On her first visit to me, 60-year-old Jenny said, "Every time I hear of a supplement that might reduce my arthritis pain, I try it-but I've gotten very little relief. I've almost given up on finding anything that works." I paid close attention as she named nearly a dozen supplements she had taken for the arthritis in her hips and knees. Then I mentioned one oral supplement that had not been on her list-hyaluronic acid (HA). "I've never even heard of it, but it's worth trying." Jenny said. Six weeks later, she walked nimbly into my clinic and reported a dramatic reduction in her pain and stiffness. She was surprised at this success-but I was not.

HA has been so effective for so many of my arthritis patients that I consider it an up-and-coming superstar among nutritional supplements.

What Is Hyaluronic Acid?

A naturally occurring substance in the body, the HA molecule is formed by two sugars strung together in a long chain. HA is an essential component of the joints, skin, eyes and blood vessels (as well as the umbilical cord). HA deficiencies, which develop for reasons that are not well-understood, contribute to premature aging and disease in these tissues. As yet, there is no reliable test to measure HA levels.

HA is a key component of synovial fluid, the lubricating fluid in joint cavities. This fluid, which is secreted by a membrane that forms a capsule around the ends of bones, has two main purposes. First, it helps to minimize friction and prevent breakdown of the joints (like the oil used to lubricate moving car parts). Second, synovial fluid helps with shock absorption within joints. Cartilage is the main shock absorber, but it does not contain blood vessels--so synovial fluid transports the nutrients required for cartilage healing and regeneration, and removes waste products. In addition, HA is an actual component of cartilage and is required for healthy cartilage formation.

There are two main types of arthritis. Osteoarthritis is caused by the normal wear and tear of aging and/or by injury. Rheumatoid arthritis is an autoimmune disease in which the immune system attacks the body's own joint tissue and causes deterioration. As either type of arthritis progresses, the synovial fluid degrades, lessening its lubricating and shock-absorbing abilities ...and cartilage breaks down and becomes inflamed. Supplementing with HA helps to counteract both of these effects.

The Fight Against Arthritis

When I mention HA to patients, most say they've never heard of it. I expect this to change as news of HA's effectiveness spreads.

  • HA injections. In 1997, HA injections were approved by the FDA for patients with osteoarthritis of the knee, and they now are being studied for use in shoulder, hip and ankle joints. Injectable HA products include Hyalgan, Supartz, Orthovisc and Synvisc.

HA injections go directly into the affected joint or joints...are done in a doctor's office using local anesthetic...take just a few minutes... and usually are given three to five times, each one week apart. Side effects include minor swelling, temporary pain, rash and/or bruising at the injection site. While not everyone who receives HA injections finds relief, for many people the painful symptoms of arthritis are noticeably reduced for up to six months (especially in the early stages of the disease), allowing patients to delay or avoid joint-replacement surgery.

For now, only a limited number of rheumatologists and osteopaths provide this therapy. HA shots cost about $230 each and may or may not be covered by insurance, depending on your policy. Fortunately, there is a promising alternative—oral HA.

  • HA oral supplementation. With regard to HA's use as an oral supplement, the big question is whether it can be absorbed and used by the body when taken in capsule form. Critics of HA supplementation say that its molecular structure is too large to be absorbed in the digestive tract-yet several studies in the past four years have shown otherwise.

One of the first studies to demonstrate that HA is absorbed effectively into the bloodstream and the joints was presented at the 2004 Experimental Biology Conference. Researchers gave rats and dogs one oral dose of HA that was radio labeled (chemically joined with a radioactive substance), allowing it to be tracked with diagnostic imaging.

Result: HA was absorbed into the animals bloodstreams and distributed to their joints. Although no similar studies have been done on people, I think it is logical to assume that HA's absorbability in humans may be similar to its action in animals.

Why am I keen on supplemental HA for arthritis? During the past year, several dozens of my patients with osteoarthritis and rheumatoid arthritis have taken nonprescription oral HA with good results. I have found that HA by itself can produce significant results-and in many cases, results are even better when HA is taken in combination with mainstay joint supplements, such as chondroitin, fish oil, glucosamine, methysulfonylmethane (MSM) and/or S-adenosylmethionine (SAMe).

This is wonderful news, because HA often allows patients to reduce or discontinue pharmaceutical nonsteroidal anti-inflammatory (NSAID) drugs, such as ibuprofen (Motrin) and naproxen (Aleve). These drugs are associated with serious adverse side effects, including bleeding stomach ulcers, liver and kidney damage and increased risk for heart attack and stroke.

What The Research Says

HA is an example of a supplement that works well in the real world but has generated limited published data. Existing research mostly involves a patented HA product called BioCell Collagen II (714-632-1231, www.biocelltechnol ogy.com), made from the sternal cartilage of chickens and used as an ingredient in various brands of HA oral supplements. One small study included 16 patients with osteoarthritis of the knee or hand who were taking COX-2 inhibitors or other NSAIDs. Eight patients took 1,000 mg of BioCell daily, while the other eight took a placebo. After two months of treatment, the group receiving BioCell reported significant improvement in pain, range of motion and swelling-whereas the placebo group showed no significant changes. One such product, sold at health food stores, is BioCell Chicken Sternum Collagen Type II, made by Premier Labs (800-887-5227, www.premierlabs.com).

Other oral products contain a type of HA called sodium hyaluronate, which is produced during microbial fermentation. While I am not aware of any human studies on this form of HA, animal studies suggest that it is safe and several of my patients have reported positive effects. One such product available in health food stores is Now Foods Hyaluronic Acid (888-669-3663, www.nowfoods.com). The recommended dosage is 100 mg twice daily. The Now Foods capsules, like brands that contain BioCell, can be used indefinitely, generally are safe and only rarely cause mild digestive upset.

Maximum Relief from Arthritis

For maximum relief from arthritis pain and T inflammation, combine hyaluronic acid (HA) oral supplements or injections with other natural supplements described below. All are available in health food stores and, unless noted, generally are safe for everyone. Mild arthritis symptoms may respond to the lower end of the dosage range, while severe symptoms may require the higher dosage.

  • Chondroitin, a substance derived from cow cartilage.

Dosage: 1,200 mg daily. Lower the dosage or discontinue use if you experience digestive upset, such as nausea.

  • Fish oil in the form of docosabexaenoic acid (DHA) and eicosapentaenoic acid (EPA), combined.

Dosage: 1,000 mg to 2,000 mg daily.

Caution: Get your doctor's approval first if you take a blood thinner, such as aspirin or warfarin (Coumadin).

  • Glucosamine, a substance derived from shellfish

Dosage: 1,500 mg daily. Lower the dosage or discontinue use if you experience digestive upset, such as diarrhea.

Caution: Check with your doctor before using if you are allergic to shellfish...or if you have diabetes, because glucosamine may cause blood-sugar fluctuations.

  • Methylsulfonylmethane (MSM), an organic sulfur compound.

Dosage: 2,000 mg to 6,000 mg daily.

  • S-adenosylmethionine (SAMe), an amino acid-like substance.

Dosage: 600 mg to 1,200 mg daily.

How to use: For rheumatoid arthritis, take fish oil and MSM. For osteoarthritis, start with glucosamine and MSM...and if symptoms are not adequately relieved within two months, also take chondroitin, fish oil and SAMe.

Best Options for Pain

Nonsteroidal anti-inflammatory drugs (NSAIDs) are good for mild-to-moderate joint pain. I typically prescribe ibuprofen (Advil, etc.) or naproxen (Aleve)—you can't tell in advance which will work better for an individual Talk to your doctor about the best dosage for your situation. Don't rely on these drugs for more than a week at a stretch. When NSAIDs don't stop chronic pain, you must address the root cause of the pain.

Some patients tell me that their joints feel better when they take the supplements glucosamine and/or chondroitin sulfate, widely touted for this purpose. In fact, I feel there is no good evidence that these products build cartilage or have a statistically significant benefit for joint pain.

However, there is no evidence that these supplements are harmful (assuming you are not allergic)—so if a patient wants to try them or to continue using them, I don't object.

Foods That Help Reduce Arthritis Pain

Vegetables, fruits and whole grains provide antioxidants that may ease the pain and swelling of arthritis, an inflammation of the joints. Also helpful are omega-3 fatty acids (found in cold water fish, flaxseed and other foods), which the body converts to anti-inflammatory compounds. Fat eight to 12 ounces weekly of fish rich in omega-3s, such as salmon, mackerel and sardines. Limit polyunsaturated fats, such as corn oil and safflower oil, which are high in omega-6 fatty acids, substances converted in the body into compounds that promote inflammation. Also limit your intake of saturated fat, found primarily in meat and dairy products, because these unhealthy fats may increase inflammation.

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