Askep - Osteoarthritis

Transcript

Arthritis AJN, American Journal of Nursing, Nursing, February 2004 Clinical Topic: Pain management Expires: 02/28/2007 TNF Inhibitors: A New Age in Rheumatoid Arthritis Treatment iana !" An#erson Ph, $N AN! Ameri"an ourna# o$ Nursing February 2004 %olume &04 Number 2 Pages '0 ( ') %#u"osamine and &steoarthritis Ju#ith A" *la+eley *A, *-cN AN! Ameri"an ourna# o$ Nursing %ioleta ." -" $ibeiro N-c, -, *N-c February 2004 %olume &04 Number 2 Pages /4 ( / 1 2004 !ippincott illiams 3 il+ins, nc" %olume &04526, February 2004, pp /4(/ 7lucosamine an# 8steoarthritis: 7lucosamine pro#ucts, sai# to slo9 or een halt the  progression of osteoarthritis, are rising rising in popularity" *ut #o they 9or+; *la+eley, Ju#ith A" *A, *-cN? $ibeiro, %ioleta ." -" N-c, -, *N-c Ju#ith A" *la+eley is an associate professor an# %ioleta ." -" $ibeiro is an honorary research professor at the -chool of Nursing of emorial =niersity of Ne9foun#lan#, -t" John@s, NF, Cana#a" Contact author: bla+eleBmun"ca" The author of this article has no significant ties, financial or other9ise, to any company that might hae an interest in the publication of this e#ucational actiity" As she tells frien#s an# family, osteoarthritis robbe# ')(year(ol# Anne Fairban+s of a happy retirement an# blac+ene# my gol#en years"D -eere pain afflicte# both of her +nees as 9ell as her cerical an# lumbar spine" uscle relaEants an# nonsteroi#al n onsteroi#al antiinflammatory #rugs 5N-As6 allo9e# her to function, but she nonetheless became increasingly incapacitate# an# #epresse# as her symptoms 9orsene#" To#ay, &2 years after #iagnosis, s" Fairban+s is houseboun# an# spen#s most of her time in her recliner or in be#" Although s" Fairban+s@s #ecline 9as eEtreme, she@s far from alone: 20" million Americans, mostly 9omen, suffer from some #egree of osteoarthritis" & hile it@s not al9ays incapacitating, this #egeneratie oint #isease affects the fingers an# the 9eight(  bearing oints of the spine, +nees, an# hips" ost freGuently cause# by 9ear an# tear on the oints, osteoarthritis is particularly prealent among the el#erly" n the =nite# -tates, for eEample, )/H of those ages ag es / an# ol#er suffer from osteoarthritis" 2 n its early stages, osteoarthritis is characteriIe# by pain an# stiffness" -tiffness is usually 9orse in the morning an# after prolonge# sitting but ten#s to improe 9ith moement" For eEample, after sitting for a 9hile, .mily hite, 2, laughs as she struggles to get out of her chair" @m rusting up,D she says" Nee# an oil ob"D 8nce out of her chair, ho9eer, she can moe about 9ith little or no #ifficulty" Pain, on the other han#, is more #ebilitating" At first, it occurs only 9ith moement of the affecte# oint" *ut as the con#ition progresses, pain can become a chronic, unrelenting problem, een 9hen oints are at rest" n the case of s" Fairban+s, intractable pain hin#ers almost eery moement" First(line #rug therapies for osteoarthritis inclu#e acetaminophen, topical analgesics, an#  N-As" The latter can hae serious a#erse effects, such as gastric ulceration, renal insufficiency, an# prolonge# blee#ing time" f pain an# inflammation are not controlle#, glucocorticoi# inections can be gien"  Ko9eer, none of these therapies slo9s or reerses the #egeneratie process of osteoarthritis" To fin# a safe alternatie treatment, many people hae turne# to glucosamine pro#ucts" 7lucosamine is sai# to slo9 or een halt the progression of osteoarthritis, in a##ition to haing a 9ea+ antiinflammatory effect, re#ucing pain, an# improing the range of motion in affecte# oints" 4 hile promising results hae been reporte#, research fin#ings are still inconclusie" .en so, its popularity has gro9n" n 200& global retail sales of glucosamine pro#ucts totalle# L&"2 billion, an# they@re eEpecte# to increase by about 2&H each year" / Claims of the benefits of glucosamine are increasingly common in a#ertising an# in consumer publications, an# starting glucosamine therapy is as easy as a Guic+ trip to the local pharmacy or grocery store" Met, because glucosamine is consi#ere# a #ietary supplement, the Foo# an# rug A#ministration 5FA6 #oesn@t regulate it an# its manufacture isn@t stan#ar#iIe#" ietary supplements are manufacture# by many #ifferent companies an# sol# in arying #osages an# at 9i#ely ranging prices, often in combination 9ith other compoun#s, such as chon#roitin sulfate or methylsulfonylmethane 5-6" Ko9 can consumers choose from among the many options; s glucosamine a iable therapy; C8!!A7.N, P$8T.87!MCAN-, AN 7!=C8-AN. The pathogenesis of osteoarthritis lies in the #estruction of cartilage, possibly as a result of the loss of collagen an# proteoglycansthe buil#ing bloc+s of cartilage" ', Collagen, the fibrous protein that ma+es up connectie tissue, an# proteoglycans, 9hich proi#e the cartilage@s resilience, are essential to the iscoelasticity of cartilage" As the #isease  progresses, the articular cartilage, a thin layer of cartilage coering the bones in oints, roughens, becomes pitte#, an# eentually ero#es" Kypertrophy of the un#erlying bone an# formation of osteophytes may also occur" 7lucosamine, an amino sugar synthesiIe# in the bo#y from glucose an# the amino aci# glutamine, helps regenerate #amage# cartilage by proi#ing the substrate for the  pro#uction of proteoglycans" 4 nsi#e the cartilage cell 5+no9n as the chon#rocyte6, glucosamine is synthesiIe# into glycosaminoglycans 57A7s6" hen attache# to a core  protein, chains of 7A7s become proteoglycans, the eEtracellular component of cartilage" Proteoglycans are configure# li+e bottle(brushes an# inter9oen 9ith tubeli+e collagen fibers that proi#e strength an# support an# anchor the relatiely fe9 chon#rocytes in the eEtracellular matriE" The gel(li+e proteoglycans are strongly hy#rophilic 5cartilage consists of 0H 9ater6, proi#ing fleEibility an# cushioning" 7lucosamine manufacturers recommen# #osages of &,/00 mg per #ay, ta+en orally in three eGual #oses" ost of the clinical trials that reporte# glucosamine effectieness hae use# this #osage an# route of a#ministration" Fin#ings hae suggeste# that this regimen may be effectie in a#ults, although some sources a#ise increasing the #osage to 2,000 mg #aily in a#ults 9ho 9eigh more than 200 lbs", an# #ecreasing it to &,000 mg #aily in those un#er &20 lbs" 4,) F7=$. Figure &" 8steoarthritic Joint 8steoarthritis is a #egeneration of the articular cartilage capping the en#s of the bones in synoial oints" Pathologic changes inclu#e roughening an# pitting of the cartilage surface, thinning of the cartilage layer, an# ultimately, #enu#ing of the bone" ConseGuently, there is a narro9ing of the oint space" *ecause the cartilage can no longer bear 9eight place# on the oint an# the bones grin# against one another, the un#erlying bone becomes remo#ele#, resulting in osteophyte 5bone spur6 formation at the outer ri#ges of the oint, the #eelopment of cystli+e structures, an# sclerosis 5har#ening of the bone from increase# #ensity6" -oft tissue s9elling an# increase# flui# in the synoial caity 5oint effusion6 cause enlargement of the oint" 7lucosamine is most often obtaine# from chitin, foun# in the eEos+eleton of shellfish, but it can also be chemically synthesiIe#" Pac+age# as oral tablets or capsules, the most common commercial compoun#s are glucosamine sulfate, N(acetyl(glucosamine, an# glucosamine hy#rochlori#e"  CK88-N7 AN =-N7 7!=C8-AN. e inestigate# the self(me#ication practices of glucosamine users by con#u cting a small(scale surey of '/ ol#er a#ults 5oer /0 years of age6 9ho use# the supplement" &0 8nly 20H of participants began ta+ing glucosamine as a result of a physician@s recommen#ation? the rest attribute# their #ecisions to the influence of frien#s, family, a#ertising, boo+s, magaIine or ne9spaper articles, or the a#ice of health(foo# store employees" .ighty(siE percent of those sureye# 9ere managing their o9n treatment, )2H use# glucosamine regularly, an# 'H beliee# it ha# a beneficial effect on symptoms" 8nly one(thir#, ho9eer, follo9e# the recommen#e# #osage of &,/00 mg per #ay? more than one(thir# too+ either 2,000 mg or &,000 mg or less per #ay" Those remaining arie# the #osage accor#ing to ho9 they felt, ho9 long they ha# been using the treatment, oramong those ta+ing supplements combining glucosamine 9ith - or chon#roitinaccor#ing to ho9 much glucosamine 9as present in the tablet" Ko9 often  participants too+ the supplement also arie#: from one to three times a #ay" -een reporte# ta+ing glucosamine to treat either rheumatoi# arthritis or fibromyalgia, although no ei#ence supports the use of glucosamine for such con#itions" F7=$. Figure 2" The $ole of 7lucose an# ts eriaties in the Pro#uction of Cartilage Although cartilage has no bloo# supply, synoial flui# is rich in nutrients, inclu#ing glucose, 9hich is use# by the chon#rocytes 5&6" n normal cartilage pro#uction, the #eriaties of glucose 5glucosamine, galactose, an# glucuronic aci#6 form chains calle# glycosaminoglycans 57A7s6" Those forme# by the #eriaties of glucose inclu#e hyaluronic aci#, chon#roitin sulfate, an# +eratan sulfate" The latter t9o bin# to protein cores 9ithin the cell an# are eEcrete# into the eEtracellular matriE 526? there they bin# to the longer hyaluronic aci# chains 56" hen boun# to the hyaluronic aci#, these 7A7O   protein structures 5proteoglycans6, 9hich resemble bottle brushes, constitute the hy#rophilic, gel(li+e, cushioning portion of the cartilage" *u n#les of collagen fibrils form the three(#imensional support of cartilage tissue" The theory behin# oral glucosamine supplementation is that the chon#rocytes 9ill ta+e it up, in effect preferringD it to the more rea#ily aailable glucose an# glutamine 5an amino aci# reGuire# for synthesis of glucosamine6, an# more cartilage 9ill be pro#uce#" hile the results of this stu#y can@t be 9i#ely generaliIe#, they #o suggest the nee# for  public e#ucation in the correct use of glucosamine an# the treatment of osteoarthritis" They also suggest the alue of superision of glucosamine use by a health care  professional" .FFCACM $eginster an# colleagues foun# that glucosamine effectiely controlle# osteoarthritis symptoms an# pro#uce# some reersal of the #isease process" && This three(year, #ouble(  blin#, placebo(controlle# stu#y, base# on a ran#om sample of 2&2 patients, sho9e# that those gien glucosamine sulfate eEperience# no significant loss of oint spaceD an# sho9e# improement in their osteoarthritis symptoms as measure# by the estern 8ntario an# caster =niersities 8steoarthritis n#eE 5+no9n as the 8AC6" ost glucosamine trials to #ate hae been of shorter #uration, an# many hae sho9n  promising results" For eEample, in a three(month, ran#omiIe#, #ouble(blin#, placebo( controlle# trial of 2/2 outpatients 9ith osteoarthritis of the +nee, Noac+ an# colleagues foun# glucosamine sulfate to be as 9ell tolerate# as placebo an# conclu#e# that it may  be a safe an# effectie symptomatic slo9 acting #rug for osteoarthritis"D &2 Thie an# colleagues compare# glucosamine sulfate 9ith ibuprofen an# foun# that glucosamine  proi#e# a significantly greater #ecrease in pain among patients 9ith temporoman#ibular  oint osteoarthritis" & Ko9eer, using the 8AC in an eight(9ee+ open(label trial of  patients 9ith osteoarthritis of the +nee, Koupt an# colleagues foun# no significant #ifference in pain re#uction bet9een the glucosamine hy#rochlori#e an# placebo groups,D although they #i# state that their results suggeste# that glucosamine hy#rochlori#e may be effectie for some patients" &4 -ince 2000, three metaanalyses hae eEamine# the effectieness of glucosamine" cAlin#on an# associates reie9e# &/ #ouble(blin#, ran#omiIe#, placebo(controlle# trials lasting four 9ee+s or longer an# conclu#e# that some #egree of efficacy appears  probable for these preparations"D &/ To9hee# an# associates reie9e# &' ran#omiIe#, controlle# trials an# conclu#e# that more research 9as nee#e#" &' An# most recently, $ichy an# associates stu#ie# the reporte# effects in &/ stu#ies of either glucosamine or chon#roitin on osteoarthritis of the +nee an# foun# treatment 9ith either glucosamine or glucosamine plus chon#roitin to be effectie" & The 7lucosamineOChon#roitin Arthritis nterention Trial 57AT6 9ill inole more than &,/00 a#ults 40 years of age an# ol#er in a t9o(year, multisite trial comparing glucosamine, chon#roitin sulfate, celecoEib 5CelebreE6, an# a combination of glucosamineOchon#roitin sulfate against placebo in the treatment of +nee pain associate# 9ith osteoarthritis" &) A substu#y 9ill assess 9hether the supplements slo9 or stop the  progression of +nee osteoarthritis" -ponsore# by the National Center for Complementary an# Alternatie e#icine, the National nstitutes of Keath, the epartment of %eterans Affairs, an# the epartment of %eterans Affairs Cooperatie -tu#y Program, the stu#y is currently un#er 9ay? stu#y results shoul# be aailable 9ithin three years" A%.$-. .FF.CT- AN C8NT$ANCAT8NA#erse effects, 9hich are sel#om reporte#, inclu#e s+in rashes? peripheral e#ema? tachycar#ia? transitory central nerous system reactions such as #ro9siness an# hea#ache? an# mil# gastrointestinal symptoms such as #yspepsia, nausea, ab#ominal  pain, #iarrhea, an# flatulence" 4,),&,20 hile gastrointestinal blee#ing an# other serious a#erse effects of N-As haen@t been reporte# by people ta+ing glucosamine, it@s not +no9n 9hether long(term use pro#uces other serious complications" iuretics may #ecrease the effectieness of glucosamine" &,20 People 9ho are allergic to the chitin in shellfish from 9hich glucosamine is eEtracte# shoul# aoi# glucosamine" / omen 9ho are breastfee#ing an# chil#ren shoul# also aoi# using glucosamine because its effects in those populations are un+no9n" 20 $esults of in itro stu#y of glucosamine an# in io stu#y in rats suggest that it can impair insulin secretion an# cause beta(cell secretory #ysfunction similar to that seen in patients 9ith type 2 #iabetes" 2& For this reason, an# because the glucosamine molecule is glucose  base#, it coul# be harmful to patients 9ith #iabetes or those 9ith impaire# glucose tolerance" 7lucosamine may also increase resistance to insulin an# to anti#iabetic agents?  people 9ith #iabetes 9ho use the supplement shoul# be particularly #iligent in monitoring bloo# glucose leels" &,20  N=$-N7 P!CAT8N Nurses can help ensure that patients 9ho self(treat are 9ell informe# an# can lobby the goernment for stronger regulations" Patient e#ucation" 7lucosamine users shoul# un#erstan# that research on the effectieness of glucosamine is still inconclusie an# that eEisting ei#ence refers primarily to a #aily #osage of &,/00 mg of glucosamine sulfate, ta+en in three #oses of /00 mg" =ntil further information is aailable, patients shoul# be encourage# to follo9 this #osage" They shoul# also be a#ise# that, li+e all supplements, glucosamine is minimally regulate#, an# fe9 rules goern the 9ays in 9hich it@s mar+ete#" There is no assurance that 9hat@s on the label accurately reflects 9hat@s in the bottle" Patients beginning glucosamine therapy, therefore, may be 9ell a#ise# to try one or more of the preparations aailable on the mar+et an# choose the one they fin# most effectie" *ecause of potential #rugO#rug interactions, patients ta+ing glucosamine pro#ucts shoul#  be urge# strongly to inform proi#ers" t@s also important to tell patients that symptom relief 9on@t be imme#iate? reporte# benefits are usually felt one to three months after initiating treatment" n the interim, they shoul# continue other therapies for controlling  pain an# stiffness" nformation on glucosamine can be foun# at health foo# stores, through pharmacists, on the nternet, an# in natural health magaIines an# research ournals" .ncourage your  patients to become informe#" iscuss the critical appraisal of information an#, in  particular, claims base# on anec#otal ei#ence" !obbying" Through professional associations, nurses can use their collectie po9er to lobby the appropriate goernment agencies 5such as the FA6 to test glucosamine pro#ucts currently on the mar+et" This 9oul# ensure that supplements meet basic stan#ar#s? for eEample, that the supplements contain the substances that manufacturers claim an# that the substances are not contaminate# by foreign or #angerous ingre#ients" f strong ei#ence is foun# sho9ing glucosamine to be effectie in slo9ing or een reersing the  progression of osteoarthritis, the supplement shoul# be ma#e aailable to eeryone, irrespectie of purchasing po9er" !obbying the appropriate goernment organiIations an# priate health insurance companies 9ill be the first step to9ar# ensuring such aailability" Complete the C. test for this article by using the mail(in form aailable in this issue or  by going to 8nline C. at http:999"anonline"com" After rea#ing this article an# TNF nhibitors: A Ne9 Age in $heumatoi# Arthritis Treatment, 9hich begins on the neEt page, ta+e the test on page ' to earn "/ hours of continuing e#ucation cre#it" $.F.$.NC.&" The Arthritis Foun#ation" 8steoarthritis 58A6 <eb page>" 200" http:999"arthritis"orgcon#itions#iseasecenteroa"asp" 2" *runner !-, et al" *runner an# -u##arth@s teEtboo+ of me#ical(surgical nursing" Phila#elphia: !ippincott? 2000" " 8steoarthritis treatments <eb page>" 200" http:999"hop+ins( arthritis"som"hmi"e#uosteoosteoQtreat"html" 4" Professional gui#e to complementary an# alternatie therapies" -pringhouse, PA: -pringhouse? 200&: 2O4" /" Jaris !" *. to launch =-(base# glucosamine pro#uction" Chemical ar+et $eporter 2002" '" !ing -, *athon J" 8steoarthritis pathophysiology <eb page>" 200" http:999"hop+ins(arthritis"som"hmi"e#uosteoosteoQpatho"html" " *eers , *er+o9 $" 8steoarthritis an# neurogenic arthropathy" n: erc+ manual of #iagnosis an# therapy" &th e#" $ah9ay, NJ: erc+? &" p" 44O/&" )" Ruhn A, et al" Kerbal therapy an# supplements: a scientific an# tra#itional approach" Phila#elphia: !ippincott? 2000: ')O&" " National Nutritional Foo#s Association" 7lucosamine <eb site>" 200" http:999"nnfa"orgsericessciencebgQglucosamine"htm" &0" *la+eley JA, $ibeiro %" A surey of self(me#ication practices an# perceie# effectieness of glucosamine pro#ucts among ol#er a#ults" Complement Ther e# 2002? &05 6:&/4O'0" &&" $eginster JM, et al" !ong(term effects of glucosamine sulphate on osteoarthritis  progression: a ran#omise#, placebo(controlle# clinical trial" !ancet 200&? /5 2/26:2/&O'" &2" Noac+ , et al" 7lucosamine sulfate in osteoarthritis of the +nee" 8steoarthritis Cartilage &4? 25 &6:/&O" &" Thie N, et al" .aluation of glucosamine sulfate compare# to ibuprofen for the treatment of temporoman#ibular oint osteoarthritis: a ran#omiIe# #ouble blin# controlle# three(month clinical trial" J $heumatol 200&? 2)5 '6:&4O//" &4" Koupt J*, et al" .ffect of glucosamine hy#rochlori#e in the treatment of pain of osteoarthritis of the +nee" J $heumatol &? 2'5 &&6:242O0" &/" cAlin#on T., et al" 7lucosamine an# chon#roitin for treatment of osteoarthritis: a systematic Guality assessment an# meta(analysis" JAA 2000? 2)5 &&6:&4'O/" &'" To9hee# T., et al" 7lucosamine therapy for treating osteoarthritis" Cochrane atabase -yst $e 200&5 &6: C0024'" &" $ichy F, et al" -tructural an# symptomatic efficacy of glucosamine an# chon#roitin in +nee osteoarthritis: a comprehensie meta(analysis" Arch ntern e# 200? &'5 &6: &/&4O22" &)" 7lucosamineChon#roitin Arthritis nterention Trial 57AT6 <eb page>" 200" http:clinicaltrials"goctsho9NCT0002)0;or#erS&" &" Nursing herbal me#icine han#boo+" -pringhouse, Pa": -pringhouse? 200&: 204" 20" C F, J$ A" Professional han#boo+ to complementary an# alternatie therapies" -pringhouse, PA: -pringhouse? 200&: 4O/" 2&" *al+an *, unning *." 7lucosamine inhibits gluco+inase in itro an# pro#uces a glucose(specific impairment of in io insulin secretion in rats" iabetes &4? 45 &06:&&O" ithout a Prescription -elf(me#ication creates ne9 options, rene9s lies" !ee .lman has been running #aily since &), an# she@s an ai# tennis player" *ut about three years ago, an achy, s9ollen, right +nee too+ the pleasure out of her athletic actiity" -he un#er9ent surgery to repair tears in the +nee, follo9e# by physiotherapy" t 9asn@t long before she resume# her #aily run" *ut the 9ea+ +nee ma#e it impossible for s" .lman to play tennis" Then a fe9 months after surgery, she began haing #ifficulty #escen#ing stairs" -he consulte# another orthope#ic specialist, 9ho thought that arthritis 9as contributing to the problem" Ke sche#ule# another operation for a fe9 months later" *ut she neer ha# the secon# proce#ure" 7lucosamine an# chon#roitin spare# her the operation an# brought tennis bac+ into her life" s" .lman began self(me#icating 9ith glucosamine an# chon#roitin in February 200" *y April, she coul# 9al+ #o9n stairs 9ithout #ifficulty" -he pic+e# up her tennis rac+et again an# no9 plays regularly" @m going to be ta+ing this for the rest of my life" t@s li+e a miracle"  hae n o achy@ #ays no9,D sai# s" .lman, a mar+eting consultant in Cambri#ge, assachusetts" !i+e many 9ho #eci#e to try glucosamine, she #i# not consult a health care proi#er" -he  began ta+ing it at a frien#@s suggestion" s" .lman chose #ouble(strength Cosamin-" .ach capsule contains /00 mg glucosamine hy#rochlori#e, 400 mg chon#roitin sulfate, an#  mg manganese" .lman 9as attracte# by the label@s claim that this is the only bran#  proen effectie in controlle#, publishe# ="-" stu#ies to re#uce oint pain an# protect cartilage"D The pac+age also calls the pro#uct the number(one #octor an# pharmacist recommen#e# bran#"D -he 9as gla# the label state# that the entire #osage coul# be ta+en all at once" Follo9ing label #irections, she starte# 9ith three capsules a #ay an# lo9ere# the #aily #ose to t9o pills after three months" A bottle of 20 capsules costs her L'/, although s" .lman recently foun# a #ifferent bran# of similar composition for consi#erably less" Although s" .lman #i# not as+ a physician or nurse for a#ice on ta+ing glucosamine, other patients might" Ko9 shoul# you respon#; -houl# you ta+e a proactie approach, on the chance that patients 9ho hae hear# stories of success 9ith glucosamine might #eci#e to try it 9ithout gui#ance from a health care professional; -usan !uc+, $N, CNN, a holistic nurse an# clinical nutritionist in Flori#a, #eals 9ith such issues all the time" -he as+s patients 9ho complain of oint pain about their use of supplements" Then she often suggests three +in#s: omega( fatty aci#s, 9hich hae antiinflammatory effects? glucosamine sulfate plus chon#roitin? an# a goo# multiitamin" -he also recommen#s eEercise, such as 9al+ing" There are #ifferent forms of glucosamine"  prefer glucosamine sulfate becau se it goes  best to the cartilage, ligaments, an# ten#ons,D !uc+ sai#"  thin+ the combination 9ith chon#roitin is better than glucosamine alone"D hen e#ucating patients, !uc+ emphasiIes that glucosamine is not an instant pain relieer li+e ibuprofen" t ta+es up to &2 9ee+s for glucosamine to hae a noticeable effect"  tell patients that glucosamine is a natural substance that helps the bo#y strengthen its ability to repair itself" *ecause this process ta+es time, they shoul# +eep ta+ing other pain relieers as nee#e#,D she sai#" ith the 9i#e array of pro#ucts on the mar+et, patients may be confuse# about 9hich one is best" f nurses are going to suggest these pro#ucts, they shoul# see 9hat@s aailable in their area,D !uc+ sai#" A useful resource is http:999"consumerlab"coman# the relate#  boo+ 7ui#e to *uying %itamins an# -upplements 5200, Consumer!ab"com6" *oth the eb site an# the boo+ present results of Consumer!ab"com@s in#epen#ent testing of #ietary supplements an# in#icate ho9 accurate the pro#uct@s list of ingre#ients is" !aurie !e9is #eas for Nursing $esearch U .Eplore the public@s un#erstan#ing an# use of glucosamine pro#ucts" U nestigate nursing +no9le#ge about these an# other supplements" U .Eamine ho9 prepare# nurses are to teach patients about proper glucosamine use" U Participate in clinical trials testing glucosamine@s efficacy, arious #osages, an# #ifferent routes of a#ministration C. Collection ' A## to Planner  '  Ta+e Test UContact Kours? Contact KoursA#ance# Pharmacology Kours For more information about ta+ing C. on NursingCenter, ie9 our Kelp an# Accre#itation nformation"