Polysulfated glycosaminoglycan (PSGAG), sold under the brand name Adequan, is an injectable drug for dogs and horses that is used to alleviate the limpness, pain, and lowered range of motion caused by

arthritis Arthritis is a term often used to mean any disorder that affects joints. Symptoms generally include joint pain and stiffness. Other symptoms may include redness, warmth, swelling, and decreased range of motion of the affected joints. In some ...

. It is made of repeat

disaccharide A disaccharide (also called a double sugar or ''biose'') is the sugar formed when two monosaccharides are joined by glycosidic linkage. Like monosaccharides, disaccharides are simple sugars soluble in water. Three common examples are sucrose, ...

units (comprising hexosamine and

hexuronic acid Hexuronic acid is any uronic acid derived from a hexose. These include fructuronic acids, galacturonic acids, glucuronic acids, guluronic acids, iduronic acids, mannuronic acids, and tagaturonic acids. In the early 1900s, ascorbic acid ...

), and is similar to

glycosaminoglycans Glycosaminoglycans (GAGs) or mucopolysaccharides are long, linear polysaccharides consisting of repeating disaccharide units (i.e. two-sugar units). The repeating two-sugar unit consists of a uronic sugar and an amino sugar, except in the case o ...

already present in the cartilage; PSGAG thus easily integrates itself there. ''In vitro'' studies have shown it to inhibit the enzymes that degrade cartilage and bone, as well as suppress inflammation and stimulate the synthesis of replacement cartilage. While it can cause an increased risk of bleeding, it is relatively safe and has a high

LD50 In toxicology, the median lethal dose, LD50 (abbreviation for "lethal dose, 50%"), LC50 (lethal concentration, 50%) or LCt50 is a toxic unit that measures the lethal dose of a toxin, radiation, or pathogen. The value of LD50 for a substance is the ...

. PSGAG is one of the most widely prescribed joint treatments for horses. While it is widely used, some studies still show conflicting results in terms of efficacy, causing some to claim that PSGAG is not solely responsible for the significant mitigation of arthritis seen in success cases.

Medicinal uses

PSGAG is mostly used in dogs and horses for treating traumatic arthritis and degenerative joint disease (osteoarthritis). It has shown to be better at treating acute than chronic

, though some studies say that its effectiveness in acute cases is still limited if degenerative enzymes have not played a role. While it is currently only FDA-approved for dogs and horses, PSGAG is also used off-label to treat lameness in swine, as a chondroprotectant ("joint protector") or treatment of

interstitial cystitis Interstitial cystitis (IC), a type of bladder pain syndrome (BPS), is chronic pain in the bladder and pelvic floor of unknown cause. It is the urologic chronic pelvic pain syndrome of women. Symptoms include feeling the need to urinate right a ...

in cats, and to treat arthritis in rabbits.

Available forms

PSGAG is first administered as a series of injections over several weeks, and can be continued once or twice a month thereafter. It is normally injected intramuscularly, though can also be injected intra-articularily (directly into the joint) in horses or

subcutaneously The subcutaneous tissue (), also called the hypodermis, hypoderm (), subcutis, superficial fascia, is the lowermost layer of the integumentary system in vertebrates. The types of cells found in the layer are fibroblasts, adipose cells, and ma ...

in off-label uses. Giving PSGAG intra-articularily requires it to be given aseptically, and is sometimes supplemented by the antibiotic amikacin to prevent infection. There are no generic or human-labeled equivalents of PSGAG in the US.

Side effects and overdose

Side effects from intra-articular administration can include joint pain, swelling, lameness, and, rarely, infection of the joint. Intramuscular injection can cause dose-dependent

inflammation Inflammation (from la, wikt:en:inflammatio#Latin, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or Irritation, irritants, and is a protective response involving im ...

and

bleeding Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, vag ...

, since PSGAG is an analogue of the anticoagulant

heparin Heparin, also known as unfractionated heparin (UFH), is a medication and naturally occurring glycosaminoglycan. Since heparins depend on the activity of antithrombin, they are considered anticoagulants. Specifically it is also used in the trea ...

. In dogs, this may manifest as bleeding from the nose or as bloody stools. The increased risk of bleeding has some advising not to give PSGAG to animals with bleeding disorders, though its only

absolute contraindication In medicine, a contraindication is a condition that serves as a reason not to take a certain medical treatment due to the harm that it would cause the patient. Contraindication is the opposite of indication, which is a reason to use a certain tre ...

is hypersensitivity to PSAGs when it is being given intra-articularily. Overdose on PSGAG is quite rare, as the

is over 1000 mg/kg when given

intravenously Intravenous therapy (abbreviated as IV therapy) is a medical technique that administers fluids, medications and nutrients directly into a person's vein. The intravenous route of administration is commonly used for rehydration or to provide nutrie ...

to dogs. Signs of overdose include exacerbated side effects such as joint pain, swelling, and lameness. When dogs received three times the normal dose intramuscularly twice a week for 13 weeks, they had increased

liver The liver is a major organ only found in vertebrates which performs many essential biological functions such as detoxification of the organism, and the synthesis of proteins and biochemicals necessary for digestion and growth. In humans, it ...

and

kidney The kidneys are two reddish-brown bean-shaped organs found in vertebrates. They are located on the left and right in the retroperitoneal space, and in adult humans are about in length. They receive blood from the paired renal arteries; bloo ...

weight, as well as microscopic

lesions A lesion is any damage or abnormal change in the tissue of an organism, usually caused by disease or trauma. ''Lesion'' is derived from the Latin "injury". Lesions may occur in plants as well as animals. Types There is no designated classif ...

on the liver, kidneys, and

lymph nodes A lymph node, or lymph gland, is a kidney-shaped organ of the lymphatic system and the adaptive immune system. A large number of lymph nodes are linked throughout the body by the lymphatic vessels. They are major sites of lymphocytes that incl ...

. At 11 times the normal dose, they also had increased

alanine transferase Alanine transaminase (ALT) is a transaminase enzyme (). It is also called alanine aminotransferase (ALT or ALAT) and was formerly called serum glutamate-pyruvate transaminase or serum glutamic-pyruvic transaminase (SGPT) and was first character ...

cholesterol Cholesterol is any of a class of certain organic molecules called lipids. It is a sterol (or modified steroid), a type of lipid. Cholesterol is biosynthesized by all animal cells and is an essential structural component of animal cell membr ...

, and

prothrombin time The prothrombin time (PT) – along with its derived measures of prothrombin ratio (PR) and international normalized ratio (INR) – is an assay for evaluating the ''extrinsic'' pathway and common pathway of coagulation. This blood test is al ...

(i.e. coagulation via the extrinsic pathway took longer), and fewer

platelets Platelets, also called thrombocytes (from Greek θρόμβος, "clot" and κύτος, "cell"), are a component of blood whose function (along with the coagulation factors) is to react to bleeding from blood vessel injury by clumping, thereby i ...

Pharmacology

Mechanism of action

Normally, joint cartilages have

proteoglycan Proteoglycans are proteins that are heavily glycosylated. The basic proteoglycan unit consists of a "core protein" with one or more covalently attached glycosaminoglycan (GAG) chain(s). The point of attachment is a serine (Ser) residue to w ...

complexes, which are proteins with side chains made of

such as

keratan sulfate Keratan sulfate (KS), also called keratosulfate, is any of several sulfated glycosaminoglycans (structural carbohydrates) that have been found especially in the cornea, cartilage, and bone. It is also synthesized in the central nervous system ...

and

chondroitin sulfate Chondroitin sulfate is a sulfated glycosaminoglycan (GAG) composed of a chain of alternating sugars ( N-acetylgalactosamine and glucuronic acid). It is usually found attached to proteins as part of a proteoglycan. A chondroitin chain can have over ...

attached to strands of

hyaluronic acid Hyaluronic acid (; abbreviated HA; conjugate base hyaluronate), also called hyaluronan, is an anionic, nonsulfated glycosaminoglycan distributed widely throughout connective, epithelial, and neural tissues. It is unique among glycosaminoglycan ...

. The glycosaminoglycan side chains are polyanionic, which causes adjacent side chains to push each other away and create a "bottle brush", where hyaluronic acid is the stem and the side chains are the bristles. When pressure is exerted on the joint, fluids move between the

chondrocytes Chondrocytes (, from Greek χόνδρος, ''chondros'' = cartilage + κύτος, ''kytos'' = cell) are the only cells found in healthy cartilage. They produce and maintain the cartilaginous matrix, which consists mainly of collagen and prote ...

and

synovial fluid Synovial fluid, also called synovia, elp 1/sup> is a viscous, non-Newtonian fluid found in the cavities of synovial joints. With its egg white–like consistency, the principal role of synovial fluid is to reduce friction between the articul ...

, exchanging nutrients. In degenerative joint disease, the proteoglycan complexes start disappearing, and the hyaluronate becomes poorer in quality and scarcer. This lowers the viscosity of the synovial fluid (which increases friction) and causes

white blood cell White blood cells, also called leukocytes or leucocytes, are the cells of the immune system that are involved in protecting the body against both infectious disease and foreign invaders. All white blood cells are produced and derived from mult ...

s and enzymes to enter and effect cartilage degradation and inflammation.

Steroids A steroid is a biologically active organic compound with four rings arranged in a specific molecular configuration. Steroids have two principal biological functions: as important components of cell membranes that alter membrane fluidity; and ...

that are released as a result kill the chondrocytes. The remaining chondrocytes have trouble exchanging nutrients with the synovial fluid, which would allow them to repair some damages. The mechanism of PSGAG ''in vivo'' is based on observations and studies ''in vitro''. PSGAG inhibits many of the catabolic enzymes that degrade cartilage, proteoglycans, and hyaluronic acid. The enzymes that are inhibited include serine proteases, which play a role in the IL-1 degradation of proteoglycans and collagen;

lysosomal enzymes A lysosome () is a membrane-bound organelle found in many animal cells. They are spherical vesicles that contain hydrolytic enzymes that can break down many kinds of biomolecules. A lysosome has a specific composition, of both its membrane prote ...

that cause proteoglycans to dissociate from hyaluronic acid; elastase; metalloproteinases such as stromelysin, which degrade cartilage matrix proteins;

collagenases Collagenases are enzymes that break the peptide bonds in collagen. They assist in destroying extracellular structures in the pathogenesis of bacteria such as ''Clostridium''. They are considered a virulence factor, facilitating the spread of ga ...

such as cathepsin B1; and

hyaluronidase Hyaluronidases are a family of enzymes that catalyse the degradation of hyaluronic acid (HA). Karl Meyer classified these enzymes in 1971, into three distinct groups, a scheme based on the enzyme reaction products. The three main types of hyalu ...

. PSGAG inhibits the synthesis of

prostaglandin E2 Prostaglandin E2 (PGE2), also known as dinoprostone, is a naturally occurring prostaglandin with oxytocic properties that is used as a medication. Dinoprostone is used in labor induction, bleeding after delivery, termination of pregnancy, a ...

, which is released upon joint injury and causes inflammation, increases the loss of proteoglycan, and reduces the threshold of pain receptors. Inhibiting the complement pathway further reduces inflammation, most likely by altering

C-reactive protein C-reactive protein (CRP) is an annular (ring-shaped) pentameric protein found in blood plasma, whose circulating concentrations rise in response to inflammation. It is an acute-phase protein of hepatic origin that increases following interleukin ...

. The inhibition of blood coagulation reduces resultant fibrinolysis, which would cause cell death and increase local inflammation. PSGAG also stimulates the synthesis of glycosaminoglycans, hyaluronic acid, and collagen, which increase synovial viscosity. It cannot, however, completely reverse the disappearance of cartilage, nor can it reverse bone loss caused by arthritis.

Pharmacokinetics

PSGAG reaches peak blood concentration in 20–40 minutes when injected intramuscularly; 30–40% of it binds to blood proteins. It enters all tissues, reaching cartilage within two hours. When PSGAG reaches the synovial fluid, it is then taken up by the cartilage matrices, with osteoarthritic cartilage showing a stronger preference for taking it up. It reaches its peak levels in the joints at 48 hours, and lasts up to 96 hours, before leaving and being excreted by the

kidneys The kidneys are two reddish-brown bean-shaped organs found in vertebrates. They are located on the left and right in the retroperitoneal space, and in adult humans are about in length. They receive blood from the paired renal arteries; bloo ...

References

{{Glycosaminoglycans Veterinary drugs Glycosaminoglycans