Safety and Efficacy of JointAlive™ on the Knee-joint Function in Adults With Knee Arthritis

Osteoarthritis (OA) is a joint disorder caused by wear and tear on the joint over time; as a result, the protective cartilage of the bone in the joint gradually wears down. The lifetime risk of developing OA in the knee, with symptoms such as pain, aching, and stiffness, is 40% in men and 47% in women. It is estimated that approximately 19% of Americans aged 45 and older are affected by knee OA. Knee OA accounts for 83% of the global burden caused by all OA types. Pain and stiffness in knees, a large weight-bearing joint, often leads to disability, which interferes with daily life activities and demands expensive medical treatments or care. Due to the limitations of current OA treatment methods, there is an increasing demand for effective and safer alternatives, such as natural health products with pain-relieving potential. The investigational product, JointAlive™, is a supplement designed to alleviate knee OA symptoms and to improve knee functionality. The present study will investigate the safety and efficacy of JointAlive™ in reducing knee OA symptoms and improving joint functionality in an otherwise healthy adult population with mild to moderate knee OA. JointAlive™ is a proprietary blend of Epimedium brevicornum Maxim leaves, Dioscorea nipponica Makino rhizome, Salvia miltoiorrhiza Bunge root and rhizome extracts

Osteoarthritis (OA) is a joint disorder caused by wear and tear on the joint over time; as a result, the protective cartilage of the bone in the joint gradually wears down. The lifetime risk of developing OA in the knee, with symptoms such as pain, aching, and stiffness, is 40% in men and 47% in women. It is estimated that approximately 19% of Americans aged 45 and older are affected by knee OA. Knee OA accounts for 83% of the global burden caused by all OA types. Pain and stiffness in knees, a large weight-bearing joint, often leads to disability, which interferes with daily life activities and demands expensive medical treatments or care. Losina et al. reported that in the United States, the average lifetime costs for symptomatic knee OA management is $12,400 USD, but the cost can be higher with knee surgeries for advanced OA. The economic burden is expected to continue increasing in the near future due to the aging population and increasing prevalence of obesity in many developed countries.

Although the exact etiology of OA is unknown, many risk factors are associated with the development of knee OA, such as obesity, repetitive use of joints, age, and previous knee injury or surgery. Multiple studies have shown a positive association between pro-inflammatory cytokines (e.g. tumor necrosis factor (TNF)-α, interleukin (IL)-1β, and IL-6) and OA development. Cytokine-induced nuclear factor-κB (NF-κB) activation can stimulate articular chondrocyte catabolism and extracellular matrix degradation, leading to the breakdown of articular cartilage. The severity of cartilage disintegration and osteophyte (a bony outgrowth) formation can be identified radiographically and used for the Kellgren-Lawrence (KL) grading scheme. A KL score of one (doubtful narrowing of the joint space with possible osteophyte formation) is considered possible OA, while a score of two (possible narrowing of joint space with definite osteophyte formation) or three (definite narrowing of joint space and moderate osteophyte formation) is considered as a definite/mild OA.

It is crucial to treat OA early, before it develops into more severe cases and causes mobility disability. The first step of OA treatment is exercise and/or physiotherapy, which has demonstrated long-term benefits but often difficult to maintain compliance. Once the pain is difficult to manage, over-the-counter medicines such as Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are introduced to provide relief. NSAIDs are effective in reducing pain, however, long-term usage requires medical supervision. Chronic NSAID use is associated with high incidence of adverse events such as upper gastrointestinal tract problems, kidney and liver injury, hypertension, and congestive heart failure. When the abovementioned treatments are ineffective, intra-articular injections of hyaluronic acid, cortisol, or platelet rich plasma are applied and proven effective, but they can be costly and may cause reactive flares or infections at the injection site. Surgery serves as last resort; it is a successful treatment for advanced OA, but it is invasive and may increase risks of infection, bleeding, and deep vein thrombosis. Given the limitations of current OA treatment methods, there is an increasing demand for effective and safer alternatives, such as natural health products with pain-relieving potential.

The investigational product, JointAlive™, is a supplement designed to alleviate knee OA symptoms and to improve knee functionality. JointAlive™ contains extract from flowering plants that are endemic to China.The main bioactive component is icariin; a flavonoid glycoside demonstrating various antioxidant and anti-inflammatory benefits. Numerous in vitro cell culture studies showed that icariin has the potential to suppress inflammatory pathways involved in OA. In rodent OA models, joint injection of icariin for 32 and 84 days was found to protect the articular cartilage from degeneration.

The present study will investigate the safety and efficacy of JointAlive™ in reducing knee OA symptoms and improving joint functionality in an otherwise healthy adult population with mild to moderate knee OA. Based on the previous studies conducted on the ingredients of this investigational product and their previous application in OA, participants identifying mild or moderate OA in a target knee will be investigated in this study. As OA is a secondary complication in sports injuries as well as a primary development during aging, an age range between 40-75 years will be considered for enrolment. The Kellgren-Lawrence grading scale will be used to confirm OA. As well, BMI cut offs between 18.5 and 29.9 kg/m2 will be considered to excluded those with complications due to obesity and the associated increase in concomitant medication use. To allow for pain relief, as this study involves a placebo group, a rescue medication will be provided. However, in order to ensure that the capture of pain in the target knee is unbiased, participants will be required to abstain from the rescue medication use for 48 hours prior to their clinic visits. Confounders due to medical history and concomitant medications will be ensured by several targeted exclusion criteria with the intent of decreasing potential confounders of the study results.

Eligibility Criteria:
Inclusion Criteria:

1. Males and females between 40 and 75 years of age, inclusive
2. BMI between 18.5 to 29.9 kg/m2, inclusive
3. Female participant is not of child-bearing potential, defined as females who have undergone a sterilization procedure (e.g. hysterectomy, bilateral oophorectomy, bilateral tubal ligation, complete endometrial ablation) or have been post-menopausal for at least 1 year prior to screening Or,

   Females of child-bearing potential must have a negative baseline urine pregnancy test and agree to use a medically approved method of birth control for the duration of the study. All hormonal birth control must have been in use for a minimum of three months. Acceptable methods of birth control include:
   * Hormonal contraceptives including oral contraceptives, hormone birth control patch (Ortho Evra), vaginal contraceptive ring (NuvaRing), injectable contraceptives (Depo-Provera, Lunelle), or hormone implant (Norplant System)
   * Double-barrier method
   * Intrauterine devices
   * Non-heterosexual lifestyle or agrees to use contraception if planning on changing to heterosexual partner(s)
   * Vasectomy of partner at least 6 months prior to screening
4. Self-reported pain or swelling in target knee
5. The diagnosis of mild to moderate osteoarthritis as confirmed by the Qualified Investigator using qualifiers based on physical exam, medical history and x-ray report qualified as mild to moderate by the radiologist
6. Agrees to refrain from taking any pain relievers during the study, except acetaminophen as a rescue medication specified by the study site
7. Agrees to refrain from taking rescue medication for 48 hours prior to study visits
8. Agrees to maintain current diet and current exercise routine throughout the study
9. Willingness to complete questionnaires, records, and diaries associated with the study and to complete all clinic visits
10. Provided voluntary, written, informed consent to participate in the study
11. Healthy as determined by medical history, laboratory results, and physical exam as assessed by the Qualified Investigator (QI)

Exclusion Criteria:

1. Allergy, sensitivity, or intolerance to the investigational product's active or inactive ingredients
2. Allergy to rescue medication
3. Women who are pregnant, breast feeding, or planning to become pregnant during the study
4. Clinically significant abnormal laboratory results at baseline as assessed by the QI
5. Individuals who are unable to give informed consent
6. Injury in the target knee within the past 3 months
7. Intraarticular injections in the target knee within the past 6 months, or plan to have intraarticular injections during the study
8. Individuals with knee joint diseases, such as rheumatoid arthritis, gouty arthritis, septic arthritis or any other infective arthritis
9. Self-reported history of gout or pseudo gout within the past 6 months
10. Skin defects (e.g. skin and soft tissue infections that cause necrosis of the skin, or post-burn contractures) and ulcers around the affected knee joint, as assessed by the QI
11. History of knee surgery or replacement in the target knee, or any non-knee surgical procedures that may impact the study outcomes as assessed by the QI
12. Individuals with muscle or skeletal disorders as assessed by the QI
13. Unstable metabolic disease or chronic diseases as assessed by the QI
14. In a state of acute exacerbation or seizure of chronic disease
15. Type I or Type II diabetes
16. History of or current diagnosis with severe cardiopulmonary, kidney and/or liver dysfunctions, with the exception of history of kidney stones in participants who are symptom free for 6 months
17. Self-reported confirmation of current or pre-existing thyroid condition. Treatment on a stable dose of medication for at least 3 months will be considered by the QI
18. Current or history of any significant diseases of the gastrointestinal tract including diarrhea or dysentery as assessed by the QI
19. Significant cardiovascular event in the past 6 months. Participants with no significant cardiovascular event on stable medication may be included after assessment by the QI on a case-by-case basis
20. Self-reported confirmation of medical or neuropsychological condition and/or cognitive impairment that, in the QI's opinion, could interfere with study participation
21. Cancer, except skin basal cell carcinoma completely excised with no chemotherapy or radiation with a follow up that is negative. Volunteers with cancer in full remission for more than five years after diagnosis are acceptable
22. Verbal confirmation of blood/bleeding disorders as assessed by the QI
23. Individuals with an acute infectious disease, autoimmune disease or are immune-compromised
24. Self-reported confirmation of a HIV-, Hepatitis B- and/or C-positive diagnosis
25. Current use of prescribed medications listed above
26. Current use of over-the-counter medications, supplements, foods and/or drinks listed above
27. Use of medical cannabinoid products
28. Chronic use of cannabinoid products (\>2 times/week) and is unwilling to stop use for the duration of the study. Occasional use to be assessed by the QI on a case-by-case basis
29. Alcohol or drug abuse within the last 12 months
30. High alcohol intake (average of \>2 standard drinks per day)
31. Blood donation 30 days prior to screening, during the study, or a planned donation within 30 days of the last study visit
32. Participation in other clinical research studies 30 days prior to screening
33. Any other condition, that, in the opinion of the QI, may adversely affect the participant's ability to complete the study or its measures or pose significant risk to the participant

Participants on the following concurrent prescribed medications and/or treatments will be excluded during enrollment unless they have been taken off these therapies by their family physician. In the latter event, the frequency and route of administration of use and/or dosage may be considered by the QI on a case-by-case basis prior to recommending an appropriate washout or their enrollment in the study.

1. Oral NSAIDs or topical application on the target knee
2. Narcotics
3. Oral corticosteroids or topical application on the target knee
4. Oral analgesics except acetaminophen as a rescue medication or topical application on the target knee
5. Digoxin
6. Anti-hypertensive drugs
7. Anticoagulants or antiplatelet drugs
8. Medications used for OA treatment
9. Diazepam