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Table of Contents  

Aim ............................................................................................................................................... 1 

Study Design ................................................................................................................................. 1 

Background and Hypothesis ......................................................................................................... 2 

Methods ........................................................................................................................................ 3 

Participants ............................................................................................................................... 4 

Materials and Procedures ......................................................................................................... 4 

Demographic and Screening Procedure ................................................................................... 5 

Osteoarthritis Knee Pain, Mobility and Severity Questionnaires. ............................................ 7 

Lequesne Index ..................................................................................................................... 7 

WOMAC ............................................................................................................................... 7 

Daily Pain and Rescue Medication Recordings ..................................................................... 7 

Health-Related Quality of Life [QoL] Questionnaire ............................................................... 9 

Statistical Analyses ....................................................................................................................... 9 

Results ......................................................................................................................................... 10 

Demographics .......................................................................................................................... 10 

Outcome Measures .................................................................................................................. 10 

Analysis of Variance ................................................................................................................ 11 

Dropouts .................................................................................................................................. 12 

Rescue Medication ................................................................................................................... 12 

Conclusion ................................................................................................................................... 13 

Appendix A .................................................................................................................................. 14 

 

  

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Aim To investigate the therapeutic efficacy and further safety of a Green-Lipped Mussel (GLM) extract to improve pain and joint mobility in a group of male and females diagnosed with Osteoarthritis (OA) of the knee(s). Study Question Does GlycOmegaTM PLUS [GLM extract] from Aroma NZ relieve pain and improve knee joint mobility in males and females diagnosed with OA of the knee?

Study Design Clinical Trial Type: An open label single-group allocation pilot trial. Allocation: Not concealed. Blinding: Not blinded [participants and investigators].

Study Particulars

Setting: To investigate the effectiveness and safety of GlycOmegaTM PLUS [proprietary name] in addition to routine care in the treatment of patients with chronic pain and poor mobility due to OA of the knee.

Participants: This report comprises a total of 21 participants [8 males, 13 females] with an age range from 41-87 years (mean ± SD, 61.1 ± 12.2 years) who completed an 8–week trial from the Brisbane and outer lying areas.

Intervention: Participants were allocated to 3000 mg/day of GlycOmegaTM PLUS capsules [3 x 500 mg b.i.d] dispensed in opaque white bottles. Pain medication was allowed and was recorded for analysis.

Duration: 8–weeks Inclusion criteria: See Methods section Exclusion criteria: See Methods section Follow–up period: Baseline Screening [visit 1]; 4–weeks [visit 2]; 8–weeks [visit 3]. Competitive interests declaration:

- This study was funded by a research grant from Aroma New Zealand Ltd. - The University of Queensland, School of Medicine, Centre for Integrative

Clinical and Molecular Medicine conducted the study as an independent contract research organization.

- Authors S. Coulson, L. Vitetta, Shoshannah Beck H. Gramotnev and P. Vecchio have no other competitive interests to declare.

  

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Background and Hypothesis Osteoarthritis [OA] is one of the most common forms of arthritis among the 150 musculoskeletal syndromes and conditions known and is associated with increasing age, female gender, trauma or overuse of the joint, genetics and obesity.1 OA can occur in any joint but is most common in the knee, with the hip and joints of the hand, foot and spine also being affected.2,3 OA is characterized by loss of articular cartilage within synovial joints, which is associated with the development of osteophytes and thickening of the joint capsule. Clinically, the condition presents as joint pain, tenderness, limitation of movement, crepitus, occasional effusion, and variable degrees of local inflammation.4 Current treatment strategies include both non-pharmacologic and pharmacologic therapies that aim to reduce pain, physical disability and handicap, and some of them attempt to limit structural deterioration in affected joints. Given the numerous complementary and alternative medicine (CAM) modalities marketed for the treatment of OA, self-medication has become an option for many patients diagnosed with rheumatic disorders.5 The use of dietary supplements by OA patients has been attributed to limiting the toxic side effects that anti-inflammatory drugs [e.g. celebrex, aspirin that are associated with GIT inflammation and permeability] and paracetamol [e.g., constipation] produce and patients will often favour a treatment with less associated toxicity.6 The high prevalence of CAM use by rheumatic patients is reported worldwide, estimating to be 18-94% in the United States, 60-91% in Canada, 56-83% in Mexico, 40-82% in Australia, 78% in Germany and 43-72% in India.7 Regardless of the short term effectiveness of pain management offered by NSAIDs for OA of the knee, current analysis does not support long term use of NSAIDs for this condition and only limited use can be recommended. Green-Lipped Mussel (Perna canaliculus) products have been marketed for the treatment of arthritic symptoms since the early 1970’s, and it is now recognised that the anti-inflammatory activity of GLM extract varies in potency depending on the stability of the preparation.8                                                             1 Abramson SB, Attur M. Developments in the scientific understanding of osteoarthritis. Arthritis Research & Therapy 2009;11:227. 2 Bremander A, Bergman S. Non-pharmacological management of musculoskeletal disease in primary care. Best Practice & Research Clinical Rheumatology 2008;22:563-77. 3 Vitetta L, Cicuttini F, Sali A. Alternative therapies for musculoskeletal conditions. Best Practice & Research Clinical Rheumatology 2008;22:499-522. 4 Woolf A, Pfleger B. Burden of major musculoskeletal conditions. Bulletin of the World Health Organisation 2003;81:646-56. 5 Ehrlich G. Global treatment of osteoarthritis. Inflammopharmacology 2003;11:333-336. 6 Ernst E, Willoughby M, Weihmayr T. Nine possible reasons for choosing complementary medicine. Perfusion 1995;8:356-8. 7 Ramos-Remus C, Raut A. Complementary and alternative practices in Rheumatology. Best Parctice & Research Clinical Rheumatology 2008;22:741-57. 8 Ulbricht C, et al. An evidence-based systematic review of green-lipped mussel (Perna canaliculus) by the Natural Standard Research Collaboration. Journal of Dietary Supplements 2009;6:54-90.

  

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Numerous in vitro9 and animal studies10,11,12 have suggested an immunomodulatory role of GLM in regulating inflammation with stabilised mussel powder extracts showing much greater anti-inflammatory effects that unstabilised extracts, 14% and 97%, respectively.10,13 Stabilised GLM lipid extracts have been shown to moderately inhibit COX-1 and COX-2 enzymes in vitro, in vivo, and in clinical studies which is associated with marked reductions in several pro-inflammatory cytokines.10,14,15

GlycOmega-PLUS™ is a stabilized GLM supplement in which the GLM meat is cold opened, freeze dried and combined with a botanical anti-oxidant to ensure maximum potency of the bioactive compounds responsible for its anti-inflammatory activity. This clinical trial investigated the therapeutic efficacy of GlycOmega-PLUS™ in improving knee pain and joint mobility associated with OA of the knee(s).

Methods The study has ethical clearance from the University of Queensland Human Research Ethics Committee and the Princess Alexandra Human Research Ethics Committee.

Trial Registration: Australia/New Zealand Clinical Trial Registry Number ANZCTRN 12611000517976. 

                                                            9 Mani S, Lawson J. In vitro modulation of inflammatory cytokine and IgG levels by extracts of Perna canaliculus. BMC Complementary Alternative Medicine 2006;6:1. 10 Whitehouse M, et al. Anti-inflammatory activity of a lipid fraction (Lyprinol) from the NZ green-lipped mussel. Inflammopharmacology 1997;5:237-46. 11 Rainsford KD, Whitehouse M. Gastroprotective and anti-inflammatory properties of green-lipped mussel (Perna canaliculus) preparation. Arzneimittelforschung 1980;30:2128-32. 12 Miller T, Ormrod D. The anti-inflammatory activity of Perna canaliculus (NA green-lipped mussel). The New Zealand Medical Journal 1980;92:187-93. 13 Brien S, et al. Systematic review of the nutritional supplement Perna canaliculus (green-lipped mussel) in the treatment of osteoarthritis. QJM 2008:101:167-79. 14 Halpern GM. Anti-inflammatory effects of stabilised lipid extract of Perna canaliculus (Lyprinol). Allerg Immunol (Paris) 2000;32:272-8. 15 McPhee S, et al. Anti-cyclooxygenase effects of lipid extracts from the New Zealand green-lipped mussel, Perna canaliculus. Comp Biochem Physiol B Biochem Mol Biol 2007;146:343-56.

  

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Participants Participants were recruited on the basis of the following inclusion and exclusion criteria. Snapshot 1: Inclusion and Exclusion Criteria

Study Design The study was a non-randomised, single-group allocation study.

Materials and Procedures Patients were recruited from the Director of Rheumatology’s patient data base at the Princess Alexandra Hospital, Brisbane Queensland. Prior to a participant being invited to enrol into the study, all participants had the trial explained to them and given a chance to ask any relevant questions about the study. A signed informed consent form was then signed by all participants. Measurements of primary and secondary outcomes and socio-demographic variables were assessed at baseline [visit 1], at 4–weeks [visit 2] and 8–weeks participation [visit 3]. Participants were supplemented with 3 x 500 mg GlycOmegaTM PLUS capsules twice daily, during the morning and evening with meals.

  

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Demographic and Screening Procedure Participants were screened for the following demographic variables.

Snapshot 2: Patient Demographics

  

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Osteoarthritis Knee Pain, Mobility and Severity Questionnaires.

Lequesne Index Provides an index of severity for OA of the knee. The Lequesne index is a 10-question interview-style survey given to patients with OA of the knee. It assesses pain or discomfort, maximum distance walked and activities of daily living. The total questionnaire is scored on a 0 to 24 scale, with lower scores indicating less functional impairment.

WOMAC The Western Ontario and McMaster Universities (WOMAC) index is used to assess patients with OA of the hip or knee assessing pain, stiffness and physical function. It can be used to monitor the course of the disease or to determine the effectiveness of anti-rheumatic medications. The total questionnaire is scored on a 0 to 96 scale with lower scores indicating a lesser degree of pain, stiffness, or physical dysfunction.

Daily Pain and Rescue Medication Recordings Participants were asked to complete 2 participant diaries that recorded daily intake of GLM, daily knee pain experienced and any rescue medication taken for knee pain. Participants recorded the overall knee pain experienced each evening before going to bed on a 5- Point Likert scale. Intake of any rescue medication to treat knee pain was also recorded daily.

  

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Snapshot 3: Daily Pain and Rescue Medication Recordings

Compliance Participant compliance was based on the daily recordings of capsule ingestion. If participants forgot to take GLM capsules they were instructed to leave entry blank or with a line through space provided. Snapshot 4: Participant Diary Recordings of Compliance

  

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Health-Related Quality of Life [QoL] Questionnaire Quality-of-Life Health [SF-12]

The SF-12 measures generic health concepts relevant across age, disease and treatment groups. It includes physical functioning, bodily pain, general health, vitality, social functioning, emotional functioning and mental health. Results are expressed in terms of two meta-scores: the Physical Component Summary (PCS) and the Mental Component Summary (MCS). The SF-12 is scored so that a high score indicates better physical functioning with score greater than 50 representing above average health status. Body Mass Index Body Mass Index [BMI] was calculated from height and weight measurements according to the formula weight divided by height squared (kg/m2). This was implemented as a heuristic proxy for human body fat based on an individual's weight and height. Hip to Waist Ratio Hip and waist measurements were also recorded for further verification of possible changes in weight throughout the study period. Blood Pressure Blood pressure was recorded using an electronic inflating sphygmomanometer cuff. Blood Sample Collections Participants provided a venous blood sample in at baseline and week 8 in order to determine further safety issues. They were venipunctured and 10 mL of blood collected for C-Reactive Protein [CRP], Eosinophilic Sedimentation Rate [ESR], Full Blood Estimates, Liver Function Tests and Blood Chemistries. Adverse Events Adverse events were ascertained through participant diary records and face-to-face visits at both 4 weeks and 8 weeks. Statistical Analyses The data in this clinical trial was treated according to an intention-to-treat analysis. Participants were included in the analysis if they had returned at least one diary [e.g. visit 2]. At this visit, participants were evaluated for all study parameters. Paired samples t-tests were conducted for significant or marginally significant interactions. These were performed to investigate the difference in pre- and post-supplementation scores. Repeated measures analysis of variance (ANOVA) was conducted to investigate the changes between the time periods. The significance level was set at p <0.05.

  

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Results

Demographics Thirty prospective participants were screened for the inclusion and exclusion criteria and a total of 23 [9 male, 14 female] were invited to participate in the trial. Recruitment took place at the Princess Alexandra Hospital, Brisbane from July 2010 to March 2011 [Table 1]. Table 1: Baseline demographic data of interest.

Variables Baseline [week 0] Visit 2 [week 4] Visit 3 [week 8] Gender

- Females n (%) - Males n (%)

8 (65%) 13 (35%)

Age [mean ± SD years] 61.1 ± 12.2 years BMI [mean ± SD] 34.0 ± 9.0 34.6 ± 9.3 34.5 ± 9.2 W:H ratio [mean ± SD] 0.9 ± 0.1 0.9 ± 0.1 0.9 ± 0.1 Blood Pressure [mean ± SD]

- Systolic - Diastolic

130.4 ± 18.3 80.8 ± 11.8

130.3 ± 22.3 75.9 ± 13.2

125.8 ± 17.3 76.0 ± 11.3

Outcome Measures Paired t-tests were performed on the Lequesne, WOMAC (average), PCS and MCS scores between Baseline and Week 4, Week 4 and Week 8, and Baseline and Week 8. Lequesne and WOMAC scores showed significant changes between all intervals (p < 0.001); MCS scores significantly changed from Baseline to Week 4 (p=0.012) only and PCS scores were not significant different [Table 2]. Table 2: Mean and Paired t-tests for Outcome Measures at Separate Intervals.

Outcome Measure Mean [95% CI] t-statistic p value Lequesne 0 to 4 weeks 12.88 [10.38–15.37] 3.936 0.001 4 to 8 weeks 10.30 [7.47–13.13] 3.251 0.004 0 to 8 weeks 9.13 [6.41–11.84] 5.721 < 0.001 WOMAC 0 to 4 weeks 1.80 [1.38–2.21] 3.843 0.001 4 to 8 weeks 1.35 [1.00–1.71] 4.367 < 0.001 0 to 8 weeks 1.04 [0.67–1.41] 7.849 < 0.001 PCS 0 to 4 weeks 37.12 [32.06–42.17] -1.198 0.246 4 to 8 weeks 39.09 [34.07–44.11] 0.314 0.757 0 to 8 weeks 38.30 [32.55–44.05] -0.44 0.665 MCS

  

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0 to 4 weeks 46.86 [40.16–53.56] -2.783 0.012 4 to 8 weeks 55.74 [52.13–59.34] 1.423 0.171 0 to 8 weeks 51.68 [46.76–56.59] -1.429 0.169

We have also presented the results in Table 5 graphically to demonstrate the significant changes in primary outcome measures e.g., Lequesne and WOMAC with clinical trial progress time [Figures 1A–D]

Figure 1A: Lequesne Figure 1B: WOMAC

Figure 1C: MCS Figure 1D: PCS

Analysis of Variance A repeated measures ANOVA that was performed over the three time points gave significant results for all scores except PCS (F=0.364, p=0.649). Lequesne and WOMAC score differences were predominantly significantly strong (p<0.001).

  

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Table 3: ANOVA for Primary Outcome Measures.

Repeated Measures ANOVA Score F value p value

Lequesne Index 20.337 < 0.001 WOMAC 31.222 < 0.001

PCS 0.364 0.649 MCS 3.992 0.028

Dropouts There were 3 dropouts in total, 2 males and 1 female. These participants were lost to follow up due to adverse events [2 male] and lack of interest in the trial [1 female]. One of the male dropouts did return his first diary and data was included for analysis as intention-to-treat.

Rescue Medication Rescue medication for knee pain associated with OA was allowed and recorded daily by participants. The type of rescue medication, the number of participants who used rescue medication and the range of tablets/capsules taken is shown in Table 4. Concomitant medications taken by participants that were not associated with the treatment of OA is shown in Table 5. Table 4: Rescue Medication: Number of participants and Range of Capsules/Tablets taken during the clinical trial period.

Medication type

Baseline – week 4 Week 4 – week 8

Rescue Medication for OA Knee Pain: Number of Participants [Range] Paracetamol 7 [2–186] 4 [8–108] Panadol Osteo 4 [4–112] 3 [12–122] NSAIDs 3 [1–24] 1 [12] Panadeine Forte 1 [70] 1 [116] Steroid 1 [5] 0 Nurofen Plus 1 [16] 1 [15] Opioid 2 [2] 0

 

  

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Table 5: Concomitant Medications used by participants during the clinical trial period.

Concomitant Medications Number of Participants [%] NSAID 8 (38.1%) Statins 6 (28.6%) Proton Pump Inhibitor 7 (33.3%) Blood Pressure 10 (47.6%) Methotrexate 1 (4.8%) Steroids 2 (9.5%) Anti-Depressants 9 (42.9%) Flu Vaccination 12 (57.1%) Recent Antibiotics 7 (33.3%) Opioid 2 (9.5%) Anti-histamine 2 (9.5%) Thyroid Medication 3 (14.3%) Diabetic Medication 2 (9.5%) Anti-Coagulant 1 (4.8%) Gout Medication 1 (4.8%) Herpes Medication 1 (4.8%)

Adverse Events Two male participants reported gastrointestinal disturbances that lead to their dropout from the trial. Adverse events included reflux [n=1] and abdominal pain, reflux and diarrhoea [n=1]. In addition two participants who completed the 8–week trial did report experiencing episodes of gout while taking the GLM. Conclusion A non-randomised single group, allocation trial was conducted to investigate the safety and therapeutic efficacy of 3000mg per day of GlycOmegaTM PLUS for OA of the knee(s) over 8 weeks duration. The results demonstrated that GlycOmegaTM PLUS significantly improved joint pain, joint mobility and overall physical function indices in patients with OA of the knee(s). The Lequesne Index demonstrated a 30% improvement from baseline to week 8 and the WOMAC a 43% improvement from baseline to week 8. The SF-12 MCS demonstrated borderline significance from baseline to week 8. The SF-12 PCS did not show any significant improvement. Overall, GlycOmegaTM PLUS may be significantly indicated for the symptomatic relief of joint pain and poor mobility in patients’ diagnosed with OA of the knee(s).

  

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Appendix A Blood Tests Performed – Means and Standard Deviations Blood tests were performed on 19 participants at both baseline and week 8 and 2 participants at baseline only.

Test Performed Baseline Mean ± SD

Week 8 Mean ± SD

Reference Range

Sodium 137.53 [2.82] 138.71 [2.39] 135–145 mmol/L Potassium 4.34 [0.32] 4.39 [0.43] 3.5–4.5 mmol/L Chloride 103.26 [3.30] 103.18 [3.57] 100–110 mmol/L

Bicarbonate 27.84 [1.77] 28.65 [1.77] 22–32 mmol/L Anion Gap 6.32 [2.03] 6.82 [1.74] 4–13 mmol/L Osmolarity 285.79 [5.84] 288.06 [6.28] 275–295 mmol/L

Glucose 5.74 [1.41] 5.66 [2.14] 3.0–6.0 Fasting Urea 6.14 [1.24] 6.31 [1.45] 2.1–7.1 mmol/L

Creatinine 73. 47 [19.46] 74.86 [20.73] 46–90 µmol/L Urea/Creatinine 90.68 [36.58] 89.14 [31.01] 40–100

Glomerular Filtration Rate 70.45 [7.98] 77.07 [12.79] >60 mL/min/1.73m2 Urate 0.39 [0.07] 0.36 [0.11] 0.15–0.45 mmol/L

Protein Total 69.27 [3.50] 68.82 [2.58] 60–83 g/L Albumin 40.45 [1.69] 41.18 [2.79] 35–50 g/L Globulin 28.82 [3.63] 27.71 [2.26] 25–45 g/L

Bilirubin Total 13.36 [3.76] 13.76 [4.04] <20 µmol/L Bilirubin Conjugate < 4.00 4.06 [0.24] <4 µmol/L

Alkaline Phosphatase 81.81 [25.65] 75.65 [23.20] 42–98 U/L Gamma GT 40.64 [49.71] 39.07 [39.00] <38 U/L

Alanine Transferase 30.50 [19.40] 28.00 [15.77] <34 U/L Aspartate Transferase 23.79 [9.30] 21.20 [6.04] <34 U/L

Lactate Dehydrogenase 216.79 [32.35] 216.53 [36.07] 150–280 U/L Calcium 2.33 [0.08] 2.35 [0.07] 2.15–2.55 mmol/L

Calcium corrected 2.32 [0.07] 2.33 [0.07] 2.15–2.55 mmol/L Phosphate 1.27 [0.20] 1.32 [0.19] 0.81–1.45 mmol/L

Haemoglobin 142.18 [12.13] 142.14 [11.14] 115–160 g/L White Cell Count 7.65 [1.73] 7.11 [1.63] 4.0–11.0 x109/L

Platelets 234.50 [52.77] 229.93 [44.75] 140–400 x109/L Haematocrit 0.44 [0.03] 0.43 [0.03] 0.33 – 0.47

Red Cell Count 4.72 [0.32] 4.70 [0.24] 3.8–5.2 x109/L Mean Cell Volume 92.32 [3.70] 92.25 [3.42] 80–100 fL

Neutrophils 4.38 [1.20] 3.94 [1.02] 2.0–8.0 x109/L Lymphocytes 2.34 [0.78] 2.34 [0.80] 1.0–4.0 x109/L

Monocytes 0.65 [0.16] 0.60 [0.14] 0.1–1.0 x109/L Eosinophils 0.29 [0.19] 0.29 [0.28] <0.6 x109/L Basophils 0.03 [0.02] 0.03 [0.01] <0.2 x109/L

C - reactive protein 4.08 [3.49] 3.31 [2.69] < 5.0 mg/L Erythrocyte Sedimentation Rate 14.59 [8.61] 14.21 [7.66] < 19 mm/Hr