Supplements for Hip Osteoarthritis: Evidence-Based Recommendations
Primary Recommendation
Do not use supplements to reduce inflammation in hip osteoarthritis—the highest quality evidence from the 2019 American College of Rheumatology guidelines strongly recommends against glucosamine, chondroitin sulfate, vitamin D, fish oil, and bisphosphonates for hip OA, as rigorous trials show no meaningful benefit over placebo. 1, 2
Why Supplements Don't Work for Hip OA
The evidence against supplements is particularly strong when examining studies with low risk of bias:
Glucosamine is strongly recommended against because when industry-sponsored trials are excluded and only publicly-funded studies with rigorous methodology are analyzed, the data fail to show any important benefits over placebo 1, 2
Publication bias from industry-sponsored trials created a false impression of efficacy that does not hold up under scrutiny 1
While glucosamine has low toxicity, it may elevate serum glucose levels in some patients 1
Chondroitin sulfate is strongly recommended against for hip OA (though conditionally recommended for hand OA only) 1, 2
The 2019 ACR guidelines supersede older 2005 EULAR recommendations that suggested possible benefit 1, 2
Pooled effect sizes from older mixed hip/knee trials showed statistical significance, but these studies had higher risk of bias 1
Combination products (glucosamine + chondroitin) are strongly recommended against for hip OA 1, 2
Other Supplements Evaluated and Rejected
Vitamin D
- Conditionally recommended against because pooled data across multiple trials yielded null results 1, 2
- Small effect sizes in some trials were not clinically meaningful 1
Fish Oil
- Conditionally recommended against as only one published trial exists, which failed to show efficacy of higher versus lower doses 1, 2
- Despite being the most commonly used dietary supplement in the US, evidence for OA is essentially absent 1
Avocado Soybean Unsaponifiables (ASU)
- Initial small trials suggested benefit (effect size 0.76), but larger, longer trials with 163 patients over 2 years showed no significant pain relief or structural benefits 1, 2
Bisphosphonates
- Strongly recommended against as the preponderance of data shows no improvement in pain or functional outcomes 1, 2
Critical Pitfall to Avoid
Many patients believe that different glucosamine formulations or brands have varying effectiveness and will ask for specific recommendations. 1 You must explain that regardless of formulation (sulfate, hydrochloride, or combination products), the highest quality evidence shows no benefit over placebo for pain relief or disease modification 1, 2, 3
What to Recommend Instead
Direct patients toward evidence-based treatments with proven efficacy: 2, 3
- Physical activity and exercise programs as first-line non-pharmacologic treatment 2, 3
- Weight loss interventions for overweight or obese patients 2, 3
- Acetaminophen as first-line pharmacologic treatment for mild to moderate pain 2, 3
- Topical NSAIDs for localized joint pain 2, 3
- Oral NSAIDs when topical agents are insufficient 1
Understanding the Discrepancy in Evidence
The apparent contradiction between older positive studies and current recommendations stems from:
- Risk of bias assessment: When limited to trials with low risk of bias, meta-analyses show effect sizes approaching zero 1
- Industry sponsorship: Discrepancies between industry-sponsored versus publicly-funded trials raised serious concerns about publication bias 1
- Large placebo effects: Many patients perceive glucosamine as efficacious due to contextual effects rather than true pharmacologic benefit 1
The 2019 ACR/Arthritis Foundation guidelines represent a change from prior conditional recommendations, now providing a strong recommendation against these supplements based on the weight of evidence indicating lack of efficacy. 1, 2