17 12.7 ± 1.14 16.4 ± 1.16 0.0063 - 0.0059 -
120 12.9 ± 1.28 15.6 ± 1.22 19.9 ± 1.26 0.0005 - 0.0004 0.040
150 15.0 ± 1.21 17.5 ± 1.16 21.5 ± 1.20 0.0007 - 0.0006 0.047
180 17.0 ± 1.25 19.2 ± 1.20 24.0 ± 1.23 0.0003 - 0.0003 0.016
WOMAC stiffness 7 3.47 ± 0.64 4.22 ± 0.61 4.24 ± 0.62 - - - -
30 6.81 ± 1.10 8.76 ± 1.05 9.28 ± 1.07 - - - -
60 9.36 ± 1.28 11.5 ± 1.25 13.1 ± 1.27 - - - -
90 11.3 ± 1.36 13.8 ± 1.32 17.0 ± 1.35 0.0158 - 0.010 -
120 13.6 ± 1.40 15.0 ± 1.34 20.0 ± 1.39 0.0035 - 0.0039 0.029
150 15.5 ± 1.32 17.7 ± 1.26 21.3 ± 1.31 0.0079 - 0.0058 -
180 17.8 ± 1.31 19.4 ± 1.27 23.8 ± 1.30 0.0043 - 0.004 0.044
WOMAC physical function 7 3.17 ± 0.56 4.14 ± 0.53 3.91 ± 0.53 - - - -
30 6.30 ± 1.00 7.80 ± 0.96 9.26 ± 0.98 - - - -
60 7.75 ± 1.08 9.50 ± 1.05 11.9 ± 1.07 0.0278 - 0.020 -
90 10.4 ± 1.17 12.1 ± 1.14 15.1 ± 1.16 0.0182 - 0.0136 -
120 12.7 ± 1.20 14.5 ± 1.15 17.9 ± 1.19 0.0083 - 0.0064 -
150 14.8 ± 1.19 16.9 ± 1.14 20.0 ± 1.18 0.0078 - 0.006 -
180 17.3 ± 1.21 18.8 ± 1.16 22.5 ± 1.20 0.0068 - 0.007 -
Values presented as Mean ± SE
a
Overall p value was obtained by comparing the mean changes among the three groups using ANCOVA
b
Significant difference between the UC-II and the placebo groups using Tukey-Kramer test
c
Significant difference between the UC-II and the GC groups using Tukey-Kramer test. ‘-’denotes a non-significant statistical outcome
Table 7 Change from baseline to day 180 in serum and synovial fluid biomarkers
Matrix Parameter reduction Day Placebo (n) GC (n) UC-II (n)
Serum COMP (ng/mL) 180 −51.2 ± 31.3 (53) −56.5 ± 36.0 (56) −69.6 ± 40.8 (53)
CRP (mg/L) 180 15.1 ± 6.33 (26) 9.09 ± 5.36 (28) 13.0 ± 4.64 (28)
Synovial IL-6 (ng/mL) 180 −9.54 ± 4.83 (23) −9.72 ± 5.28 (24) −11.8 ± 5.37 (21)
MMP-3 (μg/mL) 180 −2.24 ± 1.26 (25) −0.93 ± 0.79 (27) −2.67 ± 1.85 (23)
Values presented as Mean ±SE. Statistical analysis was performed on log transformed and baseline adjusted values. No significant differences were observed
between the study groups (p> 0.05)
Lugo et al. Nutrition Journal (2016) 15:14 Page 10 of 15
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the attending physician and center staff and judged as
not related to GC consumption.
Discussion
We assessed the ability of UC-II to improve joint symp-
toms in moderate-to-severe knee OA subjects. The re-
sults presented herein demonstrate that individuals
consuming UC-II presented with better clinical out-
comes versus those supplemented with placebo or GC.
Analysis of the WOMAC subscales showed that reduc-
tions in all three WOMAC subscales contributed to the
improvement in the overall WOMAC score observed in
subjects supplemented with UC-II. In contrast, GC sup-
plementation failed to induce a statistically significant
improvement in the WOMAC, VAS or LFI scores versus
placebo. These results confirm previous findings by
Crowley et al. [5], which reported greater reduction in
knee OA symptoms after 90 days of UC-II supplementa-
tion than what was observed with GC.
An interesting finding that emerged from this study is
that stratification, according to baseline COMP levels,
appears to have selected for individuals that responded
better to UC-II supplementation. A greater reduction in
knee OA symptom scores was observed among individ-
uals with baseline serum COMP levels ≥285 ng/mL and
supplemented with UC-II. This improvement was of suf-
ficient magnitude that statistically significant outcomes
for UC-II were observed versus both placebo and GC
supplementation under all the statistical analyses we
employed (ANCOVA, MMRM and iAUC). COMP, a car-
tilage turnover marker, is released into serum by chon-
drocytes and synovial cells [10–12]. Levels of this
biomarker have been shown in several studies to have
modest correlation with OA severity. However, serum
COMP levels in groups of OA subjects overlap with
levels observed in healthy populations, and this has lim-
ited the use of COMP as a prognostic marker for OA
progression [12–14]. While the biologic or clinical
significance to these findings remains to be understood,
we find this preliminary observation an interesting one
suitable for further investigation and confirmation.
The etiology behind UC-II’s impact on OA symptoms
is not known. However, undenatured type II collagen
has been shown to protect animals against the onset of
joint damage in both OA and RA experimentally in-
duced arthritis models [15–18]. This protection is hy-
pothesized to occur via the induction and migration of
T regulatory cell (Tregs) to the area of inflammation and
damage [19, 20]. The proposed role of Tregs may also
have relevance to the moderation of OA symptoms, as
in vitro studies have found that Tregs produce anti-
inflammatory cytokines that stimulate chondrocytes to
synthesize cartilage matrix components [21–23]. Add-
itional studies that elucidate the precise mechanism
through which UC-II mediates a reduction in knee OA
symptoms are required.
The in vivo effects mentioned above may only be initi-
ated by ingesting undenatured type II collagen as dena-
tured (e.g., hydrolyzed) type II collagen fails to protect
animals against the onset of arthritis [15]. This latter ob-
servation could explain why van Vijven and coworkers
[24] concluded that there was insufficient evidence to sup-
port collagen for the treatment of OA as they combined
data from all published clinical studies regardless whether
native or denatured collagen was used in the trial.
We failed to observe any changes in knee ROM and dis-
tance walked regardless of supplementation. Improve-
ments in these clinical outcomes are likely to be based not
just on a symptomatic reduction in pain but also on phys-
ical improvements in the knee joint’s overall functionality.
Until we undertake trials of longer duration, it remains an
open question as to whether a slow acting supplement like
UC-II can impact the biomechanical status of the OA
knee sufficiently to improve knee ROM.
In the current study, GC supplementation did not sig-
nificantly improve the signs and symptoms associated
with knee OA. The scientific literature supporting the
efficacy of GC is mixed, but there are various published
studies which suggest that GC may moderate OA symp-
toms [25–27]. The GAIT study found that GC, and each
component of GC individually, failed to impact OA
symptoms as measured by the WOMAC pain scale;
however, the placebo effect in that study was nearly
60 % which resulted in an underpowered study to deter-
mine differences between the treatments [28]. In con-
trast, a significant difference in knee pain was observed
in the GC subgroup with moderate-to-severe knee pain
compared to the placebo treated group [28]. To confirm
the observation that GC may be more efficacious in sub-
jects with moderate-to-severe knee OA pain, Hochberg
and coworkers [29] performed a study in which OA sub-
jects with moderate-to-severe knee pain, were randomized
Table 8 Number of subjects reporting use of rescue medication
Day Placebo GC UC-II
7 11/58 12/65 3/63
30 18/58 7/63 4/61
60 12/58 9/61 6/59
90 12/56 8/59 3/57
120 13/54 13/59 7/55
150 10/54 12/59 3/55
180 11/53 7/57 4/54
Entire study period 28/58 21/65 11/63
a
The table summarizes the number of unique individuals reporting the use of
rescue medication. Data presented as number of subjects using rescue
medication / total number of subjects observed.
a
statistically significant versus
the placebo (p= 0.001) based on pairwise Tukey-Kramer multiple comparison
test. The overall group effect p-value was 0.002 using logistic regression
Lugo et al. Nutrition Journal (2016) 15:14 Page 11 of 15
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Table 9 Safety parameter assessment at baseline and day 180 in placebo, GC and UC-II groups
Parameter (Units) Baseline Day 180
Normal
range
Placebo
(n= 58)
GC
(n= 65)
UC-II
(n= 63)
pvalue GC
vs PBO
pvalue UC-II
vs PBO
pvalue UC-II
vs GC
Placebo
(n= 53)
GC
(n= 56)
UC-II
(n= 53)
pvalue GC
vs PBO
pvalue UC-II
vs PBO
pvalue UC-II
vs GC
Hematology
Hemoglobin (gm/dL) 12.1–17.2 12.1 ± 0.22 11.9 ± 0.21 12.1 ± 0.20 0.7613 0.9948 0.8095 12.7 ± 0.24 12.4 ± 0.20 12.7 ± 0.18 0.4454 0.9727 0.5851
ESR (mm/h) 0–29 21.1 ± 1.77 23.9 ± 2.18 17.5 ± 1.56 0.7629 0.1034 0.0144 15.1 ± 1.24 17.0 ± 1.91 13.6 ± 1.28 0.9424 0.5364 0.3387
RBC (million/mm
3
) 4.7–6.1 4.29 ± 0.08 4.21 ± 0.08 4.33 ± 0.09 0.7747 0.9388 0.5498 4.32 ± 0.08 4.25 ± 0.08 4.37 ± 0.08 0.7935 0.8946 0.5129
WBC (/mm
3
) 4500-10,000 7979 ± 234 8248 ± 222 7795 ± 249 0.7020 0.8483 0.3523 7984 ± 204 7981 ± 209 7769 ± 204 1.0000 0.7706 0.7639
Platelet count
(x100000/mm
3
)
1.5-4.5 2.77 ± 0.08 2.84 ± 0.08 2.78 ± 0.08 0.7837 0.9946 0.8319 2.77 ± 0.07 2.84 ± 0.07 2.77 ± 0.09 0.8304 0.9993 0.8113
Liver Function
Albumin (gm/dL) 3.5–5.5 3.98 ± 0.06 4.02 ± 0.06 3.94 ± 0.06 0.8957 0.9089 0.6503 4.00 ± 0.05 4.03 ± 0.05 3.96 ± 0.04 0.8931 0.8902 0.6292
ALP (IU/L) 44–147 117 ± 5.74 118 ± 5.84 115 ± 5.57 0.9871 0.9838 0.9404 123 ± 5.72 116 ± 5.49 115 ± 5.59 0.5622 0.4847 0.9890
SGOT (U/L) 10–34 25.2 ± 0.93 24.0 ± 0.97 24.4 ± 0.60 0.5778 0.7796 0.9421 24.6 ± 0.73 23.9 ± 0.81 23.9 ± 0.65 0.7711 0.7930 0.9995
SGPT (U/L) 5–35 25.9 ± 1.23 25.0 ± 1.40 24.1 ± 0.95 0.5977 0.6004 1.0000 24.5 ± 0.94 24.3 ± 1.00 23.3 ± 0.99 0.9688 0.7119 0.8427
Total bilirubin (mg/dL) 0.3–1.9 0.78 ± 0.08 0.69 ± 0.03 0.72 ± 0.03 0.5376 0.9424 0.7343 0.72 ± 0.03 0.67 ± 0.03 0.78 ± 0.04 0.4243 0.6098 0.0718
Cardiac Function
Systolic BP (mm Hg) <120 125 ± 1.28 127 ± 1.35 127 ± 1.21 0.5980 0.7320 0.9752 127 ± 1.18 125 ± 1.33 128 ± 1.22 0.7263 0.8949 0.4409
Diastolic BP (mm Hg) < 80 81.2 ± 1.19 80.2 ± 0.83 81.7 ± 1.02 0.7544 0.9283 0.5094 80.2 ± 1.03 80.5 ± 1.07 78.9 ± 0.96 0.9877 0.6233 0.5180
Pulserate(beats/min) 60–100 80.0 ± 0.92 79.6 ± 0.98 80.3 ± 0.99 0.9149 0.9719 0.7956 80.0 ± 0.89 78.2 ± 0.82 79.2 ± 1.03 0.3201 0.8018 0.6989
Renal Function
Creatinine (mg/dL) 0.6–1.3 1.00 ± 0.03 1.01 ± 0.04 0.96 ± 0.03 0.9995 0.5767 0.5778 0.96 ± 0.03 0.95 ± 0.02 0.96 ± 0.02 0.9904 0.9846 0.9508
BUN (mg/dL) 6–24 18.1 ± 1.08 18.0 ± 1.11 18.0 ± 1.15 0.9929 0.9878 0.9992 18.6 ± 1.11 17.8 ± 1.09 17.9 ± 1.02 0.7602 0.7953 0.9985
Results are presented as Mean ± SE. Normal ranges were obtained from Medline
a
and the Mayo Clinic
b
. Data was analyzed using ANCOVA followed by Tukey’s multiple comparisons test (p> 0.05)
Abbreviations:
ESR erythrocyte sedimentation rate; RBC red blood cell; WBC white blood cell; ALP alkaline phosphatase; SGOT serum glutamic oxaloacetic transaminase; SGPT serum glutamic pyruvic transaminase; BP blood pressure;
BUN blood urea nitrogen
a
ADAM, Inc.: http://www.nlm.nih.gov/medlineplus/encyclopedia.html (accessed October 2015)
b
Mayo Foundation for Medical Education and Research: Mayo Clinic. www.mayoclinic.org (accessed October 2015)
Lugo et al. Nutrition Journal (2016) 15:14 Page 12 of 15
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to GC or celecoxib for a period of 6 months. The results
showed that GC treatment reduced WOMAC measured
knee pain by 50 %, comparable to the results obtained
with celecoxib [28]. It is worth noting that results such as
these are not consistent across a number of studies for
reasons yet to be determined [25–27].
In recent years, interest has focused on developing
various biomarkers for monitoring OA progression and
drug development [12, 30]. We therefore assessed sev-
eral biomarkers of inflammation (CRP, IL-6 and MMP-
3) plus cartilage breakdown (COMP) and found no
significant change for any of these biomarkers in this
clinical trial. Since OA appears to impact the biology of
several key components of the knee (e.g., synoviocytes,
chondrocytes, etc.), the ability to achieve a significant
change in any one biomarker could prove challenging
for a slow acting supplement like UC-II. Also, multiple
factors including ethnicity, physical activity, gender
differences, and diurnal variation influence these bio-
markers resulting in large variability in their levels
[31–35]. Therefore, any change in these markers would
have to occur as a result of a highly significant impact on
the underlying pathophysiology of OA, given that the cor-
relation between these biomarkers and OA pathophysi-
ology are weak [12]. Such effects might be expected to
occur more readily with a targeted agent [4, 36].
Conclusion
This study found that UC-II, a nutritional ingredient
containing undenatured type II collagen, significantly
improved knee function in OA subjects by day 180,
compared to placebo and to GC, and was well-tolerated.
Based on the data presented herein, we believe that add-
itional research is warranted both to confirm and to de-
fine these findings more extensively.
Abbreviations
AEs: adverse events; ANCOVA: analysis of covariance; ANOVA: analysis of
variance; cGMP: current good manufacturing practice; CI: confidence interval;
COMP: cartilage oligomeric matrix protein; CRF: case report form; CRP: C-reactive
protein; GC: glucosamine hydrochloride plus chondroitin sulfate;
iAUC: incremental area under the curve; IEC: Institutional Ethics Committee;
IL-6: interleukin-6; ITT: intent-to-treat; K-L: Kellgren and Lawrence; LFI: Lequesne
functional index; mITT: modified intent-to-treat; MMP-3: matrix metalloproteinase-
3; MMRM: mixed model repeated measures; NSAIDs: nonsteroidal anti-
inflammatory drugs; OA: osteoarthritis; PBO: placebo; ROM: range of motion;
Tregs: T regulatory cell; UC-II: undenatured type II collagen; VAS: visual analog
scale; WOMAC: Western Ontario McMaster Universities Osteoarthritis Index.
Table 10 Summary of analysis of adverse events in all subjects
Study group
Placebo
(n= 58)
GC
(n= 65)
UCII
(n= 63)
Severity
Mild 7 21 5
Moderate 2 7 3
Severe 0 0 0
Relationship to Test Article
Not related 8 14 8
Possible 1 13 0
Definite 0 1 0
Body System and AEs
Gastrointestinal
Acidity 2 3 2
Acute peptic disorder 1 0 1
Diarrhea 1 1 0
Epigastric burning 0 1 0
Febrile Enteritis 0 1 0
Heart burn 0 1 0
Vomiting 0 1 0
Nausea 0 1 0
Pain
Arthralgia 0 1 0
Body pain 0 1 0
Low back pain 1 1 0
Neck Pain 0 1 1
Headache 2 4 0
Myalgia 0 1 0
Dermatology
Itching 0 2 0
Xerotic skin 0 0 1
Pulmonary/Upper Respiratory
Lower respiratory tract
infection
00 2
Upper respiratory tract
infection
01 0
Cough 0 2 0
Genitourinary
Burning micturition 1 0 0
Burning sensation 0 0 1
Cardiovascular
Palpitation 0 2 0
Constitutional Symptoms
Fever 1 2 0
Insomnia 0 1 0
9288
Table 10 Summary of analysis of adverse events in all subjects
(Continued)
Total Number of Adverse
Events Experienced During
Study
Total Number of Subjects
Experiencing Adverse
Events: n (%)
7/58 (12 %) 20/65 (31 %) 8/63 (13 %)
Lugo et al. Nutrition Journal (2016) 15:14 Page 13 of 15
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Competing interests
JPL and ZMS are employees of InterHealth Nutraceuticals. NEL provided
consulting services to InterHealth. This study was sponsored by InterHealth
Nutraceuticals, Inc. Benicia, CA. The study was run and managed
independently by Laila Pharmaceuticals Pvt. Ltd., India. Data collection was
done by the clinical study staff at each respective site. Data analyses was
performed by an independent statistician.
Authors’contributions
JPL and ZMS contributed in the conception and design of the study, data
interpretation and manuscript preparation. NEL participated in data
interpretation, manuscript drafting and revisions. All authors read and
approved the final version of the manuscript.
Acknowledgements
We gratefully acknowledge the support of Janet M. Peerson, M.S., University
of California, Davis, for carrying out the statistical analyses shown herein and
for helpful discussions. We acknowledge the support of the Laila Pharma
Clinical team and the study investigators including Dr. Sundar Subramanian
from V. S. Hospital, Tamilnadu; Dr. Meenakshi Sundaram from Vinayaka
Mission Hospital, Tamilnadu; Dr. Balaji Thiruvadi and Dr. GM Bharat Kumar
from Gram Clinical Research Karpagam Hospital, Tamilnadu; Dr. Saji Thomas
from Little Flower Hospital and Research Center, Kerala; Dr. K. Balakondiah
from Bollineni Superspeciality Hospital, Andhra Pradesh; Dr. Siva Prasad from
Apollo Hospitals, Andhra Pradesh; Dr. K Rajapandian from Apollo Speciality
Hospitals, Tamilnadu; Dr. K. Vasu from Pujitha Hospital, Andhra Pradesh; Dr.
MAVV Prasad from Vijaya Super Speciality Hospitals, Andhra Pradesh; Dr. P.
Ashok Kumar from King George Hospital, Andhra Pradesh; Dr. P. Pavan
Kumar from R. K. Hospital, Andhra Pradesh; Dr. G Satish Reddy from Prime
Hospital, Andhra Pradesh. We thank Jonathan Hull, Ph.D. and Weiman Xu,
Ph.D. for assisting with data assembly and manuscript preparation.
Author details
1
InterHealth Nutraceuticals, Benicia, CA, USA.
2
Center for Musculoskeletal
Health, University of California Davis Health System, 4625 2nd Avenue, Suite
2006, Sacramento, CA 95817, USA.
Received: 7 November 2015 Accepted: 20 January 2016
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