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Anti-In Ammatory Activity of Chondroitin Sulfate: M. Iovu M.D., G. Dumais B.S. and P. Du Souich M.D., PH.D
Anti-In Ammatory Activity of Chondroitin Sulfate: M. Iovu M.D., G. Dumais B.S. and P. Du Souich M.D., PH.D
ª 2008 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.joca.2008.06.008
International
Cartilage
Repair
Society
Summary
Osteoarthritis is primarily characterized by areas of destruction of articular cartilage and by synovitis. Articular damage and synovitis are sec-
ondary to local increase of pro-inflammatory cytokines (interleukin-1b and tumor necrosis factor-a), enzymes with proteolytic activity (matrix
metalloproteinases), and enzymes with pro-inflammatory activity (cyclooxygenase-2 and nitric oxide synthase-2). Enhanced expression of
these proteins in chondrocytes and in synovial membrane appears associated to the activation and nuclear translocation of nuclear factor-
kB (NF-kB). Chondroitin sulfate (CS) prevents joint space narrowing and reduces joint swelling and effusion. To produce these effects, CS
elicits an anti-inflammatory effect at the chondral and synovial levels. CS and its disaccharides reduce NF-kB nuclear translocation, probably
by diminishing extracellular signal-regulated kinase1/2, p38mitogen-activated protein kinase and c-Jun N-terminal kinase activation. This re-
view discusses the evidence supporting that CS pleiotropic effects in chondrocytes and synoviocytes are primarily due to a common mech-
anism, e.g., the inhibition of NF-kB nuclear translocation.
ª 2008 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.
Key words: Chondroitin sulfate, Disaccharides, Osteoarthritis, Inflammation, NF-kB, Signal transduction.
S14
Osteoarthritis and Cartilage Supplement 3 S15
Fig. 1. Pro-inflammatory cytokines, EMFs and FN-f activate chondrocytes by increasing the phosphorylation of MAPK, such as ERK/MAPK,
p38MAPK and JNK, and nuclear translocation of NF-kB and AP-1. These transcription factors will induce the expression of cytokines, PLA2,
COX-2, MMPs, NOS-2, etc.
of the knee11,13 and fingers15,16 more effectively than genase-2 (COX-2), and the concentrations of prostaglandin
placebo. According to these effects, CS has been classified E2 (PGE2)18,19. Moreover, in joints CS reduces the concen-
as a symptomatic slow acting drug in osteoarthritis trations of pro-inflammatory cytokines, such as TNF-a20 and
(SYSADOA) and a structure/disease modifying anti-osteo- IL-1b21, and systemic and joint concentrations of NO19,22
arthritis drug (S/DMOAD)11,15. and of reactive oxygen species (ROS)20. On the other
hand, protection of the joint structure may be explained by
the fact that in chondrocytes, CS diminishes IL-1b-mediated
Effect of CS on articular cartilage, increase in MMP-218, MMP-318, MMP-918,19,21, MMP-
mechanism of action 1318,19, and MMP-1418. Moreover, it has been documented
that hyaluronan and mixtures of low concentrations of CS
The complex clinical response to CS may tentatively be and glucosamine are able to prevent the release of MMP-
explained by the numerous effects elicited by CS. On the 3 and MMP-13 triggered by FN-f23,24. Finally, in subchon-
one hand, the decrease in pain and swelling may be dral bone, CS increases osteoprotegerin (OPG) and
explained by an anti-inflammatory effect of CS, probably reduces the expression of receptor activator of NF-kB
through diverse mechanisms such as diminishing the ligand (RANKL), effects that may result in the reduction of
expression of phospholipase A2 (PLA2)17, of cyclooxy the resorptive activity in subchondral bone25.
Fig. 2. Repetitive trauma on the articular cartilage leads to the production of debris of EMFs that will activate the chondrocyte and/or synoviocytes
that will release pro-inflammatory cytokines and MMPs, that will maintain local inflammation and cartilage and subchondral bone destruction.
S16 M. Iovu et al.: Anti-inflammatory activity of CS
In chondrocytes, CS diminishes ERK1/2 phosphorylation macrophages, T lymphocytes, and mast cells infiltration34.
and abrogates the phosphorylation of p38MAPK induced FLS release IL-1b, IL-6, IL-8, MMP-1, MMP-2, MMP-3,
by IL-1b; as a consequence, CS reduces IL-1b-induced MMP-13, MMP-14, MMP-16, tissue inhibitor of metalloprotei-
NF-kB nuclear translocation. However, CS does not reduce nases-1 (TIMP-1), RANKL, transforming growth factor-
IL-1b-induced AP-1 nuclear translocation. On the other b (TGF-b), vascular endothelial growth factor (VEGF), and
hand, CS decreases nitroprusside-induced apoptosis of the fibroblast growth factor (FGF)4.
chondrocytes probably by preventing p38MAPK activation26. There is evidence supporting that the role of NF-kB in the
In chondrocytes, chondroitin disaccharides sulfated at posi- development of synovitis appears pivotal. In FLS, the pro-
tions 4 and/or 6, (1-4)-O-(D-glucopyranosyluronic acid)e(1-3)- duction of IL-1b, IL-6, IL-8, and MMP-1, MMP-3, requires
O-(2-N-acetamido-2-deoxy-D-galactopyranosyl-4/6-sulfate) the activation and nuclear translocation of NF-kB35,36.
(Ddi-4S, Ddi-6S and Ddi-4,6S) reduce IL-1b-induced NF-kB Moreover, the activation of NF-kB increases FLS prolifera-
nuclear translocation to a similar extent as CS, e.g., Ddi-4S, tion and changes the phenotype of these cells to highly
Ddi-6S and Ddi-4,6S reduce NF-kB translocation by 11, 13 invasive FLS with great motility and ability to secrete
and 17%, respectively (P < 0.05, N ¼ 9) (Fig. 3). cytokines and MMP-1337. Inhibition of the IkB kinase
It has been widely documented in the chondrocytes that (IKK) complex impedes the phosphorylation of the inhibitor
IL-1b-induced increase in expression of MMP-327, MMP- of kB (IkBa) and as a consequence, prevents NF-kB activa-
928, MMP-1327,29,30, COX-230,31, nitric oxide synthase-2 tion. In synovial macrophages, inhibition of IKK diminishes
(NOS-2), IL-1b and TNF-a32 is mediated by the activation IL-1b-induced production of IL-6; moreover, in rats with
and nuclear translocation of NF-kB and AP-1. Moreover, adjuvant-induced arthritis, intra-articular injection of a spe-
there is evidence that the activation of PLA2 requires the cific IKK-b inhibitor reduces arthritis activity and bone
activation of p38MAPK and ERK1/231, and that the induc- destruction; synovial inflammation was also decreased as
tion of RANKL expression requires the activation of documented by the reduction in synovial cellularity, TNF-
ERK1/2 and phosphatidylinositol 3-kinase/protein kinase B a, IL-1-b concentrations, and reduction of the volume of
(PI-3K/Akt) pathways33. Since the above mentioned effects the paw38. The role of NF-kB in the initiation of synovitis
of IL-1b in the chondrocyte are mediated by the activation of was further supported by administering in the articulation
p38MAPK and of ERK1/2, and the nuclear translocation of of the rat with adjuvant-induced arthritis a dominant-nega-
NF-kB, it is tempting to speculate that the pleiotropic effects tive form of IKK-b that reduced synovial cellularity by
of CS are dependent, at least in part, by its ability to inhibit 50%, and diminished synovial concentrations of IL-1b,
p38MAPK and ERK1/2 phosphorylation and NF-kB nuclear TNF-a and MMP-339. These results provide evidence that
translocation. activation and nuclear translocation of NF-kB is an impor-
tant step in the development of synovitis.
There is little information about the effect of osteoarthri-
Effect of CS on the synovial membrane, tis treatment with CS on synovitis manifestations, e.g.,
mechanism of action joint swelling and effusion. The multicenter, double-blind,
placebo- and celecoxib-controlled Glucosamine/chondroi-
Synovial tissue from patients with early osteoarthritis tin Arthritis Intervention Trial (GAIT) assessed the effect
shows activated fibroblast-like synoviocytes (FLS), of CS and glucosamine alone or in combination on joint
swelling and/or effusion in 1583 patients with mild to se-
vere knee osteoarthritis14. The patients received
1200 mg of CS, or 1500 mg of glucosamine or both CS
and glucosamine, or 200 mg of celecoxib or placebo, daily
for 24 weeks. The trial demonstrates that CS diminished
the percentage of patients with signs of synovitis (joint
swelling and effusion) from 28.3% at baseline to 12.4%
at the end of 24 weeks of treatment (P ¼ 0.01, N ¼ 307).
It is of interest that the beneficial effect of CS (P ¼ 0.02,
N ¼ 248) was observed in the patients with mild pain
(Western Ontario and McMaster Universities Osteoarthritis
Index (WOMAC) pain scores 125e300). In patients with
moderate to severe pain (WOMAC pain scores
301e400) receiving CS, the percentage of patients with
swelling and/or effusion tended to decrease from 30.0%
at baseline to 14.9% (P ¼ 0.3, N ¼ 67) at the end of
follow-up.
Further supporting that CS reduces the signs and symp-
toms of synovitis, a study showed that intra-articular injec-
tion of hyaluronate, a glycosaminoglycan with a molecular
weight of 8.4 105, to patients with rheumatoid arthritis im-
proves local clinical symptoms, decreases synovial fluid,
reduces PGE2 concentrations and diminishes pain40.
Fig. 3. Effect of CS disaccharides sulfated in positions 4 and/or 6 Several animal studies demonstrate that CS reduces the
(Ddi-4S, Ddi-6S Ddi-4,6S) on Il-1b-induced NF-B nuclear signs and symptoms of synovitis. In DBA/1J mice with
translocation. 200 mg/ml of the disaccharides were incubated with
chondrocytes of rabbits and 24 h later, IL-1b (5 ng/ml) was added,
a type II collagen-induced arthritis, treated for 9 weeks
and the chondrocytes were incubated for an additional 48 h when with various dosages of CS, the infiltration of inflammatory
the nuclear translocation of NF-kB was assessed by immunofluo- cells, granulated tissue formation, proliferation of synovial
rescence as described elsewhere26. *,&P < 0.05 compared with lining cells, paw edema and destruction of articular cartilage
control and IL-1b, respectively. were partially prevented by treatment with 1000 mg/kg/day
Osteoarthritis and Cartilage Supplement 3 S17
Fig. 4. Diagram depicting the potential sites of effect of CS and/or its disaccharides. Local microtraumas produce EMFs and FN-f that activate
chondrocytes by increasing the nuclear translocation of NF-kB in the chondrocytes, synovial macrophages and synoviocytes. NF-kB has
a key role in the pro-inflammatory activation of chondrocytes, and synovial macrophages, mast cells, T-cells and synoviocytes and in the
release of cytokines and MMPs, that will sustain cartilage and subchondral bone destruction.
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