Chondroitin sulfate

Chemical structure of one unit in a chondroitin sulfate chain. Chondroitin-4-sulfate: R₁ = H; R₂ = SO₃H; R₃ = H. Chondroitin-6-sulfate: R₁ = SO₃H; R₂, R₃ = H.

Chondroitin sulfate - alternate diagram

Chondroitin sulfate is a sulfated glycosaminoglycan (GAG) composed of a chain of alternating sugars (N-acetylgalactosamine and glucuronic acid). It is usually found attached to proteins as part of a proteoglycan. A chondroitin chain can have over 100 individual sugars, each of which can be sulfated in variable positions and quantities. Chondroitin sulfate is an important structural component of cartilage and provides much of its resistance to compression.^[1] Along with glucosamine, chondroitin sulfate has become a widely used dietary supplement for treatment of osteoarthritis.

Terminology

Chondroitin sulfate was originally isolated well before the structure was characterised, leading to changes in terminology with time.^[2] Early researchers identified different fractions of the substance with letters.

Letter identification	Site of sulfation	Systematic name
Chondroitin sulfate A	carbon 4 of the N-acetylgalactosamine (GalNAc) sugar	chondroitin-4-sulfate
Chondroitin sulfate C	carbon 6 of the GalNAc sugar	chondroitin-6-sulfate
Chondroitin sulfate D	carbon 2 of the glucuronic acid and 6 of the GalNAc sugar	chondroitin-2,6-sulfate
Chondroitin sulfate E	carbons 4 and 6 of the GalNAc sugar	chondroitin-4,6-sulfate

"Chondroitin sulfate B" is an old name for dermatan sulfate, and it is no longer classified as a form of chondroitin sulfate.^[3]

Chondroitin, without the "sulfate", has been used to describe a fraction with little or no sulfation.^[4] However, this distinction is not used by all.

Although the name "chondroitin sulfate" suggests a salt with a sulfate counter-anion, this is not the case, as sulfate is covalently attached to the sugar. Rather, since the molecule has multiple negative charges at physiological pH, a cation is present in salts of chondroitin sulfate. Commercial preparations of chondroitin sulfate typically are the sodium salt. Barnhill et al. have suggested that all such preparations of chondroitin sulfate be referred to as "sodium chondroitin" regardless of their sulfation status.^[5]

Structure

Chondroitin sulfate chains are unbranched polysaccharides of variable length containing two alternating monosaccharides: D-glucuronic acid (GlcA) and N-acetyl-D-galactosamine (GalNAc). Some GlcA residues are epimerized into L-iduronic acid (IdoA); the resulting disaccharide is then referred to as dermatan sulfate.

Protein attachment

Chondroitin sulfate chains are linked to hydroxyl groups on serine residues of certain proteins. Exactly how proteins are selected for attachment of glycosaminoglycans is not understood. Glycosylated serines are often followed by a glycine and have neighboring acidic residues, but this motif does not always predict glycosylation.

Attachment of the GAG chain begins with four monosaccharides in a fixed pattern: Xyl - Gal - Gal - GlcA. Each sugar is attached by a specific enzyme, allowing for multiple levels of control over GAG synthesis. Xylose begins to be attached to proteins in the endoplasmic reticulum, while the rest of the sugars are attached in the Golgi apparatus.^[6]

Sulfation

Each monosaccharide may be left unsulfated, sulfated once, or sulfated twice. In the most common scenario, the hydroxyls of the 4 and 6 positions of the N-acetyl-galactosamine are sulfated, with some chains having the 2 position of glucuronic acid. Sulfation is mediated by specific sulfotransferases. Sulfation in these different positions confers specific biological activities to chondroitin GAG chains.

Function

Chondroitin's functions depend largely on the properties of the overall proteoglycan of which it is a part. These functions can be broadly divided into structural and regulatory roles. However, this division is not absolute, and some proteoglycans have both structural and regulatory roles (see versican).

Structural

Chondroitin sulfate is a major component of extracellular matrix, and is important in maintaining the structural integrity of the tissue. This function is typical of the large aggregating proteoglycans: aggrecan, versican, brevican, and neurocan, collectively termed the lecticans.

As part of aggrecan, chondroitin sulfate is a major component of cartilage. The tightly packed and highly charged sulfate groups of chondroitin sulfate generate electrostatic repulsion that provides much of the resistance of cartilage to compression. Loss of chondroitin sulfate from the cartilage is a major cause of osteoarthritis.

Regulatory

Chondroitin sulfate readily interacts with proteins in the extracellular matrix due to its negative charges. These interactions are important for regulating a diverse array of cellular activities. The lecticans are a major part of the brain extracellular matrix, where the chondroitin sugar chains function to stabilize normal brain synapses as part of perineuronal nets. The levels of chondroitin sulfate proteoglycans are vastly increased after injury to the central nervous system where they act to prevent regeneration of damaged nerve endings. Although these functions are not as well characterized as those of heparan sulfate, new roles continue to be discovered for the chondroitin sulfate proteoglycans.

In cortical development, chondroitin sulfate is expressed by the Sub Plate and acts as a stop signal for neurons migrating from the Ventricular Zone. Neurons stopping here may then be programmed for further migration to specific layers in the cortical plate.

Medical use

Chondroitin is in dietary supplements used as an alternative medicine to treat osteoarthritis and also approved and regulated as a symptomatic slow-acting drug for this disease (SYSADOA) in Europe and some other countries.^[7] It is commonly sold together with glucosamine. Chondroitin and glucosamine are also used in veterinary medicine.^[8]

Pharmacology

The dosage of oral chondroitin used in human clinical trials is 800–1,200 mg per day. Most chondroitin appears to be made from extracts of cartilaginous cow and pig tissues (cow trachea and pig ear and nose), but other sources such as shark, fish, and bird cartilage are also used. Since chondroitin is not a uniform substance, and is naturally present in a wide variety of forms, the precise composition of each supplement will vary.^[5] In fact, although many food supplement companies produce their products in compliance with human food processing GMP, most of them do not produce their products in compliance with the GMP regulations for pharmaceuticals, resulting in products without pharmaceutical requirements.^[9]

Recent testing has revealed several flaws in the older testing methods. Without knowing the source of the chondroitin (e.g., shark, porcine, or bovine) and the approximate age of the animal, it is impossible to get a reliable reference standard, and, thus, results from previous testing had yielded percentages between 50 and 400%. In 2007, David Ji et al. reported in the Journal of Analytical Chemistry an extremely accurate method of quantification. The method included using an enzyme to break the chondroitin into its individual unsaturated disaccharides, and then measuring them using HPLC with an ion-pairing column and UV detection.^[10]

Clinical studies have not identified any significant side effects or overdoses of chondroitin sulfate, which suggest its long-term safety.^[11] The Task Force of the European League Against Rheumatism (EULAR) committee recently granted chondroitin sulfate a level of toxicity of 6 in a 0-100 scale, confirming it is one of the safest drugs for osteoarthritis.^[7] Moreover, its safety is supported by an absence of drug-drug interactions (chondroitin sulfate is not metabolized by cytochrome P450),^[12] and the lack of safe alternatives for patients multi-medicated for osteoarthritis and other accompanying diseases, e.g. diabetes, hypertension, hyperlipidemia, etc.

While it is a prescription or over-the-counter drug in 22 countries, chondroitin is regulated in the U.S. as a dietary supplement [1] by the Food and Drug Administration. As a result, in chondroitin sulfate supplements, there are no mandatory standards for formulation, and no guarantee that the product is correctly labelled. This is not the case in Europe, where there is a chondroitin sulfate formulation approved as a drug and considered as the reference product, with evidenced efficacy and safety demonstrated by clinical trials in osteoarthritic patients.^[13] Adebowale et al. reported in 2000 that of 32 chondroitin supplements they analysed, only 5 were labeled correctly, and more than half contained less than 40% of the labeled amount.^[14] Hence, the importance of testing the bioequivalence of all chondroitin sulfate formulations with the reference product approved in Europe. However, United States Pharmacopoeia (USP) testing standards now exist for the identification and quantification of chondroitin.

Bioavailability and pharmacokinetics

Pharmacokinetic studies performed on humans and experimental animals after oral administration of chondroitin sulfate revealed that it can be absorbed orally. Chondroitin sulfate shows first-order kinetics up to single doses of 3,000 mg.^{[15][16][17][18]} Multiple doses of 800 mg in patients with osteoarthritis do not alter the kinetics of chondroitin sulfate. The bioavailability of chondroitin sulfate ranges from 15% to 24% of the orally administered dose. More particularly, on the articular tissue, Ronca et al.^[19] reported that chondroitin sulfate is not rapidly absorbed in the gastro-intestinal tract and a high content of labeled chondroitin sulfate is found in the synovial fluid and cartilage.

Mechanisms of action

The effect of chondroitin sulfate in patients with osteoarthritis is likely the result of a number of reactions including its anti-inflammatory activity, the stimulation of the synthesis of proteoglycans and hyaluronic acid, and the decrease in catabolic activity of chondrocytes inhibiting the synthesis of proteolytic enzymes, nitric oxide, and other substances that contribute to damage cartilage matrix and cause death of articular chondrocytes. A recent review summarizes data from relevant reports describing the biochemical basis of the effect of chondroitin sulfate on osteoarthritis articular tissues.^[20] The rationale behind the use of chondroitin sulfate is based on the belief that osteoarthritis is associated with a local deficiency in some natural substances, including chondroitin sulfate.

Recently, new mechanisms of action have been described for chondroitin sulfate. In an in vitro study, chondroitin sulfate reduced the IL-1β-induced nuclear factor-kB (NF-κB) translocation in chondrocytes.^[21] In addition, chondroitin sulfate has recently shown a positive effect on osteoarthritic structural changes occurred in the subchondral bone.^[22]

Clinical trials

Many randomized controlled trials have been conducted with mixed results. These trials have been summarized:

• Reichenbach et al^[23] used explicit methods to conduct and report^[24] a systematic review of 20 trials and concluded "large-scale, methodologically sound trials indicate that the symptomatic benefit of chondroitin is minimal or nonexistent. Use of chondroitin in routine clinical practice should therefore be discouraged."
• Bruyere et al^[25] without using explicit methodology for reviewing trials concluded "there is compelling evidence that glucosamine sulfate and chondroitin sulfate may interfere with progression of OA."

The major trial included in the two review above was the GAIT study.^[26] GAIT was funded by National Institutes of Health to test the effects of chondroitin and glucosamine on osteoarthritis of the knee. This multicenter, placebo-controlled, double-blind, six month long trial found that glucosamine plus chondroitin had no statistically significant effect on symptoms of osteoarthritis in the overall group of osteoarthritis patients. However, in the moderate-to-severe pain subgroup, the combination of chondroitin and glucosamine was found to be more effective in treating pain than celecoxib or chondroitin and glucosamine taken individually. Due to small sample sizes in the sub-group (roughly 250 people), the researchers concluded that this needs further validation. The study also found chondroitin sulfate to have a significant effect in reducing joint swelling, effusion, or both. These results indicate that glucosamine and chondroitin do not effectively relieve osteoarthiritic pain in the overall group of osteoarthritis patients, though it may be an effective treatment for those suffering from moderate-to-severe pain.[2] Some of the researcher's ties to Pfizer (who makes celecoxib), have brought into question the validity of the study. [3]

Clinical practice guidelines based on trials prior to publication of the negative review by Reichenbach^[23] and the negative GAIT trial^[26] recommended used of cohondroitin. The OARSI (OsteoArthritis Research Society International) recommended chondroitin sulfate as the second-most-effective treatment for moderate cases of osteoarthritis (although the guidelines were published in 2008, the developers closed their search date in January, 2006 prior to the GATE trial).^[27] Likewise, the European League Against Rheumatism (EULAR) supported the usefulness of chondroitin sulfate in the management of knee osteoarthritis and grants the highest level of evidence, 1A, and strength of the recommendation, A, to this product.^[28]

Contamination in heparin

On Wednesday, March 19, 2008 the U.S. Food and Drug Administration (FDA) identified "oversulfated chondroitin sulfate" as a contaminant in heparin originating from China.^[29]

In this regard, "it is very important to remark on the relevant chemical differences between the chondroitin sulfate formulation approved in Europe as a drug and considered the reference product, and the “oversulfated chondroitin sulfate” identified as a contaminant in heparin originating from China."

The “oversulfated chondroitin sulfate” is not a product extracted from biological sources; it is synthesized through a sulfation reaction from the biological molecule. This is a semi-synthesis process that uses naturally derived chondroitin sulfate as a reagent in combination with various potentially dangerous chemicals, though their significance in the toxicity of "oversulfated chondroitin sulfate" is not known.

The resulting product contains 3 or 4 sulfate groups per disaccharide, and, therefore, its structure differs considerably from the original one (see #Sulfation section above). Furthermore, analysis of the contaminant unexpectedly revealed an unusual type of sulfation not found in any natural sources of chondroitin sulfate. In addition, a tetrasulfated disaccharide repeat unit has not been isolated to date from animal tissues^[30]

Thus, chondroitin sulfate is merely the substrate of the reaction: The final, oversulfated molecule constitutes a new entity, whose pharmacological and clinical properties are most likely very different from the biological molecule, as it is demonstrated in a recent article published in New England Journal of Medicine. In this study,^[31] Sasisekharan and colleagues showed that the oversulfated chondroitin sulfate (OSCS) found in contaminated lots of unfractionated heparin, as well as a synthetically generated OSCS reference standard, directly activated the kinin–kallikrein pathway in human plasma, which can lead to the generation of bradykinin, a potent vasoactive mediator. In addition, OSCS induced generation of C3a and C5a, potent anaphylatoxins derived from complement proteins. Chondroitin sulfate A was also tested and it showed no induction of amidollytic activity. Screening of plasma samples from various species indicated that swine and humans are sensitive to the effects of OSCS in a similar manner. OSCS-containing heparin and synthetically derived OSCS-induced hypotension associated with kallikrein activation when administered by intravenous infusion in swine. In contrast, none of the three pigs treated with chondroitin sulfate A showed any significant changes in blood pressure or heart rate.

See also

• Gout
• Heparin sulfate - a glycosaminoglycan of major pharmaceutical importance for many decades
• Heparan sulfate - a glycosaminoglycan component of proteoglycans in a wide range of vertebrate & invertebrate life
• Methylsulfonylmethane

References

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2. ^ P. A. Levene and F. B. La Forge (1913). "On Chondroitin Sulphuric Acid". J. Biol. Chem. 15: 69–79.  Free PDF online
3. ^ MeSH Chondroitin+sulfates
4. ^ Davidson EA, Meyer K (1954). "Chondroitin, a new mucopolysaccharide". J Biol Chem 211 (2): 605–11. PMID 13221568.  Free PDF online
5. ^ ^{a b} Barnhill JG, Fye CL, Williams DW, Reda DJ, Harris CL, Clegg DO (2006). "Chondroitin product selection for the glucosamine/chondroitin arthritis intervention trial". J Am Pharm Assoc (Wash DC) 46 (1): 14–24. PMID 16529337. 
6. ^ Silbert JE, Sugumaran G (2002). "Biosynthesis of chondroitin/dermatan sulfate". IUBMB Life 54 (4): 177–86. doi:10.1080/15216540214923. PMID 12512856. 
7. ^ ^{a b} Jordan KM, Recommendations Arden NK. EULAR (2003). "an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT)". Ann Rheum Dis 62 (12): 1145–1155. doi:10.1136/ard.2003.011742. PMC 1754382. PMID 14644851. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1754382. 
8. ^ Forsyth R, Brigden C, Northrop A (2006). "Double blind investigation of the effects of oral supplementation of combined glucosamine hydrochloride (GHCL) and chondroitin sulfate (CS) on stride characteristics of veteran horses". Equine veterinary journal. Supplement (36): 622–5. PMID 17402494. 
9. ^ Jamie G. Barnhill, Carol L. Fye, David W. Williams, Domenic J. Reda, Crystal L. Harris, and Daniel O. Clegg. Chondroitin Product Selection for the Glucosamine/Chondroitin Arthritis Intervention Trial. J Am Pharm Assoc. 2006; 46:14–24.
10. ^ Ji D, Roman M, Zhou J, Hildreth J (2007). "Determination of Chondroitin Sulfate Content in Raw Materials and Dietary Supplements by High-Performance Liquid Chromatography with Ultraviolet Detection After Enzymatic Hydrolysis: Single-Laboratory Validation". J AOAC Int. 90 (3): 659–669. PMC 2614115. PMID 17580617. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2614115. 
11. ^ 13. Hathcock JN, Shao a. Risk assessment for glucosamine and chondroitin sulfate. Regulatory Toxicology and Pharmacology, 2007; 47: 78-83
12. ^ Andermann G, Dietz M. The influence of the route of administration on the bioavailability of an endogenous macromolecule: chondroitin sulfate (CSA). Eur J Drug Metab Pharmacokinet 1982;7:11–6
13. ^ Vergés J, Castañeda-Hernández, G. On the bioavailability of oral chondroitin sulfate formulations: proposed criteria for bioequivalence studies. Proc. West. Pharmacol. Soc., 2004; 47: 50-53
14. ^ Adebowale AO Cox DS, Liang Z, Eddington ND (2000). "Analysis of glucosamine and chondroitin sulfate content in marketed products and the Caco-2 permeability of chondroitin sulfate raw materials". J Am Nutr Assoc 3: 37–44. http://www.americanutra.com/itemdetail.cfm?ProductID=37. ^{[dead link]}
15. ^ Conte A, Palmieri L, Segnini D, Ronca G. Metabolic fate of partially depolymerized chondroitin sulfate administered to the rat. Drugs Exp Clin Res. 1991;17:27-33.
16. ^ Conte A, de Bernardi M, Palmieri L, Lualdi P, Mautone G, Ronca G. Metabolic fate of exogenous chondroitin sulfate in man. Arzneimittelforschung. 1991;41:768-72.
17. ^ Conte A, Volpi N, Palmieri L, Bahous I, Ronca G. Biochemical and pharmacokinetic aspects of oral treatment with chondroitin sulfate. Arzneimittelforschung. 1995;45:918-25.
18. ^ Palmieri L, Conte A, Giovannini L, Lualdi P, Ronca G. Metabolic fate of exogenous chondroitin sulfate in the experimental animal. Arzneimittelforschung. 1990;40:319-23.
19. ^ Ronca F, Palmieri L, Panicucci P, Ronca G. Anti-inflammatory activity of chondroitin sulfate. Osteoarthritis Cartilage. 1998;6 Suppl A:14-21.
20. ^ Monfort J, Pelletier J-P, Garcia-Giralt N, Martel-Pelletier J. Biochemical basis of the effect of chondroitin sulfate on osteoarthritis articular tissues. Ann Rheum Dis 2007; doi:10.1136/ard.2006.068882 .
21. ^ Jomphe C, Gabriac M, Hale TM, Heroux L, Trudeau LE, Deblois D, Montell E, Verges J, du Souich P. Chondroitin Sulfate Inhibits the Nuclear Translocation of Nuclear Factor-kappaB in Interleukin-1beta-Stimulated Chondrocytes. Basic Clin Pharmacol Toxicol. 2007 Nov 5
22. ^ Kwan Tat S, Pelletier JP, Verges J, Lajeunesse D, Montell E, Fahmi H, Lavigne M, Martel-Pelletier J. Chondroitin and glucosamine sulfate in combination decrease the pro-resorptive properties of human osteoarthritis subchondral bone osteoblasts: a basic science study. Arthritis Res Ther. 2007 Nov 9;9(6):R117
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24. ^ Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF (1999). "Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta-analyses.". Lancet 354 (9193): 1896–900. doi:10.1016/S0140-6736(99)04149-5. PMID 10584742. http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10584742. 
25. ^ Bruyere O, Reginster JY (2007). "Glucosamine and chondroitin sulfate as therapeutic agents for knee and hip osteoarthritis.". Drugs Aging 24 (7): 573–80. PMID 17658908. http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17658908. 
26. ^ ^{a b} Clegg DO, Reda DJ, Harris CL, Klein MA, O'Dell JR, Hooper MM et al. (2006). "Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis.". N Engl J Med 354 (8): 795–808. doi:10.1056/NEJMoa052771. PMID 16495392. http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16495392.  Review in: Evid Based Med. 2006 Aug;11(4):115 Review in: ACP J Club. 2006 Jul-Aug;145(1):17
27. ^ Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N et al. (2008). "OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines.". Osteoarthritis Cartilage 16 (2): 137–62. doi:10.1016/j.joca.2007.12.013. PMID 18279766. http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18279766. 
28. ^ Jordan KM, Arden NK, Doherty M, Bannwarth B, Bijlsma JW, Dieppe P et al. (2003). "EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT).". Ann Rheum Dis 62 (12): 1145–55. doi:10.1136/ard.2003.011742. PMC 1754382. PMID 14644851. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1754382. 
29. ^ Zawisza, Julie (2008-03-19). "FDA Media Briefing on Heparin" (PDF). U.S. Food and Drug Administration. http://www.fda.gov/downloads/NewsEvents/Newsroom/MediaTranscripts/UCM169335.pdf. Retrieved 2008-04-23. 
30. ^ Guerrini, M.; Beccati, D.; Shriver, Z.; Naggi, A.; Viswanathan, K.; Bisio, A.; Capila, I.; Lansing, C. et al. (Jun 2008). "Oversulfated chondroitin sulfate is a contaminant in heparin associated with adverse clinical events". Nature biotechnology 26 (6): 669–675. doi:10.1038/nbt1407. ISSN 1087-0156. PMID 18437154.  edit
31. ^ Kishimoto, K.; Viswanathan, K.; Ganguly, T.; Elankumaran, S.; Smith, S.; Pelzer, K.; Lansing, C.; Sriranganathan, N. et al. (Jun 2008). "Contaminated heparin associated with adverse clinical events and activation of the contact system". The New England journal of medicine 358 (23): 2457–2467. doi:10.1056/NEJMoa0803200. ISSN 0028-4793. PMID 18434646.  edit

External links

• General Glucosamine and Chondroitin Sulfate information at Arthritis Foundation
• "Product Review: Joint Supplements (Glucosamine, Chondroitin, and MSM)" Summary of a Consumer Labs test of the actual composition of these supplements at consumerlabs.com
• "Glucosamine/Chondroitin Products Not Measuring Up", News report of the analysis of commercial supplements by Adebowale et al. at WebMD
• "Chondroitin Sulfate Manufacturing and Risk of Mad Cow Disease" by Winston Wicomb, Ph.D., September 24, 2002. Information on methods for extraction of chondrotin sulfate from cow trachea, at the Stone Clinic of San Francisco, at stoneclinic.com
• "Testing Status: Chondroitin Sulfate M030009", A thorough review of available information on the use of chondroitin sulfate in humans from the National Toxicology Program at National Institute of Environmental Health Sciences
• Chondroitin Sulfate, summary of information on the use of chondroitin sulfate from the publishers of the Physicians' Desk Reference.

• "Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT)," ClinicalTrials.gov information on the purpose, design, and analysis of the study at clinicaltrials.gov
• "NIH News: Efficacy of Glucosamine and Chondroitin Sulfate May Depend on Level of Osteoarthritis Pain", Wednesday, February 22, 2006 at National Institutes of Health