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Multimodal Anti-Inflammatory Approach to Osteoarthritis Management - Review of T Cell Immunomodulation with Undenatured (Native) Collagen Type II, and LOX Inhibition with Boswellia

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Osteoarthritis, known to be a degenerative disease, is now seeing increasing evidence of also having an inflammatory pathophysiology involving multiple pathways. T cell mediated immune response to joint cartilage collagen is now one of the recognized pathways causing cartilage destruction. T helper cell activation, involvement of pro-inflammatory cytokines and increased destruction of cartilage by Matrix Metalloproteinase enzymes, along with a relative suppression of anti-inflammatory cytokines and T regulatory cells appear to be important inflammatory mechanisms perpetuating continuous cartilage loss. Conversion of Phospholipids released from tissue injury to arachidonate and thereafter to prostaglandins and leukotrienes by the Cyclo-oxygenase 2 (COX2) and Lipo-oxygenase 5 (5LOX) enzymes respectively, is also well known. While COX2 inhibition via Non-steroidal anti-inflammatory drugs is well established in Osteoarthritis, the role of Leukotrienes in increasing inflammatory activity and cartilage destruction requiring appropriate inhibition needs further emphasis. Therefore, controlling cartilage destruction in Osteoarthritis through addressing these multiple inflammatory pathways can be a rational therapeutic approach. This article aims to elaborate on the pharmacotherapeutic approaches involving modulating T cell immune response to cartilage and inhibiting the LOX pathways by Undenatured (Native) Collagen Type II and Boswellia extract respectively.
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Review Article
Volume 3 Issue 4 - February 2019
DOI: 10.19080/NTAB.2019.03.555618
Nov Tech Arthritis Bone Res
Copyright © All rights are reserved by Varsha Narayanan
Osteoarthritis Management - Review of T Cell
Immunomodulation with Undenatured (Native)
Rakesh Mahajan12 and Varsha Narayanan3*
1Director of Orthopaedics, Institute for Bone, Joint Replacement, Orthopaedics Spine & Sports Medicine, BLK Super speciality Hospital, New Delhi
2Consultant Orthopaedic Surgeon, Rathod Orthopaedic Hospital, Borivali, Mumbai
3Chief - Medical Affairs, Integrace Health (Bone Health and Pain Management), Mumbai
Submission: February 08, 2019; Published: February 25, 2019
 Varsha Narayanan, Integrace Health, Raheja Platinum, Marol, Mumbai 400059
Osteoarthritis (OA) has traditionally been a degenerative
disease caused by long term and repeated wear and tear of the
cartilage of weight bearing joints leading to loss of cartilage
followed by exposure and damage to underling bone surfaces
[1]. The joint hyaline cartilage is made up of Chondrocytes which
synthesize and maintain the main components of cartilage:
Type II Collagen and Extracellular Matrix (ECM) Proteoglycans
containing Glycosaminoglycans (GAGs) like Chondroitin sulphate
and Hyaluronic acid [2]. Chondrocytes also produce lubricating
         
and destruction of cartilage leads to decreased number of
chondrocytes and thereby also a decrease in synthesis of Collagen
type II and GAGs. Therefore, in Osteoarthritis, an overall imbalance
Inammatory Pathways in Osteoarthritis
tion in the joint as a result of T cell mediated immune response
plays an important role in ongoing cartilage destruction as well
as symptoms of pain, swelling and loss of mobility. Studies have
shown increased number of CD4 cells in the serum and synovial
   Response to autologous chondrocytes of
peripheral T cells isolated from OA patients is greater than that
of peripheral T cells isolated from controls, and this response is
partially blocked by antibodies against human leukocyte antigen
(HLA) classes I and II, CD4, and CD8 [5]. -
id of OA patients expressed class II HLA (an indicator of activated
T cells) and the percentages of CD4+ and CD8+ cells in the syno-
Nov Tech Arthritis Bone Res 3(4): NTAB.MS.ID.555618 (2019) 001
               
involving multiple pathways. T cell mediated immune response to joint cartilage collagen is now one of the recognized pathways causing
               
       
thereafter to prostaglandins and leukotrienes by the Cyclo-oxygenase 2 (COX2) and Lipo-oxygenase 5 (5LOX) enzymes respectively, is also well
             
to elaborate on the pharmacotherapeutic approaches involving modulating T cell immune response to cartilage and inhibiting the LOX pathways
by Undenatured (Native) Collagen Type II and Boswellia extract respectively.
Keywords: Osteoarthritis; Cartilage; Undenatured (Native) Collagen Type II; Boswellia; T Cell; COX; LOX; Leukotrienes; Matrix Metalloproteinase;
How to cite this article: Rakesh M, Niranjan R R, Varsha N. Multimodal Anti-Inammatory Approach to Osteoarthritis Management - Review of T Cell
Immunomodulation with Undenatured (Native) Collagen Type II and LOX Inhibition with Boswellia. Nov Tech Arthritis Bone Res. 2019; 3(4): 555618.
DOI: 10.19080/NTAB.2019.03.555618.
Novel Techniques in Arthritis and Bone Research
    
in RA patients [6]. Synovial aggregates from OA patients express
CD80, an inducible costimulatory ligand involved in T-cell activa-
tion suggesting that synovial aggregates in OA patients are areas
of antigen recognition and T-cell activation [7].
T cell mediated immune response is postulated to be as a re-
sult of glycosylation alterations in joint cartilage collagen, and this
  
like IL1, IL6, and TNF alpha, which activate matrix metalloprotein-
ase (MMP) and cause further destruction of cartilage [8-9]. Conse-
 -
        
induce T regulatory differentiation and suppress MMPs [10-11].
Cartilage destruction leads to release of phospholipids converted
to arachidonic acid by phospholipases which are then converted
by Cyclo-oxygenase (COX2) and Lipo-oxygenase (5LOX) to prosta-
of prostaglandins (PGE2) in causing pain, swelling and increase
in temperature are well studied and therefore NSAIDs (COX in-
hibitors) are the most recognized drugs in OA management [12].
However, the LOX pathway also plays an important role in the in-
them to Leukotrienes (LTs). Leukotrienes (like LTB4 and cysteinyl
      
LTB4 enhances the production of interleukin (IL)-1 and Tumour
necrosis factor (TNF)- which activate MMP mediated cartilage
destruction. LTs also activate Interstitial Cell Adhesion Molecules
(ICAMs) which act as potent chemotactic agents stimulating mi-
gration and activation of T cells and macrophages, leading to
phagocytic activity and release of Reactive Oxygen Species (ROS),
which further mediate cartilage destruction [14-16]. These prop-
erties of LTB4, similar to PG E2, also play a role in stimulating bone
resorption in OA [17]. Therefore, cartilage destruction and loss in
and this should be taken into consideration during therapeutic
Figure 1: Inammatory pathways for cartilage loss in OA.
MMP: Matrix Metalloproteinase, LT: Leukotrienes, ICAM: Interstitial Cell Adhesion Molecule, NSAIDs: Non-steroidal Anti-inammatory drug,
TNF: Tumor Necrosis Factor, IL: Interleukin
erapeutic Approaches in OA
Current non-surgical treatment options in OA consist of
     -
        
caused by PGE2. NSAIDs though effective, have long term limita-
co-use of proton pump inhibitors (PPIs) also associated with long
term safety concerns. NSAIDs also do not address the aetiology of
continued T cell immune mediated or LOX mediated cartilage de-
struction. Inhibiting only COX pathways with NSAIDs can increase
Leukotriene synthesis through diverting arachidonate through the
LOX5 pathway.18 Drugs like Corticosteroids act by Phospholipase
inhibition which may address both prostaglandin and leukotriene
synthesis however they are generalized immune-suppressants as
response against cartilage collagen II in OA [19-20].
Corticosteroids are also associated with systemic side effects
  
IL1[21]. Hydrolysed collagen supplements and SYSADOAs- Sys-
temic slow acting drugs in Osteoarthritis (GAGs and their pre-
cursors like Chondroitin sulphate, Glucosamine sulphate and Hy-
aluronic acid) act by providing building blocks for regenerating
cartilage. These agents do not present any patient tolerance or
side effect issues but rely on the body’s ability to assimilate these
supplements to regenerate lost cartilage [22]. This proves not only
to be a slow approach but also far less effective as these agents
do not act upon arresting the ongoing immune mediated and in-
How to cite this article: Rakesh M, Niranjan R R, Varsha N. Multimodal Anti-Inammatory Approach to Osteoarthritis Management - Review of T Cell
Immunomodulation with Undenatured (Native) Collagen Type II and LOX Inhibition with Boswellia. Nov Tech Arthritis Bone Res. 2019; 3(4): 555618.
DOI: 10.19080/NTAB.2019.03.555618.
Novel Techniques in Arthritis and Bone Research
 
to address both symptom relief as well as control ongoing carti-
lage destruction in a multiprong manner in OA patients so that the
body can then regenerate and rebuild cartilage more effectively.
Undenatured (Native) Collagen Type II
The joint cartilage is made up predominantly of type II colla-
gen synthesized by chondrocytes. Collagen is a complex protein
present only in animals and humans, with a triple helical struc-
ture. Our body cannot absorb intact collagen therefore collagen
supplements are made up of heat denatured and acid hydrolysed
collagen with the prospect of absorption by the body and further
assimilation into the triple helical collagen type II by the joint car-
tilage chondrocytes [24]. However, the absorption and assimila-
tion of hydrolysed collagen would be an uphill task against on-go-
Undenatured (Native) Collagen Type II -U(N)C II is non-hydro-
lysed collagen with intact structure, active epitopes and antigenic-
ity while hydrolysed collagen loses its native structure and anti-
genicity [25-26]. Undenatured type II collagen is extracted from
chicken sternum using little or no heat unlike the high heat used
in hydrolysed collagen, and very limited processing just enough
to concentrate the collagen and make it soluble [27]. The manu-
facturing process ensures that the collagen remains biologically
active in its most native, triple helix form with antigenic sites (epi-
topes) intact for immunomodulation. ELISA studies with simulat-
tenance of triple helical form of Undenatured Type II Collagen.
Therefore, the mechanism of action of Undenatured (Native)
Collagen Type II is not related to its absorption or assimilation as
it acts in the small intestine itself through a process called oral
matory damage of type II collagen in the joint cartilage [25]. Pay-
er’s patches (also called (GALT- Gut-associated lymphoid tissue)
are GI lymph nodes rich in T cells. Dendritic cells (DCs) in GALT
take up the Undenatured (Native) Collagen Type II in its glyco-
sylated form, and repeated low dose administration of the same
with its intact antigenic sites stimulates T regulatory cell and sup-
presses T helper cell stimulation [28].
Figure 2: Mechanism of Oral Tolerance of Undenatured Type II collagen.
U(N)C II: Undenatured (Native) Collagen Type II, DC: Dendritic Cell, Th: T helper, Tc: T cytotoxic (killer), T reg: T regulatory, OA: Osteoarthritis,
IL: Interleukin, TNF: Tumor Necrosis Factor, TGF: Transforming Growth Factor, MMP: Matrix Metalloproteinase.
T helper cells (Th) develop ‘tolerance’ thereby attenuating the
immune response against cartilage collagen. The immune balance
thereby shifts towards T regulatory cells (Treg) and increased
  -
presses the cartilage collagen degrading MMP enzymes [29].
Therefore, endogenous collagen synthesis can be more effective in
suppressed. Understanding the difference between undenatured
(native) and hydrolysed collagen supplements attains crucial im-
        
How to cite this article: Rakesh M, Niranjan R R, Varsha N. Multimodal Anti-Inammatory Approach to Osteoarthritis Management - Review of T Cell
Immunomodulation with Undenatured (Native) Collagen Type II and LOX Inhibition with Boswellia. Nov Tech Arthritis Bone Res. 2019; 3(4): 555618.
DOI: 10.19080/NTAB.2019.03.555618.
Novel Techniques in Arthritis and Bone Research
  
    -
sponse against cartilage collagen type II, while hydrolysed colla-
gen needs to be supplemented in large doses (often along with
GAGs and its precursors (like Chondroitin sulphate, Glucosamine
sulphate etc) as it intends to supply building blocks for chondro-
cytes to assimilate and rebuild cartilage [24].
The distinction lies clearly in Undenatured (Native) Collagen
Type II reducing cartilage destruction while hydrolysed collagen
intending to help regenerate cartilage. However, our body is al-
        
same is limited and falls short in view of senescence and increased
ongoing cartilage destruction.
      
 
Type II - U(N)C II (40mg) in Osteoarthritis has been demonstrat-
    
combination of Glucosamine and Chondroitin sulphate (G+C:
line at 90 days which was not observed in G+C treatment group
(N=26/group). Treatment with U(N)C II reduced the Western
Ontario and McMaster Universities Osteoarthritis Index (WOM-
 -
tional Index (LFI) score by 33%, 40%, 20% as compared to 14%,
15.4% and 6% in G+C treated group after 90 days suggesting a
    -
 A higher number of subjects (23%)
on G+C demonstrated adverse events possibly related to product
as compared to 11.4% of subjects on U(N)C II (P<0.05). For U(N)
C II the possible adverse events related to products were inter-
mittent constipation and headaches while for G+C it was bloating,
stomach pain, rash, swelling around the eyes and scars, hives and
In the second study 191 volunteers were randomized into
three groups receiving a daily dose of U(N)C II (40 mg), G+C (1500
mg G+1200 mg C), or placebo. At day 180, the U(N)C II group
       
compared to placebo and G+C: U(N)C II compared to placebo (
-551 vs. -414; 95 % CI -232 to -42; p = 0.002) and compared to
G+C ( -551 vs. -454; 95 % CI -190 to -3; p = 0.04). Supplementa-
stiffness WOMAC subscales versus G+C and placebo: pain (24 vs
19.2 vs 17 ; p = 0.016 vs. G+C; p = 0.0003 vs. placebo;); stiffness
(23.8 vs 19.4 vs 17.8; p=0.044 vs. G+C ; p = 0.004 vs. placebo); and
  
17.3; p = 0.007 vs. placebo).
  
in mean VAS score at day 180 versus both G+C and placebo (22.6
vs 18.4 vs 17.0; p = 0.025 vs G+C; p = 0.002vs placebo). A signif-
icant reduction was also observed in the LFI score for the U(N)
C II group at day 180 versus G+C and placebo (2.9 vs 2.2 vs 2.1;
            
was observed between the G+C and placebo for both VAS and LFI
scores. Safety outcomes did not differ among the groups. U(N)C
II improved knee joint symptoms in knee OA subjects and was
well-tolerated [31]. 15 product related adverse events were seen,
14 of which belonged to the GC group (gastro-intestinal) and 1 to
placebo while no AEs noted for the U(N)C II cohort were deemed
to be product related.
Another study in 39 patients was performed to evaluate the
effect of adding Undenatured (Native) Collagen Type II to Acet-
aminophen (Paracetamol) 1500mg/day [32]. After 3 months of
treatment, the patients of the combination group showed sig-
       
(p=0.003), WOMAC total (p=0.004), WOMAC physical function-
ing (p=0.016) scores and subscales of SF36 bodily pain score
   -
ceiving only Acetaminophen. Comparisons between the groups
       
of the combination group (50% reduction) as compared to the
Acetaminophen monotherapy group (p=0.002). A study done in
non-arthritic healthy volunteers who had knee pain on physical
tive) Collagen Type II versus placebo in increasing degree of knee
extension and time to pain onset on physical activity [29].
Boswellia serrata is a tree from India also called Indian frank-
incense, Salai or Indian Olibanum. Boswellic Acids (BAs) with the
characteristic pentacyclic triterpene ring, present in the gum resin
of B. serrata  
 
for leukotriene production, without affecting other LOX and COX
activities. 3-O-acetyl-11-keto--Boswellic acid (AKBA) possess-
es the most potent inhibitory activity on 5LOX [33].  
preparation that contains B. serrata extract selectively enriched
with AKBA and B. serrata non-volatile oil and has shown supe-
 -
ti-osteoarthritic agent, with better oral bioavailability compared
to B. serrata extracts (BEs) commercially available in the market
[34-35]. Inhibition of 5LOX and Leukotriene formation reduce the
    
leading to decreased cartilage destruction by MMPs, increased
       
and overall tilting the balance in favour of cartilage regeneration
over cartilage loss.
ious clinical studies (Table 1). A double-blind, randomized, study
in 75 OA patients with Boswellia (BE-30 containing 30% AKBA)
100mg, 250mg) and placebo once daily showed clinically sig-
        
How to cite this article: Rakesh M, Niranjan R R, Varsha N. Multimodal Anti-Inammatory Approach to Osteoarthritis Management - Review of T Cell
Immunomodulation with Undenatured (Native) Collagen Type II and LOX Inhibition with Boswellia. Nov Tech Arthritis Bone Res. 2019; 3(4): 555618.
DOI: 10.19080/NTAB.2019.03.555618.
Novel Techniques in Arthritis and Bone Research
placebo with both Boswellia dosage groups at 90 days, with the
250-mg dose showing improvements in pain score and functional
ability in 7 days after the start of treatment [36]. Both doses of BE-
showed a rise in placebo group.
Another double blind randomized study with Boswellia
     B. serrata extract selectively
enriched with 20% AKBA and B. 
in 60 patients with mild or moderate unilateral or bilateral OA of
ments with 37.6%, 32.0%, 40.1%, 41.3% and 38.8% reductions
in VAS, LFI, WOMAC pain, WOMAC stiffness and WOMAC function
scores respectively over the placebo group. Improvement with Al-
laboratory parameters were seen [37].
          -
placebo) in 60 subjects with OA. Both groups showed clinically
       
scores versus placebo [34]. In comparison to placebo, the im-
provements in in VAS, LFI, WOMAC pain, WOMAC stiffness and
        
of 47.3% (P<0.0001), 35.8% (P=0.0004), 61.7% (P<0.0001),
60.1% (P=0.0001) and 49.4% (P=0.0001) as compared to 31.6%
(P=0.006), 18.35% (P=0.060), 30.3% (P=0.009), 42.2% (p=0.006)
and 21.25% (P=0.078) respectively.
      
and functional ability as early as 7 days of treatment with better
  
group exhibited 8.09% (P=0.002), 8.68% (P=0.031) and 8.35%
(p=0.015) reductions in VAS, WOMAC pain and WOMAC func-
       
group exhibited 12.8% (P=0.0004), 9.17% (P=0.003), 11.78%
(P=0.012), 18.48% (P=0.012) and 10.24% (p=0.005) reductions
in VAS, LFI WOMAC pain, WOMAC stiffness and WOMAC function
  level by 65.04% and 38.83%
       -
 
inhibited MMP enzymes better than BE-30 by 41.36% [33].
Cartilage destruction in Osteoarthritis involves multiple
      
Prostaglandins, 5LOX action producing Leukotrienes and T cell
activation in response to altered Collagen II glycosylation in hyaline
      
like IL1, TNF alpha and ICAM, increases the action of MMP
enzymes which degrade cartilage, and leads to recruiting more
       
       
therapeutic approach seems rational with agents which can
 
act on the COX pathway, Undenatured (Native) Collagen Type II
response and activates T regulatory cells, which reduces cartilage
damage. Boswellia acts by inhibiting the LOX pathway and
       
Therefore, using these agents together can be an effective way of
reducing cartilage damage, and increasing cartilage regeneration.
Initiating treatment with combination therapies like U(N)C II
with BE for early symptomatic relief and rapid reduction in
   
tolerance with U(N)C II alone can also be a possible approach.
More studies with combination of these agents will add further
value to this therapeutic approach.
Figure 3: Change in WOMAC scores at 30 days.
a) Undenatured (Native) Collagen vs Placebo [31] b) Boswellia Extract (Aapin) vs Placebo [37]
WOMAC Western Ontario and McMaster Universities Osteoarthritis Index, U(N)C II Undenatured (Native) Collagen.
How to cite this article: Rakesh M, Niranjan R R, Varsha N. Multimodal Anti-Inammatory Approach to Osteoarthritis Management - Review of T Cell
Immunomodulation with Undenatured (Native) Collagen Type II and LOX Inhibition with Boswellia. Nov Tech Arthritis Bone Res. 2019; 3(4): 555618.
DOI: 10.19080/NTAB.2019.03.555618.
Novel Techniques in Arthritis and Bone Research
Table 1: Summary of clinical studies with Undenatured (Native) Collagen II and Boswellia.
Study Product  Study Design Patients Duration Main Results
Collagen Type II
U(N)CII 40mg/day
G (1.5g) +C
Double blind
2 centers
(Canada) N=52
OA knee
(>3 months
90 days
U(N)C II vs G+C: Improvement from baseline
•WOMAC:33%** vs 14%
•VAS:40%** vs 15.4%
•LFI:20%* vs 6%
Product related ADRs: 11.4% vs 23%
Collagen Type II
U(N)CII 40mg/day
G (1.5g) +C
Placebo (P)
Double blind
13 centers
(South India)
OA knee
to severe
>3 months
180 days
Spacing should be as below:
U(N)C II vs G+C vs P: Improvement at 180
days- Total WOMAC: 551** vs. 454* vs 414
U(N)C II* vs G+C; U(N)C II** vs P; G+C vs P (NS)
U(N)C II vs G+C; U(N)C II vs P: Improvements
from baseline-
WOMAC pain: 24* vs 19.2; 24** vs 17
WOMAC stiffness: 23.8* vs 19.4; 23.8** vs 17.8
WOMAC physical function: 22.5 vs 18.8; 22.5**
vs 17.3
VAS: 22.6* vs 18.4; 22.6** vs 17.0
LFI: 2.9** vs 2.2; 2.9** vs 2.1
Product related ADRs: (U(N)C II vs G+C vs P):
0 vs 14 vs 1
Collagen Type II
U(N)C II 10mg/
day + 1500mg/day
Double blind
Single Centre
(Turkey) N=39
OA knee
Age: 40-75
years 90 days
U(N)C II +AP vs AP alone: Improvements from
•Total WOMAC: 9.5** vs -2
•WOMAC pain: 3**vs -2
•WOMAC stiffness: 0.5* vs 0
•WOMAC physical function: 6** vs -2
•VAS (walking): 3** vs 0
•SF36 bodily pain score 10** vs 0
Collagen Type II
U(N)C II 40mg/day
Placebo (P)
Double blind
Single Centre
(USA) N=55
with joint
120 days
Knee extension: baseline vs day 120
•U(N)C II: 73.2 vs 81** degrees
•P: 71 vs 74 degrees (U(N)C II ** vs P day 120).
Time to pain onset: baseline vs day 120:
•U(N)C II: 1.4 vs 2.8 minutes*
•Placebo: 1.1 vs 1.7 minutes
(U(N)C II* vs P day 120)
AEs: (U(N)C II vs P): 4 vs 4
=100mg, 250mg
Placebo (P)
Double blind
Single Centre
(South India)
OA knee
Age: 40-80
years 90 days
E-30: (100mg) vs BE-30 (250mg) vs P:
Improvements from baseline-
•WOMAC pain: 22.9*** vs 21.9*** vs 6.3
•WOMAC stiffness: 17.7*** vs 18.5*** vs 8.7
•WOMAC physical function: 17.2*** vs 21.3***
vs 7.2
•VAS: 35.7*** vs 41.4*** vs 15.1*
•LFI: 4*** vs 5***vs 2.6*
•MMP (ng/ml): 256.5*** vs 429.4*** vs -26.4
Product related ADRs: 18 vs 27 vs 30
How to cite this article: Rakesh M, Niranjan R R, Varsha N. Multimodal Anti-Inammatory Approach to Osteoarthritis Management - Review of T Cell
Immunomodulation with Undenatured (Native) Collagen Type II and LOX Inhibition with Boswellia. Nov Tech Arthritis Bone Res. 2019; 3(4): 555618.
DOI: 10.19080/NTAB.2019.03.555618.
Novel Techniques in Arthritis and Bone Research
(BE+ 20% AKBA +
B. serrata non-
volatile oil)
100mg daily
Placebo (P)
Double blind
Single Centre
(South India)
OA knee
(>3 months
30 days
A vs P: Improvements from baseline-
•WOMAC pain: 23.6*** vs 5.6
•WOMAC stiffness: 18.8*** vs 3.4
•WOMAC physical function: 18.6*** vs 3.8
•VAS: 23.5*** vs 8.3*** (A*** vs P)
•LFI: 4.4*** vs 0.1
Product related ADRs: 1 vs 1
BE-30 100mg/day
Placebo (P)
Double blind
Single Centre
(South India)
medial tibio-
femoral OA
Age-40 years
or more
90 days
A vs BE-30: vs P:
Improvements from baseline-
•WOMAC pain: 31.1*** vs 20.8*** vs 8.4**
•WOMAC stiffness: 27.7*** vs 22.7*** vs 9.9**
•WOMAC physical function: 25.8*** vs 17.9***
vs 10**
•VAS: 27.5*** vs 22*** vs 9.4**
•LFI: 5*** vs 3.5*** vs 1.4*
Product related ADRs: 1 vs 0 vs 1
*p ≤ 0.05, ** p ≤ 0.01, ***≤ 0.0001, NS not signicant. WOMAC Western Ontario and McMaster Universities Osteoarthritis Index, VAS Visual
Analog Scale, LFI Lequesne’s Functional Index, RCT Randomized clinical trial, N Number of patients, U(N)C II Undenatured (Native) Collagen
Type II, G+C Glucosamine + Chondroitin, P placebo, AP Acetaminophen, AE Adverse event, ADR Adverse Drug Reaction, BE Boswellia Extract,
AKBA 3-O-acetyl-11-keto-β-boswellic acid, A Aapin, MMP Matrix MetalloProteinases
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How to cite this article: Rakesh M, Niranjan R R, Varsha N. Multimodal Anti-Inammatory Approach to Osteoarthritis Management - Review of T Cell
Immunomodulation with Undenatured (Native) Collagen Type II and LOX Inhibition with Boswellia. Nov Tech Arthritis Bone Res. 2019; 3(4): 555618.
DOI: 10.19080/NTAB.2019.03.555618.
Novel Techniques in Arthritis and Bone Research
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DOI: 10.19080/NTAB.2019.03.555618
... 40 The regeneration of cartilage offered by undenatured collagen type-II increases functionality and mobility of the joints and alleviates pain in OA patients. 41 Aflapin is a synergistic composition derived from Boswellia serrata. It is selectively enriched with 3-Oacetyl-11-keto-β-boswellic acid (AKBA) and specific B Serrata-non-volatile oils to increase bioavailability. ...
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p class="abstract">Osteoarthritis (OA) is the most common joint disease affecting millions worldwide. Osteoarthritis typically affects the knees, hands, hips, and feet. It is characterized by complex pathologic changes in cartilage which haven’t been fully elucidated yet. However, recent research has shown the involvement of two contributing pathways namely the mechanical and the immune pathways which interlink to cause cartilage destruction. Patients with OA on current treatment options still inevitably progress to a more severe stage becoming candidates for total joint replacement. The cornerstones of OA management in the early stage include exercises, weight loss, education—complemented by topical or oral nonsteroidal anti-inflammatory drugs (NSAIDs) and nutraceuticals like Undenatured type II collagen and Aflapin. Both Undenatured type II collagen and Aflapin offer great promise in OA management by targeting both the immune and mechanical pathways respectively. Undenatured type II collagen works by oral tolerization turning off the immune response in the inflammatory damage (T cell response) against endogenous Type II collagen in the cartilage thus reducing joint inflammation and degradation and stimulates anti-inflammatory cytokine release. Aflapin inhibits 5-LOX and exerts anti-inflammatory action thus providing symptomatic relief of pain and inflammation. This review focusses on the role of mechanical and immune pathways in the pathogenesis of OA and the impact of the combination of Undenatured type-II collagen and Aflapin in targeting these pathways thus improving the clinical outcomes.</p
Full-text available
Osteoarthritis (OA) is the most common form of arthritis characterized by progressive destruction of joint cartilage tissue, pain and inflammation, stiffness, and impaired physical activity. It is the most prevalent and leading cause of pain and disability across the globe. During the pain and inflammatory process, 5-lipoxygenase (5-LOX) pathway is also involved, which generates leukotrienes (LTs), namely LTB4 and cysteinyl LTs. Osteoblasts also synthesize LTs, which stimulate and enhance the production of interleukin 1, tumor necrosis factor α, and various other cytokines that are potent inflammatory mediators. LT formation leads to cartilage degradation and compensates chondrocyte-mediated cartilage repair mechanism. Current therapies include nonsteroidal anti-inflammatory drugs, analgesics, and disease-modifying agents, but do not affect 5-LOX pathway. Boswellia serrata extract–derived boswellic acids are specific, non-redox inhibitors of 5-LOX, and 3-O-acetyl-11-keto-β-boswellic acid (AKBA) possesses the most potent 5-LOX inhibitory activity. B. serrata extracts have shown significant efficacy and safety in the treatment of various inflammatory disorders such as OA, rheumatoid arthritis, asthma, and inflammatory bowel diseases. Aflapin® is a novel synergistic composition containing B. serrata extract selectively enriched with 20% AKBA and B. serrata nonvolatile oil. Aflapin® is a patented, selective, and most potent 5-LOX inhibitor, which significantly reduces joint pain, inflammation, stiffness, and improves physical function compared to placebo and other B. serrata extract. Aflapin® also significantly reduces matrix metalloproteinase levels, enhances chondrocytes proliferation, and increases glycosaminoglycans levels, thereby providing cartilage protection in arthritis. Numerous in vitro studies, preclinical studies, and clinical studies suggest the potential of Aflapin® as a useful therapeutic intervention for the management of arthritis.
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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.
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Background: Treatment of osteoarthritis aims at reducing pain and improving mobility. NSAIDs are widely prescribed for symptomatic relief despite well-known adverse effects. Paracetamol with its better safety profile is recommended as the initial analgesic of choice. SYSADOA is a generic term used for symptomatic slow acting drugs for osteoarthitis, and includes glucosamine sulphate and related compounds, chondroitin sulphate, and diacerein. SYSADOA when compared to NSAIDs, are safer, comparable in symptomatic efficacy and better in structure modifying efficacy in osteoarthritis. A drug utilization study is considered to be one of the most effective methods to assess and evaluate the prescribing attitude of physicians. Despite the considerable socio-economic impact of OA, not many studies have established the drug-prescribing trend in India. Hence we decided to study the prescribing pattern of SYSADOA, paracetamol and NSAIDs in OA vis-à-vis the standard recommendations and in the process provide constructive feedback to prescribing clinicians. Methods: Prescriptions for osteoarthritic patients collected cross-sectionally for six months from an orthopaedic outpatient unit in a tertiary care hospital, were analysed. Results: Out of 154 prescriptions analysed, 7% were prescribed glucosamine and chondroitin, while 4% received diacerein. Paracetamol was prescribed in 17% cases. NSAIDs were prescribed in 84%, with 27% receiving two or more NSAIDs simultaneously. Conclusion: SYSADOA and paracetamol were under-prescribed while NSAIDs were probably over-prescribed.
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Objective: The aim of this randomized controlled study was to evaluate the efficacy of oral native type II collagen treatment on the symptoms and biological markers of cartilage degradation, when given concomitantly with acetaminophen in patients with knee osteoarthritis. Materials and methods: Thirty-nine patients diagnosed with knee osteoarthritis were included and randomly distributed into two groups: one treated with 1500 mg/day of acetaminophen (group AC; n=19) and the other treated with 1500 mg/day of acetaminophen plus 10 mg/day of native type II collagen (group AC+CII; n=20) for 3 months. Visual Analogue Scale (VAS) at rest and during walking, Western Ontario McMaster (WOMAC) pain, WOMAC function, and Short Form-36 (SF-36) scores, were recorded. Coll2-1, Coll2-1NO2 and Fibulin-3 levels were quantified in urine as biomarkers of disease progression. NCT02237989. Results: After 3 months of treatment, significant improvements compared to baseline were reported in joint pain (VAS walking), function (WOMAC) and quality of life (SF-36) in the AC+CII group, while only improvements in some subscales of the SF-36 survey and VAS walking were detected in the AC group. Comparisons between the groups revealed a significant difference in VAS walking score in favour of the AC+CII group as compared to AC group. Biochemical markers of cartilage degradation in urine did not significantly improve in any of the groups. Conclusion: All in all, these results suggest that native type II collagen treatment combined with acetaminophen is superior to only acetaminophen for symptomatic treatment of patients with knee osteoarthritis.
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UC-II contains a patented form of undenatured type II collagen derived from chicken sternum. Previous preclinical and clinical studies support the safety and efficacy of UC-II in modulating joint discomfort in osteoarthritis and rheumatoid arthritis. The purpose of this study was to assess the efficacy and tolerability of UC-II in moderating joint function and joint pain due to strenuous exercise in healthy subjects. This randomized, double-blind, placebo-controlled study was conducted in healthy subjects who had no prior history of arthritic disease or joint pain at rest but experienced joint discomfort with physical activity. Fifty-five subjects, who reported knee pain after participating in a standardized stepmill performance test, were randomized to the placebo (n = 28) or the UC-II (40 mg daily, n = 27) cohort for 120 days. Joint function was assessed by measuring knee flexion and knee extension as well as time to experiencing and recovering from joint pain following strenuous stepmill exertion. After 120 days of supplementation, subjects in the UC-II group exhibited a statistically significant improvement in average knee extension compared to placebo (81.0 +/- 1.3o vs 74.0 +/- 2.2o; p = 0.011) and to baseline (81.0 +/- 1.3o vs 73.2 +/- 1.9o; p = 0.002). The UC-II cohort also demonstrated a statistically significant change in average knee extension at day 90 (78.8 +/- 1.9o vs 73.2 +/- 1.9o; p = 0.045) versus baseline. No significant change in knee extension was observed in the placebo group at any time. It was also noted that the UC-II group exercised longer before experiencing any initial joint discomfort at day 120 (2.8 +/- 0.5 min, p = 0.019), compared to baseline (1.4 +/- 0.2 min). By contrast, no significant changes were seen in the placebo group. No product related adverse events were observed during the study. At study conclusion, five individuals in the UC-II cohort reported no pain during or after the stepmill protocol (p = 0.031, within visit) as compared to one subject in the placebo group. Daily supplementation with 40 mg of UC-II was well tolerated and led to improved knee joint extension in healthy subjects. UC-II also demonstrated the potential to lengthen the period of pain free strenuous exertion and alleviate the joint pain that occasionally arises from such activities.
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Osteoarthritis (OA) is a degenerative disease that affects various tissues surrounding joints such as articular cartilage, subchondral bone, synovial membrane, and ligaments. No therapy is currently available to completely prevent the initiation or progression of the disease partly due to poor understanding of the mechanisms of the disease pathology. Cartilage is the main tissue afflicted by OA, and chondrocytes, the sole cellular component in the tissue, actively participate in the degeneration process. Multiple factors affect the development and progression of OA including inflammation that is sustained during the progression of the disease and alteration in biomechanical conditions due to wear and tear or trauma in cartilage. During the progression of OA, extracellular matrix (ECM) of cartilage is actively remodeled by chondrocytes under inflammatory conditions. This alteration of ECM, in turn, changes the biomechanical environment of chondrocytes, which further drives the progression of the disease in the presence of inflammation. The changes in ECM composition and structure also prevent participation of mesenchymal stem cells in the repair process by inhibiting their chondrogenic differentiation. This review focuses on how inflammation-induced ECM remodeling disturbs cellular activities to prevent self-regeneration of cartilage in the pathology of OA.
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Glucocorticoids are among the most potent anti-inflammatory and immunosuppressive agents. They inhibit synthesis of almost all known cytokines and of several cell surface molecules required for immune function, but the mechanism underlying this activity has been unclear. Here it is shown that glucocorticoids are potent inhibitors of nuclear factor kappa B (NF-kappa B) activation in mice and cultured cells. This inhibition is mediated by induction of the I kappa B alpha inhibitory protein, which traps activated NF-kappa B in inactive cytoplasmic complexes. Because NF-kappa B activates many immunoregulatory genes in response to pro-inflammatory stimuli, the inhibition of its activity can be a major component of the anti-inflammatory activity of glucocorticoids.
For a targeted pharmacologically oriented basic therapy for osteoarthritis, it is important that the drugs should act against the underlying process of cartilage destruction. A deep insight and exact knowledge of the pathogenetic reactions that occur during the course of degenerative joint disease are necessary for the development of such agents. Fortunately, from the field of experimental osteoarthritis research, a large number of new and interesting findings have come to light over the last 5–10 years concerning the pathogenesis of osteoarthritic joint dysfunction. In order to illustrate the present possible starting points for a pharmacological intervention, some aspects of the pathogenesis of osteoarthritis is first briefly described as it is currently understood.
Non-steroidal anti-inflammatory drugs (NSAIDs) that are prescribed for treatment of osteoarthritis (OA) symptoms including pain and inflammation target the production eicosanoids which exhibit numerous functions in various cell types. In these studies, we have (a) identified the diverse eicosanoid pathways that are activated in human chondrocytes of normal and OA cartilage, (b) delineated the modulation of eicosanoids in the presence of NSAIDS and selective COX-2 inhibitors, and (c) characterized eicosanoid products and various transcripts modulated by various inhibitors of eicosanoids in human OA cartilage by gene expression arrays. Immunoassay analysis of culture supernatants were utilized to determine the spectrum of eicosanoids derived from both the cyclooxygenase (COX) and lipoxygenase (LOX) pathways of normal and human OA cartilage in ex-vivo conditions. Human OA cartilage was incubated in ex-vivo conditions to examine spontaneous or IL-1 induced production of eicosanoids in the presence of various COX inhibitors. Gene expression analysis was performed to analyze the expression of mRNA in the presence and absence of COX-2 inhibitors in OA cartilage in ex-vivo conditions. Normal and OA human cartilage explants produced multiple eicosanoids of the COX and LOX pathways. PGF1α, PGF2α, PGE2 > TXB2, PGD2, and LTB4 were spontaneously generated by normal and OA cartilage. Among these, elevated levels of PGE2 and LTB4 were generated in OA as compared to normal cartilage. IL-1 treatment further enhanced these eicosanoids production. Treatment of OA cartilage explants with cyclooxygenase inhibitors (celecoxib & indomethacin) augmented LTB4 accumulation by 2- to 4-fold. A follow-up pharmacogenomic analysis identified approximately 90 cytokine and growth factor related transcripts that were modulated following selective COX-2 inhibition. These studies for the first time demonstrate that normal and OA cartilage generates multiple and differential eicosanoid products. Inhibition of the COX- pathway in human OA cartilage caused accumulation of end products (LTB4) of the 5LO pathway. Furthermore, celecoxib, a selective COX-2 inhibitor, regulated numerous genes in cartilage, which are linked to the NFkB and AP-1 pathways at the mRNA level. In conclusion, these experiments demonstrate the complex and pleotropic role of eicosanoids in human cartilage homeostasis and pathophysiology of OA.