Glucosamine in its acetylated form is a natural constituent of some
glycosaminoglycans (for example,
hyaluronic acid and
keratan sulfate) in the
proteoglycans found in articular cartilage, intervertebral disc and synovial fluid.
Glucosamine can be extracted and stabilized by chemical modification and used as a
drug or a nutraceutical. It has been approved for the treatment of
osteoarthritis (OA) in Europe to promote cartilage and joint health and is sold over the counter as a dietary supplement in the United States. Various formulations of
glucosamine have been tested, including
glucosamine sulfate and
glucosamine hydrochloride. In vitro and in vivo studies have uncovered
glucosamine's mechanisms of action on articular tissues (cartilage, synovial membrane and subchondral bone) and justified its efficacy by demonstrating structure-modifying and anti-inflammatory effects at high concentrations. However, results from clinical trials have raised many concerns. Pharmacokinetic studies have shown that
glucosamine is easily absorbed, but the current treatment doses (for example, 1,500 mg/day) barely reach the required therapeutic concentration in plasma and tissue. The symptomatic effect size of
glucosamine varies greatly depending on the formulation used and the quality of clinical trials. Importantly, the effect size reduces when evidence is accumulated chronologically and evidence for the structure-modifying effects of
glucosamine are sparse. Hence,
glucosamine was at first recommended by EULAR and OARSI for the management of knee
pain and structure improvement in OA patients, but not in the most recent NICE guidelines. Consequently, the published recommendations for the management of OA require revision.
Glucosamine is generally safe and although there are concerns about potential allergic and
salt-related side effects of some formulations, no major adverse events have been reported so far. This paper examines all the in vitro and in vivo evidence for the mechanism of action of
glucosamine as well as reviews the results of clinical trials. The pharmacokinetics, side effects and differences observed with different formulations of
glucosamine and combination
therapies are also considered. Finally, the importance of study design and criteria of evaluation are highlighted as new compounds represent new interesting options for the management of OA.