Kerry Bone’s recommendations for Standard Process and/or

MediHerb product dosages are sometimes different than the doses that

appear on the product labels. Please refer to the product labels or to

the product descriptions found in the product catalogs for the

Standard Process and MediHerb dosage recommendations.

Herbal Insights for

Joint Health

Kerry Bone Co-Founder and Director Research & Development MediHerb Adjunct Associate Professor University of New England, Australia

Boswellia: A Rational Therapy for Joint Health

Boswellic Acids

CH3

HOOC CH3

HO

CH3CH3

CH3

CH3

H3C

-Boswellic Acid

Boswellia: A Rational Therapy for Joint Health A 2010 review noted the following effects of

Boswellia or boswellic acids from in vitro and in vivo experiments: • Inhibition of 5-LOX, but only minor activity on

PGE production • Downregulation of TNF- by inhibition of NF-B • Inhibition of IL-1 production • Inhibition of C3-convertase of the complement

system Particularly active are 11-keto--boswellic acid

(KBA) and acetyl-11-keto--boswellic acid (AKBA) Ammon HP. Phytomedicine 2010; 17(11): 862-867

Boswellia: The Clinical Evidence

The clinical evidence for Boswellia in Joint Health is good

In particular, there are suggestions from some trials that Boswellia therapy might be joint health modifying

These health-modifying effects should be no surprise given the broad range of its effects that are relevant to joint health

There are 4 key randomised, controlled clinical trials. Some of the results are striking

Boswellia: The Clinical Evidence A placebo-controlled, crossover trial in 30 patients

found that 8 weeks of Boswellia extract (1000 mg/day, 40% boswellic acids) significantly (p<0.001) effective1

Another trial in 66 patients found that Boswellia extract (1000 mg/day, 40% boswellic acids) was as effective as conventional therapy over 6 months2

1 Kimmatkar N, Thawani V, Hingorani L et al. Efficacy and tolerability of Boswellia serrata extract in treatment of osteoarthritis of knee-a randomized double blind placebo controlled trial. Phytomedicine 2003; 10(1): 3-7

2 Sontakke S, Thawani V, Pimpalkhute S et al. Efficacy and tolerability of Boswellia serrata extract in treatment of osteoarthritis of knee-a randomized double blind placebo controlled trial. Indian J Pharmacology 2007; 39(1): 27-29

Boswellia: The Clinical Evidence

However, while Boswellia had a slower onset of action (about 1 month), its effect persisted after discontinuation of therapy

This suggests it could be joint health modifying

In a 2008 trial, 75 patients received either two doses of a specialised Boswellia extract (100 or 280 mg/day of a AKBA-enriched extract) or a placebo for 90 days1

1 Sengupta K, Alluri KV, Satish AR et al. A double blind, randomized, placebo controlled study of the efficacy and safety of 5-Loxin® for treatment of osteoarthritis of the knee Arthritis Res Ther 2008; 10: R85

Boswellia: The Clinical Evidence Benefits were faster in the higher dose group (as

early as 7 days) and significantly better than placebo and MMP-3 in synovial fluid was significantly and substantially reduced in both Boswellia groups

A 2010 trial compared the specialised extract above at 100 mg/day with 100 mg/day of a similar extract (but with enhanced bioavailability) and a placebo over 90 days in 60 patients with knee challenges1

Clinical results were remarkable in patients taking the enhanced extract (p<0.0001)

1 Sengupta K, Krishnaraju AV, Vishal AA et al. Comparative efficacy and tolerability of 5-Loxin and AflapinAgainst osteoarthritis of the knee: a double blind, randomized, placebo controlled clinical study, Int J Med Sci 2010; 7(6): 366-377

Boswellia Bioavailability

Optimising Pharmacokinetics

In a randomised, open, single-dose, two-way crossover study, 12 healthy male volunteers received 786 mg of Boswellia extract either with or without a standard high-fat meal1

Plasma concentrations of boswellic acids were measured up to 60 hours after the oral dosing

1 Sterk V, Buchele B, Simmet T. Planta Med, 2004; 70(12): 1155-1160

Boswellia Bioavailability

Optimising Pharmacokinetics

Administration in conjunction with a high-fat meal led to a substantial improvement in the bioavailability of the boswellic acids

For example, the maximum concentration for AKBA was 6.0 ng/mL for the fasted conditions versus 28.8 ng/mL with food

This means that Boswellia is best taken with meals, especially those containing some animal or vegetable fat

Boswellia Complex

Each tablet contains:

Boswellia serrata (Boswellia) extract 1.9 g equivalent to dry gum oleoresin standardised to contain boswellic acids 180 mg

Curcuma longa (Turmeric) extract 2.0 g equivalent to dry rhizome standardised to contain curcuminoids 70.4 mg

Apium graveolens (Celery) extract 1.0 g equivalent to dry fruit

Zingiber officinale (Ginger) extract 300 mg equivalent to dry rhizome

Dosage: 1 tablet 2 to 4 times per day

Willow Bark

What is It?

Many Willow Bark species are used especially Salix alba, S. daphnoides and S. purpurea

They all contain derivatives of salicylic acid, mainly salicin

Clinical trials have found that a high potency Willow Bark extract standardised for salicin has significant activity, but with fewer side effects than conventional therapy

In fact it acts quite differently to conventional therapy

Willow Bark

A Large-Scale Study

A large-scale study found that Willow Bark when tested in a clinical setting had a superior safety and efficacy profile compared to conventional therapy

Presented at a Berlin conference 2004 and involved 922 physicians and 4,731 patients in Germany1

1 Werner G, Scheithe K. Congress Phytopharmaka and Phytotherapy. Berlin, February 26-28, 2004

Willow Bark

A Large-Scale Study

Over 6 to 8 weeks, patients with joint challenges and discomfort took various doses of Willow Bark extract (an average of around 3 tablets per day) and rated their discomfort from 1 to 10 (with 10 representing the highest intensity)

Most of the patients had previously been taking conventional therapy, but had generally discontinued these because of either a lack of efficacy or side effects

Willow Bark: Clinical Trials

A Large-Scale Study

During the observation period, only 15.5% needed supplementary support in addition to their Willow Bark

Average discomfort reduced from 6.4 to 3.7 points in the first 4 weeks of treatment and had fallen further to 2.7 after 8 weeks, with 97% of patients reporting a reduction in discomfort and 18% reporting no discomfort at all

Side effects were judged as minor and occurred in only 1.3% of patients

MediHerb Saligesic

A high potency Willow Bark extract in tablet form phytoequivalent to the extract proven in clinical trials

Each tablet contains 400 mg of extract with 60 mg of salicin, corresponding to 8 g of bark

Dose is 2 to 4 tablets per day

Nutrition and Joint Health

Low dietary vitamin C intake was associated with increased risk of progression, but not incidence of knee joint challenges

Suboptimal selenium intake has been linked to worsening musculoskeletal challenge

A low dietary intake and serum level of vitamin D was associated with progression of knee joint challenges, other results have been controversial

No relationship has been found for dietary vitamins E, B1, B6, niacin and folate

Zhang Y, Jordan JM. Clin Geriatr Med 2010; 26(3): 355-369

Cheung PP, Gossec L, Dougados M. Best Pract Res Clin Rheumatol 2010; 24(1): 81-92

Garlic and Joint Health

Previous slides propose that microcirculatory and CV factors may predispose to joint challenge

This was supported by a UK study in female twins that found a strong protective effect on radiographic hip challenge for “Allium” consumption (Odds Ratio 0.70)

Non-citrus fruit was also protective (OR 0.56)

Williams FM, Skinner J, Spector TD et al. Dietary garlic and hip osteoarthritis: evidence of a protective effect and putative mechanism of action. BMC Musculoskelet Disord 2010; 11: 280

Herbs for Joint Health

Therapeutic Strategy: Goals, Actions and Herbs

The herbal approach regards joint health not as a focal joint issue, but a systemic challenge. Emphasis is placed on an alkaline-forming diet

Herbs which make the body more alkaline are a key part of the support of joint health, and the main herb in this category is Celery Seed. This is considered to increase the excretion of acidic metabolites in the urine

Another herb used for joint health in this category is Dandelion Leaves

Herbs for Joint Health

Therapeutic Strategy: Goals, Actions and Herbs

Depuratives, which are believed to aid in the clearance of metabolic waste from the body, are often recommended. These include Burdock and Yellow Dock, but the key herb is Nettle Leaf which has recently been found to also have joint supporting properties

Bladderwrack is used for overweight patients with joint challenge because of its thyroid-supporting activity, but may also have other effects

Herbs for Joint Health

Therapeutic Strategy: Goals, Actions and Herbs St John’s Wort is used where nerve involvement

is present. Because of its positive effect on the nervous system, particularly in support of mood, it can also help to compensate for negative psychosocial factors and improve sleep quality

Joint supporting herbs are often used and these include Boswellia, Ginger and Turmeric. Herbs which may modify cytokines and other processes, eg Rehmannia, Bupleurum and Boswellia and those working on NFB like Feverfew should be considered

Herbs for Joint Health

Therapeutic Strategy: Goals, Actions and Herbs

Willow Bark is the key joint discomfort supporting herb

The importance of improving the circulation to challenged joints has long been recognised. Garlic, Ginkgo and Celery Seed are considered key herbs

Herbs to benefit the microcirculation are also relevant, such as Grape Seed and Pine Bark extracts (sources of OPCs), Bilberry, Gotu Kola and Ginkgo

Gotu Kola should be considered as a long-term management to improve viability of chondrocytes

Herbs for Joint Health

Example Tablet Therapy

Core Support

Boswellia Complex tablets (3 to 4 per day) with a possible loading dose

Additional Support (as required)

Saligesic tablets (2 to 4 per day) especially if discomfort is a substantial feature

Herbs for Joint Health

Additional Support (as required)

Herbs for circulation, especially Garlic tablets (1 to 2 per day) and Ginkgo Forte tablets (2 to 3 per day) or HerbaVital tablets (2 to 3 per day) if there are general symptoms of circulatory challenge

St John’s Wort tablets (3 to 4 per day) if nerve discomfort is present

Gotu Kola 1:1 liquid (4 mL 1 to 2 times per day) to support the body’s natural repair and healing process or Gotu Kola Complex tablets (3 to 4 per day)

Herbs for Joint Health

Example Liquid Formula

Celery Seed 1:2 35 mL

Nettle Leaf 1:2 35 mL

Ginger 1:2 10 mL

Turmeric 1:1 30 mL

110 mL

Dosage: 8 mL with water twice per day

Case History

A Case of Small Joint Challenge

This challenge can be very difficult to manage and is quite stubborn, presumably because of its hereditary aspect

The following 58-year-old female patient had significant challenge on all of her fingers, with marked stiffness and moderate discomfort

Case History

The patient was initially prescribed the following liquid:

Ginger 1:2 15 mL

Celery Seed 1:2 50 mL

Nettle Leaf 1:2 35 mL

100 mL

Dosage: 8 mL with water twice per day

Boswellia Complex tablets at 2 per day were also included

Case History

Progress was initially steady but not dramatic

In the following 6 months 2 Saligesic tablets per day were added and the patient reported a big improvement in her discomfort and stiffness, despite being more active than usual

Thank You Questions