Background
Methods
Study design
Study subjects
● Subjects with an established diagnosis of inflammatory joint disorder or osteoarthritis per ACR (American College of Rheumatology) guidelines. |
● Subjects with a history of knee or hip joint replacement surgery, or any hip or back pain which interferes with walking or exercise testing utilized throughout the study. |
● Smoking or tobacco use |
● Currently taking, or chronic use within 30 days of anti-inflammatory supplements, Boswellia, Curcumin, Omega-3 fatty acids, Glucosamine, Chondroitin, MSM, or Collagen supplements of any type. |
● Daily use of NSAIDs (non-steroidal anti-inflammatory drugs); however, daily use of 81 mg of aspirin (not >81 mg) for cardioprotection is allowed. |
● Upon physical screening by the medical staff, any subject with signs of overt nutrient deficiencies or metabolic abnormalities such as anemia. This will also need to be included in the screening assessment. |
● Glucocorticoid (Corticosteroid) injection, hyaluronic acid injection, prolotherapy, or PRP (platelet rich plasma) injection, bone marrow or other regenerative injection in affected knee within 6 months prior to enrollment in study. |
● Individual has any recent illness or condition (within 6 months of screening) that the Investigator believes would interfere with his or her ability to provide informed consent, comply with the study protocol, or might confound the interpretation of the study results or put the person at undue risk. |
● Known or suspected pregnancy, planned pregnancy, or lactation. |
● If the subjects has been treated for any psychiatric illness or hospitalized for such within the past year, upon PI discretion, will be excluded from the study. |
● History of allergic reaction or known sensitivity to Terminalia chebula or other chemically related botanical/ herbal products or supplements. |
● Any food allergy, intolerance, restriction or special diet that, in the opinion of the Investigator, could contraindicate the subject’s participation in this study. |
● Vital sign abnormalities (seated, resting systolic blood pressure lower than 90 or higher than 150 mmHg, diastolic blood pressure lower than 50 or higher than 100 mmHg, or heart rate less than 50 or more than 110 bpm) at screening. |
● History or clinically significant gastrointestinal disorder, (eg, inflammatory bowel diseases), presence of any gastrointestinal pathology, persistent gastrointestinal symptoms (eg, diarrhea, vomiting), liver or kidney disease, gastric bypass, gastric stapling, use of Lapband, or other conditions known to interfere with the absorption, distribution, metabolism, or excretion of dietary supplements. |
● History of active neurological, endocrine, cardiovascular, pulmonary, hematological, immunologic/ autoimmune, psychiatric, or metabolic disease that is considered clinically significant by the PI. |
● Recent history of (within past 12 months), or strong potential for, alcohol or substance abuse. Alcohol abuse will be defined as >14 drinks per week (1 drink = 12 oz. beer, 5.0 oz. wine, or 1.5 oz. distilled spirits). |
● Exposure to any investigational agent or drug product within 30 days prior to study entry. |
● Subjects who have any physical disability which could interfere with their ability to perform the functional performance measures included in this protocol. |
● Individual has a condition the Investigator believes would interfere with the ability to provide informed consent or comply with study instructions, or that might confound the interpretation of the study results or put the patient at undue risk. |
● Healthy male or female volunteers ≥35 to ≤70 years of age. |
● Able to understand study procedures and provide signed informed consent, and authorizes release of relevant health information to study investigator. |
● Willing to maintain current background dietary and physical activity pattern throughout study period. |
● Normally active and otherwise judged to be in good health on the basis of medical history and physical examination. |
● Knee joint: |
○ No knee joint discomfort at rest. |
○ Experience knee joint discomfort with activity or exercise within the last 2 weeks of at least 30 mm out of 100 mm on VAS rating for “knee discomfort with activity or exercise at any time over the last 2 weeks”. |
○ Must achieve a rating of at least 30 mm on a 100 mm VAS at any point throughout the standardized lower extremity exercise performance screening test (Screening test = 3 sets of 10–12 repetitions on seated knee extension machine +3-min walk test at maximal walking velocity). |
● Females: |
● Non-pregnant, non-lactating females who agree to use effective contraceptive methods throughout the course of the study. |
● Females of childbearing potential must agree to use one of the following acceptable birth control methods: |
○ Surgically sterile (hysterectomy or bilateral oophorectomy); |
○ Surgically sterile (bilateral tubal ligation with surgery at least 6 weeks prior to study initiation) |
○ Intrauterine device (IUD) in place for at least 3 months |
○ Abstinence (not having sexual intercourse) |
○ Barrier method (condom or diaphragm) with spermicide for at least 14 days prior to screening and through study completion |
Control of diet, exercise training, and physical activity
Supplementation
Outcome variables
Measures of comfort, mobility and function
Joint mobility
Functional capacity
Inflammation and safety
Statistical analyses
Results
Characteristics | AyuFlex 1 (250 mg BID) | AyuFlex2 (500 mg BID) | Placebo |
p-value
|
---|---|---|---|---|
Sex (m/f)
| 15/13 | 11/22 | 11/14 | 0.288 |
Age | 42.0 (±12.5) | 42.8 (±10.1) | 45.8 (±11.6) | 0.453 |
Height (cm) | 170.2 (±9.3) | 172.0 (±10.6) | 173.6 (±11.6) | 0.495 |
Weight (kg) | 86.5 (±15.9) | 89.8 (±15.7) | 88.1 (±18.0) | 0.734 |
BMI | 29.9 (±5.3) | 30.2 (±4.7) | 29.1 (±4.2) | 0.638 |
Systolic Pressure (mm Hg) | 125.0 (±11.8) | 127.8 (±11.5) | 127.8 (±10.3) | 0.566 |
Diastolic Pressure (mm Hg) | 79.9 (±6.5) | 80.5 (±8.1) | 79.8 (±8.2) | 0.914 |
Heart Rate (bpm) | 70.8 (±8.9) | 70.6 (±10.7) | 71.7 (±8.6) | 0.903 |
Measures of comfort, mobility and function
mKOOS scores
Visit | AyuFlex1 (n = 28)
| AyuFlex2 (n = 33)
| Placebo (n = 25) | Overalla
| AF1 + AF2 vs PBO | AF1 vs PBO | AF2 vs PBO | AF1 vs AF2 |
---|---|---|---|---|---|---|---|---|
0.115 |
0.042
| 0.140 | 0.620 | 0.485 | ||||
0 | 73.6 (±15.0) | 74.0 (±16.0) | 74.5 (±14.1) | |||||
14 | 77.7 (±14.0) | 76.5 (±17.4) | 74.8 (±14.2) | 0.970 | 0.637 | 0.635 | 0.321 | |
42 | 79.8 (±12.4) | 78.8 (±16.8) | 75.6 (±15.8) | 0.301 | 0.222 | 0.526 | 0.510 | |
84 | 83.7 (±12.6) | 80.9 (±15.3) | 77.0 (±16.4) | 0.083 |
0.036
| 0.303 | 0.227 | |
Changes to mKOOS Scoresb
| ||||||||
10.1 (±13.2) | 6.9 (±9.9) | 2.5 (±8.2) |
0.039
|
0.023
|
0.011
| 0.247 | 0.247 |
Changes in mKOOS scores
Global mWOMAC scores and subscales
Changes to physical function mWOMAC subscale
Changes to Total mWOMAC score
VAS scores
Visit | AyuFlex1 (n = 56)
| AyuFlex2 (n = 66)
| Placebo (n = 50)
|
p value
| ||||
---|---|---|---|---|---|---|---|---|
Overalla
| AF1 + AF2 vs PBO | AF1 vs PBO | AF2 vs PBO | AF1 vs AF2 | ||||
Overalla
| 0.053 |
0.046
|
0.043
| 0.105 | 0.165 | |||
0 | 35.3 (±22.9) | 38.2 (±28.0) | 31.1 (±22.8) | |||||
14 | 32.8 (±22.6) | 31.3 (±25.8) | 33.2 (±21.5) | 0.073 | 0.227 | 0.036 | 0.332 | |
42 | 27.8 (±21.7) | 31.4 (±24.5) | 32.9 (±24.3) | 0.089 | 0.059 | 0.263 | 0.537 | |
84 | 22.1 (±19.5) | 24.7 (±23.8) | 33.4 (±25.1) |
0.001
|
0.001
|
0.005
| 0.651 | |
Changes to Measures of Discomfort with Activity or Exerciseb
| ||||||||
−13.2 (±24.4) | −13.5 (±28.7) | 2.2 (±21.6) |
0.002
|
<0.001
|
0.002
|
0.001
| 0.956 |
Changes to VAS scores in knee discomfort with activity/exercise
Visit | AyuFlex1 (n = 37)
| AyuFlex2 (n = 39)
| Placebo (n = 34)
|
p value
| ||||
---|---|---|---|---|---|---|---|---|
Overalla
| AF1 + AF2 vs PBO | AF1 vs PBO | AF2 vs PBO | AF1 vs AF2 | ||||
Overalla
| 0.085 |
0.044
| 0.054 | 0.082 | 0.361 | |||
0 | 43.8 (±22.8) | 52.0 (±25.7) | 40.5 (±20.8) | |||||
14 | 39.1 (±23.5) | 41.7 (±22.8) | 40.7 (±20.2) | 0.122 | 0.266 | 0.090 | 0.536 | |
42 | 32.2 (±22.5) | 39.4 (±22.9) | 39.8 (±22.9) | 0.097 |
0.050
| 0.430 | 0.414 | |
84 | 25.7 (±19.0) | 30.3 (±21.6) | 40.9 (±24.1) |
0.001
|
0.001
|
0.008
| 0.595 | |
Changes to Measures of Discomfort with Activity or Exerciseb
| ||||||||
−18.2 (±23.5) | −21.7 (±28.6) | 0.4 (±24.1) |
0.001
|
<0.001
|
0.002
|
<0.001
| 0.547 |
Changes to VAS scores in knee discomfort with activity/exercise adjusted
Visit | AyuFlex1 (n = 28)
| AyuFlex2 (n = 33)
| Placebo (n = 25) |
p value
| ||||
Overall Knee Mobility
| Overalla
| AF1 + AF2 vs PBO | AF1 vs PBO | AF2 vs PBO | AF1 vs AF2 | |||
Overalla
| 0.577 | 0.552 | 0.344 | 0.946 | 0.341 | |||
0 | 69.4 (±21.2) | 69.4 (±17.6) | 68.8 (±21.8) | |||||
14 | 68.0 (±22.1) | 75.8 (±16.2) | 68.0 (±21.8) | 0.324 | 0.892 |
0.048
| 0.078 | |
42 | 75.5 (±16.3) | 78.2 (±14.9) | 70.1 (±21.6) | 0.078 | 0.249 | 0.078 | 0.474 | |
84 | 79.0 (±16.3) | 83.4 (±14.9) | 73.3 (±18.8) | 0.031 | 0.208 |
0.021
| 0.251 | |
Changes to Measures of Overall Knee Mobilityb
| ||||||||
9.6 (±21.6) | 13.9 (±18.9) | 4.6 (±17.9) | 0.201 | 0.115 | 0.351 | 0.074 | 0.391 | |
Overall Joint Function
| Overalla
| AF1 + AF2 vs PBO | AF1 vs PBO | AF2 vs PBO | AF1 vs AF2 | |||
Overalla
| 0.444 | 0.199 | 0.219 | 0.367 | 0.776 | |||
0 | 73.3 (±20.5) | 66.6 (±23.8) | 72.0 (±20.8) | |||||
14 | 74.8 (±17.9) | 76.0 (±18.0) | 72.6 (±20.2) | 0.304 | 0.718 | 0.158 | 0.448 | |
42 | 76.2 (±15.1) | 79.0 (±19.0) | 72.6 (±22.6) | 0.388 | 0.493 | 0.059 | 0.226 | |
84 | 81.1 (±13.0) | 82.2 (±17.9) | 72.0 (±20.8) | 0.387 | 0.055 | 0.015 | 0.522 | |
Changes to Measures of Overall Joint Functionb
| ||||||||
7.8 (±21.1) | 15.5 (±24.7) | 0.0 (±21.1) |
0.038
|
0.029
| 0.215 |
0.011
| 0.182 | |
Overall Low Back Health
| Overalla
| AF1 + AF2 vs PBO | AF1 vs PBO | AF2 vs PBO | AF1 vs AF2 | |||
Overalla
| 0.828 | 0.630 | 0.907 | 0.446 | 0.732 | |||
0 | 64.2 (±22.9) | 64.3 (±26.6) | 54.4 (±24.6) | |||||
14 | 71.8 (±18.3) | 68.3 (±23.4) | 55.8 (±21.2) |
0.032
|
0.017
| 0.153 | 0.405 | |
42 | 74.5(±22.5) | 72.4 (±23.1) | 55.8 (±21.2) |
0.007
|
0.014
|
0.024
| 0.626 | |
84 | 76.6 (±20.9) | 76.5 (±23.3) | 59.8 (±24.4) |
0.013
|
0.029
|
0.037
| 0.978 | |
Changes to Measures of Low Back Healthb
| ||||||||
12.5 (±27.1) | 12.3 (±19.6) | 5.5 (±25.0) | 0.480 | 0.224 | 0.290 | 0.285 | 0.975 | |
Willingness to Exercise
| Overalla
| AF1 + AF2 vs PBO | AF1 vs PBO | AF2 vs PBO | AF1 vs AF2 | |||
Overalla
| 0.442 | 0.204 | 0.171 | 0.412 | 0.748 | |||
0 | 74.6 (±21.2) | 73.5 (±23.8) | 69.2 (±26.8) | |||||
14 | 74.3 (±17.5) | 76.0 (±20.4) | 71.0 (±23.6) | 0.687 | 0.941 | 0.577 | 0.553 | |
42 | 79.4 (±16.0) | 77.3 (±26.6) | 68.4 (±27.5) | 0.129 | 0.112 | 0.289 | 0.766 | |
84 | 82.7 (±16.8) | 82.9 (±20.8) | 71.1 (±27.9) |
0.039
| 0.108 | 0.082 | 0.861 | |
Changes to Measures of Willingness to Exerciseb
| ||||||||
8.1 (±21.9) | 9.5 (±19.6) | 2.0 (±27.0) | 0.434 | 0.203 | 0.331 | 0.215 | 0.809 |
Joint mobility
Functional capacity
Leg extension and VAS response
Visit | AyuFlex1 (n = 56)
| AyuFlex2 (n = 66)
| Placebo (n = 50) |
p value
| ||||
---|---|---|---|---|---|---|---|---|
Overalla
| AF1 + AF2 vs PBO | AF1 vs PBO | AF2 vs PBO | AF1 vs AF2 | ||||
Overalla
| 0.125 |
0.046
| 0.258 |
0.031
| 0.584 | |||
0 | 4.1 (±2.5) | 4.2 (±3.3) | 3.9 (±2.6) | |||||
14 | 3.6 (±2.3) | 4.2 (±3.3) | 3.7 (±2.8) | 0.966 | 0.409 | 0.463 | 0.088 | |
42 | 3.0 (±2.3) | 3.4 (±3.0) | 3.6 (±2.6) | 0.122 |
0.045
| 0.392 | 0.292 | |
84 | 2.2 (±2.1) | 2.3 (±2.9) | 3.1 (±2.5) |
0.010
|
0.010
|
0.033
| 0.668 | |
Changes to Measures of VAS Score Following Leg Extensionb
| ||||||||
−1.9 (±2.2) | −1.8 (±2.5) | −0.8 (±2.5) |
0.048
|
0.039
|
0.022
|
0.043
| 0.717 |
Changes to knee pain following leg extension exercise
6-min walk test and VAS response
Changes to distance covered during 6-minute walk test
Changes to VAS score post 6-minute walk test
Inflammation and safety biomarkers
Variable | Day 0 | Day 84 | Within Group p-Value | Between Group p-Value |
---|---|---|---|---|
Human COMP (×100 ng/mL) | ||||
Placebo | 4280.4 (±1037.8) | 4577.8 (±1498.7) | 0.195 | 0.091 |
AF1 | 4151.0 (±1186.6) | 3818.9 (±1171.4) | 0.092 | |
AF2 | 4229.5 (±1339.9) | 4303.0 (±1387.6) | 0.700 | |
AF1 + AF2 | 4191.7 (±1258.4) | 4069.6 (±1296.4) | 0.371 | |
TNF-alpha (pg/mL) | ||||
Placebo | 38.9 (±26.3) | 37.2 (±22.2) | 0.733 | 0.492 |
AF1 | 51.7 (±35.6) | 49.5 (±37.3) | 0.641 | |
AF2 | 47.5 (±26.3) | 39.4 (±25.5) |
0.026
| |
AF1 + AF2 | 49.5 (±30.1) | 44.3 (±31.9) | 0.074 | |
C-Reactive Protein (mg/L) | ||||
Placebo | 2.5 (±1.8) | 1.7 (±1.5) | 0.044 | 0.137 |
AF1 | 2.5 (±2.7) | 2.5 (±3.1) | 0.909 | |
AF2 | 2.3 (±2.2) | 2.0 (±1.9) | 0.249 | |
AF1 + AF2 | 2.3 (±2.4) | 2.2 (±2.5) | 0.619 |
Changes to COMP
Variable | Day −14 | Day 84 | Within Group p-Value | Between Group p-Value |
---|---|---|---|---|
Hematocrit (%) | ||||
Placebo | 14.7 (±1.4) | 14.7 (±1.4) | 0.539 | 0.787 |
AF1 | 14.4 (±1.2) | 14.2 (±1.1) | 0.058 | |
AF2 | 14.7 (±1.2) | 14.5 (±1.1) | 0.052 | |
AF1 + AF2 | 14.6 (±1.2) | 14.3 (±1.1) | 0.006 | |
White Blood Cell (x10E3/uL) | ||||
Placebo | 6.4 (±1.2) | 6.3 (±1.8) | 0.747 | 0.929 |
AF1 | 5.7 (±2.0) | 5.8 (±1.9) | 0.826 | |
AF2 | 5.7 (±1.8) | 5.7 (±2.0) | 0.984 | |
AF1 + AF2 | 5.7 (±1.9) | 5.7 (±1.9) | 0.900 | |
Potassium (mmol/L) | ||||
Placebo | 4.3 (±0.2) | 4.3 (±0.3) | 0.608 | 0.870 |
AF1 | 4.3 (±0.2) | 4.4 (±0.2) | 0.581 | |
AF2 | 4.3 (±0.3) | 4.4 (±0.2) | 0.203 | |
AF1 + AF2 | 4.3 (±0.2) | 4.4 (±0.2) | 0.182 | |
Albumin (g/dL) | ||||
Placebo | 4.4 (±0.3) | 4.5 (±0.3) | 0.682 | 0.222 |
AF1 | 4.4 (±0.3) | 4.4 (±0.3) | 0.311 | |
AF2 | 4.4 (±0.3) | 4.4 (±0.2) | 0.049 | |
AF1 + AF2 | 4.5 (±0.3) | 4.4 (±0.3) |
0.003
| |
Sodium (mmol/L) | ||||
Placebo | 140.5 (±2.1) | 140.2 (±1.7) | 0.510 | 0.949 |
AF1 | 140.3 (±1.6) | 140.1 (±1.7) | 0.621 | |
AF2 | 141.2 (±2.1) | 141.2 (±2.2) | 0.829 | |
AF1 + AF2 | 140.8 (±1.9) | 140.7 (±2.0) | 0.622 | |
BUN (mg/dL) | ||||
Placebo | 14.6 (±3.9) | 14.3 (±2.8) | 0.617 | 0.402 |
AF1 | 13.6 (±3.5) | 13.3 (±3.5) | 0.604 | |
AF2 | 15.3 (±4.1) | 14.6 (±4.4) | 0.312 | |
AF1 + AF2 | 14.5 (±3.9) | 14.0 (±4.0) | 0.253 | |
Chloride (mmol/L) | ||||
Placebo | 101.7 (±3.9) | 102.0 (±2.1) | 0.532 |
0.032
|
AF1 | 102.9 (±3.0) | 101.4 (±2.1) |
0.004
| |
AF2 | 102.8 (±2.1) | 102.5 (±2.4) | 0.484 | |
AF1 + AF2 | 102.8 (±2.5) | 102.0 (±2.3) |
0.013
| |
Creatinine (mg/dL) | ||||
Placebo | 0.88 (±0.1) | 0.87 (±0.1) | 0.513 | 0.436 |
AF1 | 0.84 (±0.2) | 0.86 (±0.2) | 0.163 | |
AF2 | 0.92 (±0.2) | 0.92 (±0.2) | 0.977 | |
AF1 + AF2 | 0.88 (±0.17) | 0.89 (±0.18) | 0.413 | |
AST (IU/L) | ||||
Placebo | 21.5 (±5.9) | 19.9 (±4.0) | 0.059 | 0.615 |
AF1 | 21.4 (±9.8) | 20.7 (±9.0) | 0.499 | |
AF2 | 23.0 (±14.8) | 22.9 (±11.5) | 0.933 | |
AF1 + AF2 | 22.3 (±12.7) | 21.9 (±10.4) | 0.674 | |
ALT (IU/L) | ||||
Placebo | 25.8 (±11.3) | 24.4 (±9.6) | 0.427 | 0.617 |
AF1 | 23.2 (±11.6) | 19.5 (±8.0) |
0.020
| |
AF2 | 27.2 (±15.8) | 24.4 (±15.2) | 0.082 | |
AF1 + AF2 | 25.4 (±14.1) | 22.1 (±12.6) | 0.620 |
Variable | Day −14 | Day 84 | Within Group p-Value | Between Group p-Value |
---|---|---|---|---|
Cholesterol (mg/dL) | ||||
Placebo | 202.2 (±54.0) | 192.1 (±47.8) | 0.066 | 0.787 |
AF1 | 198.1 (±59.5) | 187.2 (±35.8) | 0.153 | |
AF2 | 197.0 (±43.3) | 190.9 (±39.3) | 0.086 | |
AF1 + AF2 | 197.5 (±50.9) | 189.2 (±37.4) |
0.036
| |
Triglycerides (mg/dL) | ||||
Placebo | 156.0 (±126.7) | 143.4 (±101.7) | 0.473 | 0.465 |
AF1 | 112.7 (±60.9) | 118.2 (±88.1) | 0.626 | |
AF2 | 144.4 (±112.1) | 129.7 (±80.0) | 0.153 | |
AF1 + AF2 | 129.9 (±92.9) | 124.4 (±83.3) | 0.470 | |
HDL (mg/dL) | ||||
Placebo | 55.1 (±17.4) | 53.3 (±15.9) | 0.209 | 0.294 |
AF1 | 56.5 (±18.9) | 55.5 (±19.3) | 0.258 | |
AF2 | 52.2 (±16.1) | 52.8 (±15.7) | 0.577 | |
AF1 + AF2 | 54.2 (±17.4) | 54.0 (±17.3) | 0.853 | |
LDL (mg/dL) | ||||
Placebo | 115.1 (±37.4) | 110.1 (±38.1) | 0.217 | 0.550 |
AF1 | 119.1 (±54.9) | 108.0 (±33.4) | 0.154 | |
AF2 | 119.7 (±32.8) | 116.1 (±29.0) | 0.254 | |
AF1 + AF2 | 119.4 (±43.9) | 112.4 (±31.1) | 0.072 |
Ayu Flex 1
|
Ayu Flex 2
|
Placebo
| |
---|---|---|---|
Severity | |||
Mild | 2 | 2 | 1 |
Moderate | 1 | ||
Severe | |||
Relationship to Study | |||
Unlikely | 1 | ||
Possible | 2 | 2 | 1 |
Probable | |||
Seriousness | |||
No | |||
Hospitalization | |||
Disability | |||
Life Threatening | |||
Important Medical Event | |||
Reported Symptom | |||
Crepitus | 1 | ||
Cramps | 1 | ||
Swelling (From Fall) | 1 | ||
Headaches | 1 | ||
Heart Burn | 1 | ||
Reflux | 1 |