Glucosamine

Glucosamine
Names
IUPAC name
(3R,4R,5S)-3-Amino-6-(hydroxymethyl)oxane-2,4,5-triol
Other names
2-Amino-2-deoxy-glucose
Chitosamine
Identifiers
3D model (JSmol)
1723616
ChEBI
ChemSpider
DrugBank
ECHA InfoCard 100.020.284
EC Number 222-311-2
720725
KEGG
MeSH Glucosamine
UNII
Properties
C6H13NO5
Molar mass 179.17 g·mol−1
Density 1.563 g/mL
Melting point 150 °C (302 °F; 423 K)
log P -2.175
Acidity (pKa) 12.273
Basicity (pKb) 1.724
Pharmacology
M01AX05 (WHO)
Except where otherwise noted, data are given for materials in their standard state (at 25 °C [77 °F], 100 kPa).
N verify (what is YesYN ?)
Infobox references

Glucosamine (C6H13NO5) is an amino sugar and a prominent precursor in the biochemical synthesis of glycosylated proteins and lipids. Glucosamine is part of the structure of the polysaccharides chitosan and chitin, which compose the exoskeletons of crustaceans and other arthropods, as well as the cell walls of fungi and many higher organisms. Glucosamine is one of the most abundant monosaccharides.[1] It is produced commercially by the hydrolysis of crustacean exoskeletons or, less commonly, by fermentation of a grain such as corn or wheat.

Evidence for the effectiveness of glucosamine supplements is mixed. In the United States, it is one of the most common non-vitamin, non-mineral, dietary supplements used by adults.[2]

Medical uses

Oral glucosamine is a dietary supplement and is not a pharmaceutical drug. It is illegal in the US to market any dietary supplement as a treatment for any disease or condition.[3] Glucosamine is marketed to support the structure and function of joints, and the marketing is targeted to people suffering from osteoarthritis. Commonly sold forms of glucosamine are glucosamine sulfate, glucosamine hydrochloride, and N-acetylglucosamine. Of the three commonly available forms of glucosamine, only glucosamine sulfate is given a "likely effective" rating for treating osteoarthritis.[4] Glucosamine is often sold in combination with other supplements such as chondroitin sulfate and methylsulfonylmethane.

Glucosamine, along with commonly used chondroitin, is not routinely prescribed to treat people who have symptomatic osteoarthritis of the knee, as there is insufficient evidence that this treatment is helpful.[5]

As is common with heavily promoted dietary supplements, the claimed benefits of glucosamine are based principally on clinical and laboratory studies. Clinical studies are divided, with some reporting relief from arthritic pain and stiffness, while higher quality studies report no benefit above placebo.[6]

There is no evidence to date that consumption of glucosamine by sport participants will prevent or limit joint damage after injury.[7] In a randomized placebo-controlled trial, glucosamine supplementation had no additional effect on any rehabilitation outcome when given to athletes after anterior cruciate ligament (ACL) reconstruction.[8]

Adverse effects and drug interactions

One clinical study over three years showed that glucosamine in doses of 1500 mg per day is safe to use.[9]

Glucosamine with or without chondroitin elevates the international normalized ratio (INR) in individuals who are taking the blood thinner, warfarin.[4][10] It may also interfere with the efficacy of chemotherapy for treating cancer symptoms.[4]

Adverse effects may include stomach upset, constipation, diarrhea, headache, and rash.[11] There are case reports of people who have chronic liver disease and a worsening of their condition with glucosamine supplementation.[12] More high-quality clinical research is needed before recommending glucosamine in pregnancy.[4]

Since glucosamine is usually derived from the shells of shellfish, it may be unsafe for those with shellfish allergy.[13] However, many manufacturers of glucosamine derived from shellfish include a warning that those with a seafood allergy should consult a healthcare professional before taking the product.[14] Alternative, non-shellfish-derived forms of glucosamine are available.[15]

Another concern has been that the extra glucosamine could contribute to diabetes by interfering with the normal regulation of the hexosamine biosynthesis pathway,[16] but several investigations found no evidence that this occurs.[17][18] Other studies conducted in lean or obese subjects concluded that oral glucosamine at standard doses does not affect insulin resistance.[19][20]

Biochemistry

Glucosamine is naturally present in the shells of shellfish, animal bones, bone marrow, and fungi.[21] D-Glucosamine is made naturally in the form of glucosamine-6-phosphate, and is the biochemical precursor of all nitrogen-containing sugars.[22] Specifically in humans, glucosamine-6-phosphate is synthesized from fructose 6-phosphate and glutamine by glutamine—fructose-6-phosphate transaminase[23] as the first step of the hexosamine biosynthesis pathway.[24] The end-product of this pathway is uridine diphosphate N-acetylglucosamine (UDP-GlcNAc), which is then used for making glycosaminoglycans, proteoglycans, and glycolipids.

As the formation of glucosamine-6-phosphate is the first step for the synthesis of these products, glucosamine may be important in regulating their production; however, the way that the hexosamine biosynthesis pathway is actually regulated, and whether this could be involved in contributing to human disease remains unclear.[16]

Manufacturing

Most glucosamine is manufactured by processing chitin from the shells of shellfish including shrimp, lobsters, and crabs.[25] To meet the demands of vegetarians and others with objections to shellfish, manufacturers have brought glucosamine products to market made using fungus Aspergillus niger and from fermenting corn.[15]

History

Glucosamine was first prepared in 1876 by Georg Ledderhose by the hydrolysis of chitin with concentrated hydrochloric acid.[26][27][28] The stereochemistry was not fully determined until the 1939 work of Walter Haworth.[1][29]

United States

In the United States, glucosamine is not approved by the Food and Drug Administration for medical use in humans.[30] Since glucosamine is classified as a dietary supplement in the US, evidence of safety is required by FDA regulations, and evidence of efficacy is not required so long as it is not advertised as a treatment for a medical condition.[31]

Europe

In most of Europe, glucosamine is approved as a medical drug and is sold in the form of glucosamine sulfate.[32] In this case, evidence of safety and efficacy is required for the medical use of glucosamine and several guidelines have recommended its use as an effective and safe therapy for osteoarthritis. The Task Force of the European League Against Rheumatism (EULAR) committee has granted glucosamine sulfate a level of toxicity of 5 in a 0-100 scale,[32] and recent OARSI (OsteoArthritis Research Society International) guidelines for hip and knee osteoarthritis indicate an acceptable safety profile.[33] By 2014, the OARSI did not recommend glucosamine for disease modification, and considered it "uncertain" for symptom relief, in knee osteoarthritis.[34]

Class action lawsuits

In 2013, without admitting fault, manufacturer Rexall Sundown, Inc., and NBTY, Inc., agreed to pay up to $2 million to settle consumer claims related to the wording of certain claims on the packaging of glucosamine bottles sold at Costco under the Kirkland label.[35]

In August 2012, a class action lawsuit was filed in New York claiming that 21st Century Healthcare, Inc. falsely advertises that its “Glucosamine 750 Chondroitin 600 Triple Strength” dietary supplements will restore lost cartilage.[36] In April 2013, a San Diego man launched a proposed class action lawsuit in California Federal Court accusing Nutramax Laboratories, Walmart and Rite Aid of falsely advertising the effectiveness of glucosamine.[37]

Research

Humans

Since glucosamine is a precursor for glycosaminoglycans, and glycosaminoglycans are a major component of cartilage, research has focused on the potential for supplemental glucosamine to beneficially influence cartilage structure and alleviate arthritis. Although its use as a supplement appears safe, the evidence does not support it being universally effective, as clinical trials have not provided results that support its efficacy in 100% of human subjects.[5][6]

Bioavailability

Two studies measured the concentrations of glucosamine in the synovial fluid and plasma after oral administration of glucosamine sulfate to both healthy volunteers and people with osteoarthritis.[38][39]

In the first study, glucosamine sulfate was given to healthy volunteers in doses of 750, 1500 or 3000 mg once daily. In the second study, oral glucosamine sulfate capsules (1500 mg) were given daily for two weeks to 12 people with osteoarthritis. Glucosamine concentrations in plasma and synovial fluid increased significantly from baseline levels and the levels in the two fluids were highly correlated. The authors interpreted that these levels could be biologically advantageous to articular cartilage, but the levels are still 10 - 100 fold lower than required to positively affect the cartilage (chondrocytes) to build new tissue.[40] Glucosamine sulfate uptake in synovial fluid may be as much as 20%, or could be negligible, indicating no biological significance.[41]

Veterinary medicine

Some studies have shown efficacy of glucosamine supplementation for dogs with osteoarthritis pain, particularly in combination with other nutraceuticals like chondroitin[42][43] while others have not.[44] A trial of oral combination capsules (glucosamine/chondroitin/manganese ascorbate) in dogs with osteoarthritis found no benefit on either gait analysis or subjective assessments by the veterinarian or owner.[44]

The use of glucosamine in equine medicine exists, but one meta-analysis judged extant research too flawed to be of value in guiding treatment of horses.[45]

A number of studies have measured the bioavailability of glucosamine after oral administration to horses. When given as a single oral dose (nine grams) with or without chondroitin sulfate (three grams) to ten horses, glucosamine (hydrochloride) was detected in the blood with a maximum level of 10.6 (+/- 6.9) micrograms per millilitre at two hours after dosing.[46] Another study examined both the serum and the joint synovial fluid after nasogastric (oral) or intravenous administration of 20 mg/kg glucosamine hydrochloride to eight adult horses.[47] Although joint fluid concentrations of glucosamine reached 9 - 15 micromolar following intravenous dosing, it was only 0.3 - 0.7 micromolar with nasogastric dosing. The authors calculated that these glucosamine synovial fluid levels achieved by the oral route were 500 fold lower than that required to have a positive effect on the metabolism of cartilage cells. A follow up study by the same research group compared glucosamine sulfate with glucosamine hydrochloride at the same dose (20 mg/kg) in eight horses and found a higher fluid concentration with the sulfate preparation (158 ng/mL compared to 89 ng/mL one hour post oral dose).[48] They concluded that these higher synovial fluid levels obtained with the sulfate derivative were still too low to have a relevant biological effect on articular cartilage.

A three-month trial of an oral dosage regime of a commercial preparation of glucosamine sulfate, chondroitin sulfate and methylsulfonylmethane was performed in veteran horses with no effect on gait stiffness, with exercise alone in the control group being effective.[49] The intravenous use of a combination of N-acetylglucosamine, pentosan polysulfate and sodium hyaluronate in horses with surgically-induced osteoarthritis saw improvements in xray changes to the cartilage but not histologically or in biochemical outcomes,[50] suggesting more evidence is needed for this combination and route of administration.

See also

References

  1. 1 2 Pigman WW, Horton D, Wander JD (1980). The Carbohydrates. Vol IB. New York: Academic Press. pp. 727–728. ISBN 9780125563512.
  2. ↑ "Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007" (PDF). National Center for Health Statistics. December 10, 2008. Retrieved 2009-08-16.
  3. ↑ Staff, FDA Last Updated April 11, 2013 Q&A on Dietary Supplements
  4. 1 2 3 4 "Glucosamine sulfate". MedlinePlus, US National Library of Medicine. 22 April 2016.
  5. 1 2 American Academy of Orthopaedic Surgeons (February 2013), "Five Things Physicians and Patients Should Question", Choosing Wisely: an initiative of the ABIM Foundation, American Academy of Orthopaedic Surgeons, retrieved 19 May 2013
  6. 1 2 Towheed, T. E.; Maxwell, L; Anastassiades, T. P.; Shea, B; Houpt, J; Robinson, V; Hochberg, M. C.; Wells, G (2005). "Glucosamine for osteoarthritis". The Cochrane Database of Systematic Reviews (2): CD002946. PMID 15846645. doi:10.1002/14651858.CD002946.pub2.
  7. ↑ Hespel, P; Maughan, R. J.; Greenhaff, P. L. (2006). "Dietary supplements for football". Journal of Sports Sciences. 24 (7): 749–61. PMID 16766503. doi:10.1080/02640410500482974.
  8. ↑ Eraslan A, Ulkar B (2015). "Glucosamine supplementation after anterior cruciate ligament reconstruction in athletes: a randomized placebo-controlled trial". Res. Sports Med. 23 (1): 14–26. PMID 25630243. doi:10.1080/15438627.2014.975809.
  9. ↑ Reginster, Jean Yves; Deroisy, Rita; Rovati, Lucio C; Lee, Richard L; Lejeune, Eric; Bruyere, Olivier; Giacovelli, Giampaolo; Henrotin, Yves; Dacre, Jane E; Gossett, Christiane (January 2011). "Long-term effects of glucosamine sulphate on osteoarthritis progression: a randomised, placebo-controlled clinical trial". The Lancet. 357 (9252): 251–256. doi:10.1016/S0140-6736(00)03610-2.
  10. ↑ Knudsen, J. F.; Sokol, G. H. (April 2008). "Potential glucosamine-warfarin interaction resulting in increased international normalized ratio: case report and review of the literature and MedWatch database". Pharmacotherapy. 28 (4): 540–8. PMID 18363538. doi:10.1592/phco.28.4.540.
  11. ↑ "Complementary and alternative medicines for the treatment of rheumatoid arthritis, osteoarthritis and fibromyalgia". Arthritis Research UK. October 2012. pp. 34–5. Retrieved 17 February 2017.
  12. ↑ Cerda, C; Bruguera, M; Parés, A (Aug 28, 2013). "Hepatotoxicity associated with glucosamine and chondroitin sulfate in patients with chronic liver disease". World J Gastroenterol. 19 (32): 5381–5384. PMC 3752575 Freely accessible. PMID 23983444. doi:10.3748/wjg.v19.i32.5381.
  13. ↑ Gray HC, Hutcheson PS, Slavin RG; Hutcheson; Slavin (August 2004). "Is glucosamine safe in patients with seafood allergy?". The Journal of Allergy and Clinical Immunology. 114 (2): 459–60. PMID 15341031. doi:10.1016/j.jaci.2004.05.050.
  14. ↑ "Kirkland Signature Extra Strength Glucosamine with MSM". Dietary Supplements Labels Database. U.S. National Library of Medicine. 3 February 2010. Archived from the original on 4 March 2010. Retrieved 23 April 2015.
  15. 1 2 "Another vegetarian glucosamine launched in US". NutraIngredients-USA.com. January 25, 2008. Archived from the original on April 17, 2009.
  16. 1 2 Buse MG (2006). "Hexosamines, insulin resistance, and the complications of diabetes: current status". Am. J. Physiol. Endocrinol. Metab. 290 (1): E1–E8. PMC 1343508 Freely accessible. PMID 16339923. doi:10.1152/ajpendo.00329.2005.
  17. ↑ Scroggie DA, Albright A, Harris MD; Albright; Harris (July 2003). "The effect of glucosamine-chondroitin supplementation on glycosylated hemoglobin levels in patients with type 2 diabetes mellitus: a placebo-controlled, double-blinded, randomized clinical trial". Archives of Internal Medicine. 163 (13): 1587–90. PMID 12860582. doi:10.1001/archinte.163.13.1587.
  18. ↑ Tannis AJ, Barban J, Conquer JA; Barban; Conquer (June 2004). "Effect of glucosamine supplementation on fasting and non-fasting plasma glucose and serum insulin concentrations in healthy individuals". Osteoarthritis and Cartilage / OARS, Osteoarthritis Research Society. 12 (6): 506–11. PMID 15135147. doi:10.1016/j.joca.2004.03.001.
  19. ↑ Muniyappa R; Karne RJ; Hall G; et al. (November 2006). "Oral glucosamine for 6 weeks at standard doses does not cause or worsen insulin resistance or endothelial dysfunction in lean or obese subjects". Diabetes. 55 (11): 3142–50. PMID 17065354. doi:10.2337/db06-0714.
  20. ↑ Biggee BA, Blinn CM, Nuite M, Silbert JE, McAlindon TE; Blinn; Nuite; Silbert; McAlindon (February 2007). "Effects of oral glucosamine sulphate on serum glucose and insulin during an oral glucose tolerance test of subjects with osteoarthritis". Annals of the Rheumatic Diseases. 66 (2): 260–2. PMC 1798503 Freely accessible. PMID 16818461. doi:10.1136/ard.2006.058222.
  21. ↑ "Scientific Opinion of the Panel on Dietetic Products Nutrition and Allergies on a request from the European Commission on the safety of glucosamine hydrochloride from Aspergillus niger as food ingredient". The EFSA Journal. 1099: 1–19. 2009.
  22. ↑ Roseman S (2001). "Reflections on glycobiology". J Biol Chem (free full text). 276 (45): 41527–42. PMID 11553646. doi:10.1074/jbc.R100053200.
  23. ↑ Glutamine—fructose-6-phosphate transaminase (isomerizing)
  24. ↑ "UDP-N-acetylglucosamine Biosynthesis". Recommendations of the Nomenclature Committee of the International Union of Biochemistry and Molecular Biology on the Nomenclature and Classification of Enzymes by the Reactions they Catalyse. International Union of Biochemistry and Molecular Biology. 2002. Retrieved 2012-09-10.
  25. ↑ Murray, Michael T. (2012). "Chapter 94: Glucosamine". In Pizzorno, Jr.,, Joseph E.; Murray, Michael T. Textbook of natural medicine (4th ed.). Edinburgh: Churchill Livingstone. p. 790. ISBN 9781437723335.
  26. ↑ Georg Ledderhose (1876). "Über salzsaures Glycosamin" [On glucosamine hydrochloride]. Berichte der deutschen chemischen Gesellschaft. 9 (2): 1200–1201. doi:10.1002/cber.18760090251.
  27. ↑ Ledderhose G (1879). "Über Chitin und seine Spaltungs-produkte" [On chitin and its hydrolysis products]. Zeitschrift für physiologische Chemie. ii: 213–227.
  28. ↑ Ledderhose G (1880). "Über Glykosamin". Zeitschrift für physiologische Chemie. iv: 139–159.
  29. ↑ W. N. Haworth, W. H. G. Lake, S. Peat; Lake; Peat (1939). "The configuration of glucosamine (chitosamine)". Journal of the Chemical Society: 271–274. doi:10.1039/jr9390000271.
  30. ↑ Hubbard WK, Associate Commissioner of Policy and Planning (2012). "Letter Regarding the Relationship Between the Consumption of Glucosamine and/or Chondroitin Sulfate and a Reduced Risk of: Osteoarthritis; Osteoarthritis-related Joint Pain, Joint Tenderness, and Joint Swelling; Joint Degeneration; and Cartilage Deterioration(Docket No. 2004P-0059)". United States Department of Health and Human Services, Food and Drug Administration. Retrieved 14 May 2014. FDA concludes that there is no credible evidence to support qualified health claims for glucosamine or chondroitin sulfate and reduced risk of osteoarthritis, joint degeneration or cartilage deterioration.
  31. ↑ "Dietary Supplements". U.S. Food and Drug Administration. Retrieved December 10, 2009.
  32. 1 2 Jordan KM; Arden NK; Doherty M; et al. (December 2003). "EULAR Recommendations 2003: a 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)". Annals of the Rheumatic Diseases. 62 (12): 1145–55. PMC 1754382 Freely accessible. PMID 14644851. doi:10.1136/ard.2003.011742.
  33. ↑ Zhang W; Moskowitz RW; Nuki G; et al. (September 2007). "OARSI recommendations for the management of hip and knee osteoarthritis, part I: critical appraisal of existing treatment guidelines and systematic review of current research evidence". Osteoarthritis and Cartilage / OARS, Osteoarthritis Research Society. 15 (9): 981–1000. PMID 17719803. doi:10.1016/j.joca.2007.06.014.
  34. ↑ McAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra SM, Hawker GA, Henrotin Y, Hunter DJ, Kawaguchi H, Kwoh K, Lohmander S, Rannou F, Roos EM, Underwood M (March 2014). "OARSI guidelines for the non-surgical management of knee osteoarthritis". Osteoarthritis Cartilage. 22 (3): 363–88. PMID 24462672. doi:10.1016/j.joca.2014.01.003.
  35. ↑ "Glucosamine Settlement". www.glucosaminesettlement.com. Retrieved June 17, 2013.
  36. ↑ "21st Century Glucosamine/Chondroitin Triple Strength Class Action Lawsuit". www.topclassactions.com. Retrieved June 17, 2013.
  37. ↑ "Wal-Mart, Rite Aid Face Suit Over Glucosamine Promises". www.law360.com. Retrieved June 17, 2013.
  38. ↑ Persiani S; Rotini R; Trisolino G; et al. (July 2007). "Synovial and plasma glucosamine concentrations in osteoarthritic patients following oral crystalline glucosamine sulphate at therapeutic dose". Osteoarthritis and Cartilage / OARS, Osteoarthritis Research Society. 15 (7): 764–72. PMID 17353133. doi:10.1016/j.joca.2007.01.019.
  39. ↑ Persiani S, Roda E, Rovati LC, Locatelli M, Giacovelli G, Roda A; Roda; Rovati; Locatelli; Giacovelli; Roda (December 2005). "Glucosamine oral bioavailability and plasma pharmacokinetics after increasing doses of crystalline glucosamine sulfate in man". Osteoarthritis and Cartilage / OARS, Osteoarthritis Research Society. 13 (12): 1041–9. PMID 16168682. doi:10.1016/j.joca.2005.07.009.
  40. ↑ Mroz, P. J.; Silbert, J. E. (2004). "Use of 3H-glucosamine and 35S-sulfate with cultured human chondrocytes to determine the effect of glucosamine concentration on formation of chondroitin sulfate". Arthritis & Rheumatism. 50 (11): 3574–9. PMID 15529373. doi:10.1002/art.20609.
  41. ↑ Cohen MJ, Braun L (2007). Herbs & natural supplements: an evidence-based guide. Marrickville, New South Wales: Elsevier Australia. ISBN 0-7295-3796-X.
  42. ↑ Gupta, R. C.; Canerdy, T. D.; Lindley, J; Konemann, M; Minniear, J; Carroll, B. A.; Hendrick, C; Goad, J. T.; Rohde, K; Doss, R; Bagchi, M; Bagchi, D (2012). "Comparative therapeutic efficacy and safety of type-II collagen (UC-II), glucosamine and chondroitin in arthritic dogs: Pain evaluation by ground force plate". Journal of Animal Physiology and Animal Nutrition. 96 (5): 770–7. PMID 21623931. doi:10.1111/j.1439-0396.2011.01166.x.
  43. ↑ d'Altilio, M; Peal, A; Alvey, M; Simms, C; Curtsinger, A; Gupta, R. C.; Canerdy, T. D.; Goad, J. T.; Bagchi, M; Bagchi, D (2007). "Therapeutic Efficacy and Safety of Undenatured Type II Collagen Singly or in Combination with Glucosamine and Chondroitin in Arthritic Dogs". Toxicology Mechanisms and Methods. 17 (4): 189–96. PMID 20020968. doi:10.1080/15376510600910469.
  44. 1 2 ĀMoreau, M; Dupuis, J; Bonneau, N. H.; Desnoyers, M (2003). "Clinical evaluation of a nutraceutical, carprofen and meloxicam for the treatment of dogs with osteoarthritis". The Veterinary record. 152 (11): 323–9. PMID 12665145. doi:10.1136/vr.152.11.323.
  45. ↑ Pearson, W; Lindinger, M (2009). "Low quality of evidence for glucosamine-based nutraceuticals in equine joint disease: Review of in vivo studies". Equine veterinary journal. 41 (7): 706–12. PMID 19927591. doi:10.2746/042516409X424153.
  46. ↑ Du, J; White, N; Eddington, N. D. (2004). "The bioavailability and pharmacokinetics of glucosamine hydrochloride and chondroitin sulfate after oral and intravenous single dose administration in the horse". Biopharmaceutics & drug disposition. 25 (3): 109–16. PMID 15083499. doi:10.1002/bdd.392.
  47. ↑ Laverty, S; Sandy, J. D.; Celeste, C; Vachon, P; Marier, J. F.; Plaas, A. H. (2005). "Synovial fluid levels and serum pharmacokinetics in a large animal model following treatment with oral glucosamine at clinically relevant doses". Arthritis and rheumatism. 52 (1): 181–91. PMID 15641100. doi:10.1002/art.20762.
  48. ↑ Meulyzer, M; Vachon, P; Beaudry, F; Vinardell, T; Richard, H; Beauchamp, G; Laverty, S (2008). "Comparison of pharmacokinetics of glucosamine and synovial fluid levels following administration of glucosamine sulphate or glucosamine hydrochloride". Osteoarthritis and cartilage / OARS, Osteoarthritis Research Society. 16 (9): 973–9. PMID 18295513. doi:10.1016/j.joca.2008.01.006.
  49. ↑ Higler, M. H.; Brommer, H; l'Ami, J. J.; De Grauw, J. C.; Nielen, M; Van Weeren, P. R.; Laverty, S; Barneveld, A; Back, W (2013). "The effects of three-month oral supplementation with a nutraceutical and exercise on the locomotor pattern of aged horses". Equine veterinary journal. 46 (5): 611–7. PMID 24011144. doi:10.1111/evj.12182.
  50. ↑ Koenig, T. J.; Dart, A. J.; McIlwraith, C. W.; Horadagoda, N; Bell, R. J.; Perkins, N; Dart, C; Krockenberger, M; Jeffcott, L. B.; Little, C. B. (2014). "Treatment of Experimentally Induced Osteoarthritis in Horses Using an Intravenous Combination of Sodium Pentosan Polysulfate, N-Acetyl Glucosamine, and Sodium Hyaluronan". Veterinary Surgery. 43 (5): 612–22. PMID 24819506. doi:10.1111/j.1532-950X.2014.12203.x.
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