Boswellia After 40

After 40, pain in the knees and back often becomes a constant companion, and the regular use of painkillers begins to concern both patients and doctors. Against this background, boswellia is advertised as a 'mild alternative' to NSAIDs. The editorial team examined how correct this comparison is, what studies show and what a mature person with several chronic diseases should pay attention to.

Inflammation and pain after 40

With age, the body more often shows chronic low-grade inflammation, which in the English-language literature is called inflammaging. It is associated with changes in the immune system, the accumulation of visceral fat and reduced physical activity, and is one of the factors in the development of osteoarthritis.

A typical patient after 40 with knee pain has a combination of mechanical load, muscle weakness and an inflammatory reaction in the joint. Treatment therefore must affect several links at once: strengthening the muscles, reducing weight, pain relief and control of inflammation.

Boswellic acids, according to a review by H. Ammon, inhibit 5-lipoxygenase and the synthesis of leukotrienes, and also have other anti-inflammatory effects in experiments. It is precisely on this that the idea of using boswellia for chronic joint pain is based.

However, it is important to remember that an experimental mechanism does not yet guarantee a noticeable clinical effect, and each extract has its own bioavailability and dosing. Therefore studies in humans with specific products are decisive.

Boswellia and NSAIDs: an honest comparison

NSAIDs — ibuprofen, diclofenac, naproxen and others — effectively reduce pain in osteoarthritis, but after 40 and especially after 60 their regular oral use is associated with a risk of gastrointestinal bleeding, elevated pressure, worsening kidney function and cardiovascular events.

Because of these risks, the OARSI 2019 guidelines recommend for knee osteoarthritis primarily topical NSAIDs, and oral ones — taking concomitant diseases into account and for the shortest possible course. It is precisely in this context that patients look for supplements that would allow them to reduce the need for painkillers.

So boswellia is not a direct replacement for NSAIDs: it acts more slowly, its effect is less studied, and product quality varies. At the same time, the safety profile in studies is favorable, which makes it an acceptable option as an addition for some patients.

The decision to reduce the dose or discontinue prescribed painkillers should be made by a doctor, not by the patient on the basis of a supplement advertisement.

Study data in mature patients

The participants in boswellia studies for osteoarthritis were predominantly middle-aged and older people, so their results are relevant precisely for an audience over 40. N. Kimmatkar and colleagues (2003) in a small crossover study recorded a reduction in pain and improved knee mobility.

K. Sengupta and colleagues (2008) in a 90-day study with an AKBA-enriched extract obtained improvements on pain and function scales as early as the first weeks of use. The meta-analysis by G. Yu and colleagues (2020) confirmed the general trend but pointed to the limited quality and small number of studies.

An important limitation is duration. Most studies lasted from 1 to 6 months, so it is unknown whether the effect persists over years and whether long-term use is safe.

There is also no convincing data that boswellia slows the structural progression of osteoarthritis. Laboratory markers of cartilage breakdown changed in individual studies, but this is not yet proven preservation of the joint.

Combinations and 'joint' complexes

After 40, boswellia is often taken as part of complexes: with curcumin, glucosamine, chondroitin, MSM or collagen. The logic of the combination with curcumin is that both agents affect different links of inflammation.

Several studies of combinations of boswellia with curcumin showed a reduction in osteoarthritis symptoms, but most of them are small and funded by manufacturers, so they do not allow an accurate assessment of the contribution of each component.

• Check whether the dose of boswellia in the complex matches the doses from studies.
• Look for the indicated percentage of boswellic acids and AKBA.
• Avoid taking several complexes with the same ingredients at the same time.
• Evaluate the effect by specific criteria, not by an overall feeling.

An 'all-in-one' complex is not necessarily better than a separate extract with a proven dose. Sometimes in such products there is so little of each ingredient that none reaches an effective amount.

The best combination for the joints after 40 remains unchanged: regular exercise, weight control and, if necessary, drug treatment as prescribed by a doctor.

Interactions, contraindications and choosing a product

People after 40 often take antihypertensive drugs, statins, antiplatelet agents, anticoagulants, thyroid or diabetes medications. There are few clinical studies of boswellia interactions with these drugs, and laboratory data point to a possible effect on drug-metabolizing enzymes.

Therefore, people who take warfarin and other anticoagulants, drugs with a narrow therapeutic window or immunosuppressants should agree the use of boswellia with a doctor. Caution is also needed in chronic liver diseases.

The most common side effects are heartburn, nausea, diarrhea and abdominal pain. People with peptic ulcer disease or gastritis should take the extract with food and monitor their well-being, and if symptoms appear — stop taking it.

Studies used standardized extracts in doses that depend on the degree of enrichment: from about 100 mg for highly enriched forms to several hundred milligrams for ordinary ones. Therefore the main rule is to compare not the milligrams of 'boswellia' but the content of standardized active substances.

Editorial conclusions

After 40, boswellia can be an addition for early osteoarthritis, with several positive randomized studies and a favorable safety profile in the short term.

It is not an equivalent replacement for NSAIDs: it acts more slowly and has a smaller evidence base. At the same time, for people with risks from oral NSAIDs it may be an option to discuss with a doctor.

The key to a sensible choice is a standardized extract, realistic expectations, clear criteria for assessing the effect and checking for interactions with medications.

We also recommend reading the editorial team's materials on boswellia for women, on MSM after 40 and on hyaluronic acid after 40.

References

1. Ammon HPT. Boswellic acids in chronic inflammatory diseases. Planta Med. 2006;72(12):1100–1116.
2. Kimmatkar N, Thawani V, Hingorani L, Khiyani R. Efficacy and tolerability of Boswellia serrata extract in treatment of osteoarthritis of knee – a randomized double blind placebo controlled trial. Phytomedicine. 2003;10(1):3–7.
3. Sengupta K, Alluri KV, Satish AR, et al. A double blind, randomized, placebo controlled study of the efficacy and safety of 5-Loxin for treatment of osteoarthritis of the knee. Arthritis Res Ther. 2008;10(4):R85.
4. Yu G, Xiang W, Zhang T, et al. Effectiveness of Boswellia and Boswellia extract for osteoarthritis patients: a systematic review and meta-analysis. BMC Complement Med Ther. 2020;20(1):225.
5. Bannuru RR, Osani MC, Vaysbrot EE, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019;27(11):1578–1589.
6. Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Care Res. 2020;72(2):149–162.
7. Siddiqui MZ. Boswellia serrata, a potential antiinflammatory agent: an overview. Indian J Pharm Sci. 2011;73(3):255–261.