Guideline for the management of knee and hip osteoarthritis

Recommendations

Herbal therapies

Guideline for the management of knee and hip osteoarthritis
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Last revised: 01 Jul 2018

Herbal therapies, supplements and nutraceuticals

Herbal therapies


 

Avocado/soybean unsaponifiables (ASU) – Knee and/or hip

Recommendation

We are unable to recommend for or against the use of ASU for people with knee and/or hip OA.

Strength of recommendation

Conditional (neutral) recommendation

Quality of evidence

Very low

What is it

An extract of avocado and soybean oils, known as ASU, is available in Australia. The usual dose is around 300 mg daily.

Rationale 

The 2014 Cochrane review reports ASU 300 mg produced a small and clinically questionable improvement in symptoms, and probably no increased adverse events, compared with placebo after three to 12 months treatment.127 In the new evidence review for this guideline, short-term pain and function up to six months was improved by about 0.5 standard deviations, and there were no significant longer-term benefits in pain or function. Studies examining the use of supplements are often of low quality constrained by small sample sizes, industry publication bias and potential for positive publication bias. The working group discussed that in the context of low-quality to very low-quality studies, despite some suggestion of beneficial effects, it is prudent to use caution. The working group advocates that further research is needed before a firm recommendation on ASU can be made.

Harms 

In pooled data from five randomised controlled trials (RCTs) spanning three months to three years follow-up, with a total of nearly 600 participants, there was no significant increase in adverse events over placebo.

Boswellia serrata extract – Knee and/or hip

Recommendation

We are unable to recommend for or against the use of Boswellia serrata for people with knee and/or hip OA.

Strength of recommendation

Conditional (neutral) recommendation

Quality of evidence

Very low

What is it? 

Boswellia serata, also known as Indian frankincense, is a tree that is native to India and Arabian Peninsula. The resin of Indian frankincense contains substances that may decrease inflammation. The usual dose is 100 mg of enriched Boswellia serrata daily. 

Rationale 

Three small RCTs found significant short-term benefits in pain and function; however, these are all sponsored by the same company, raising concern about possible bias. The working group discussed that, in the context of low-quality to very low-quality studies, despite potential beneficial effects, it is prudent to use caution and advocate that further research is needed before a firm recommendation on Boswellia serrata can be made.

Harms 

There is limited data on safety available on the use of Boswellia serrata. In two RCTs with follow-up of 30–90 days pooled  (n = 117), there was no significant increase in adverse events over placebo (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document).


 

Curcuma/ curcuminoid – Knee and/or hip

Recommendation

We are unable to recommend for or against the use of curcuma/curcuminoid for people with knee and/or hip OA.

Strength of recommendation

Conditional (neutral) recommendation

Quality of evidence

Low

What is it? 

Curcuma, also known as turmeric, is a commonly used yellow spice. There is insufficient research to recommend a particular dose, and there is concern about variation in the concentration and bio-availability of curcuma in a range of products marketed for arthritis. Curcuma products are readily available in Australia. 

Rationale 

Three small RCTs found significant short-term (ie six to eight weeks) benefits in pain and function; however, these are all industry-sponsored trials, raising concern about possible bias. Additionally, there were inconsistency in the results. All of the studies involved knee OA, so extrapolation to hip or other OA requires additional caution.

The working group discussed that in the context of low-quality to very low-quality studies, despite potential beneficial effects, it is prudent to use caution and advocate that further research is needed before a firm recommendation on curcuma can be made.

Harms 

There is limited data on safety available on the use of curcuma. In two RCTs with follow-up of six to eight weeks pooled  (n = 113), there was no significant increase in serious adverse events over placebo; however, there was a non-statistically significant increase in gastrointestinal adverse events of 15.8% versus 7.1% in placebo (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document).

Pine bark extract – Knee and/or hip

Recommendation

We are unable to recommend either for or against the use of pine bark extract for people with knee and/or hip OA.

Strength of recommendation

Conditional (neutral) recommendation

Quality of evidence

Low (knee)
Very low (hip)

What is it? 

A pine bark, Pinus pinaster (synonym Pinus maritima) extract. The doses used in the reviewed RCTs were 100–150 mg of pine bark extract daily. 

Rationale 

Three small RCTs found short-term benefits in pain and function; however, these could not be pooled because of heterogeneity and reporting weaknesses. All three trials were industry-sponsored, with the larger trial at very high risk of bias. Evidence is based on studies of knee OA, so extrapolation to hip or other OA requires additional caution. The working group discussed that in the context of low-quality to very low-quality studies, despite potential beneficial effects, it is prudent to use caution and advocate that further research is needed before a firm recommendation on the use of pine bark extract.

Harms

There is limited data on safety available on the use of Pycnogenol®. In two RCTs with follow-up of up to three months (n = 137), there was no significant increase in serious adverse events over placebo (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). 

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Related documents

  Administrative-report.pdf (PDF 2.76 MB)

  Implementation-plan.pdf (PDF 1.79 MB)

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