Does paracetamol (acetaminophen) reduce the pain of osteoarthritis? A meta-analysis of randomised controlled trials

Isolated and combined effects of photobiomodulation therapy, topical nonsteroidal anti-inflammatory drugs, and physical activity in the treatment of osteoarthritis induced by papain

Osteoarthritis (OA) is a chronic inflammatory disease and is characterized as a degenerative process. This study aimed to evaluate and compare the effects of a topical nonsteroidal anti-inflammatory drug (NSAID), physical activity, and photobiomodulation therapy (PBMT) applied alone and/or in combination between them in an experimental model of knee OA. OA was induced by injection of papain in the knees of rats. After 21 days, the animals started to be treated with the above treatment. Histological analysis shows that the experimental model of OA induction causes morphological changes consistent with the disease, and among treatments, the PBMT is the most effective for reducing these changes. Moreover, the results demonstrate that PBMT and NSAID reduce the total number of cells in the inflammatory infiltrate (p<0.05) and PBMT was the most effective for reducing the activity of myeloperoxidase (p<0.05). Finally, we observed that both NSAID and PBMT were effective for reducing the gene expression of MMP-3 (p<0.05), but in relation to the gene expression of MMP-13, PBMT was the most effective treatment (p<0.05). The results of this study indicate that PBMT is the most effective therapy in stopping disease progression, and improving inflammatory conditions observed in OA.

Risk of Acute Cerebrovascular and Cardiovascular Events Among Users of Acetaminophen or an Acetaminophen-Codeine Combination in a Cohort of Patients with Osteoarthritis: A Nested Case-Control Study

STUDY OBJECTIVE

To determine whether acetaminophen or an acetaminophen-codeine combination is associated with an increased risk of acute cerebrovascular and cardiovascular events (ACCEs) in patients with osteoarthritis.

DESIGN

Nested case-control study.

DATA SOURCE

Health Search IMS Health Longitudinal Patient Database.

PATIENTS

A total of 36,754 adults with a diagnosis of osteoarthritis and an incident (first-time) prescription of nonsteroidal antiinflammatory drugs (NSAIDs) between January 2002 and June 2012 were identified; of these patients, cases were defined as those who had a diagnosis of an ACCE during the follow-up period (index date was the date of ACCE diagnosis; 2182 cases). For each case, up to five controls were randomly selected who were matched based on age, sex, month and year of cohort entry, and duration of follow-up (10,301 controls). Matched controls were assigned the same index date as their respective cases.

MEASUREMENTS AND MAIN RESULTS

For each case and matched controls, all prescriptions of acetaminophen-containing medicines filled during follow-up were identified. The risk of ACCEs was investigated with respect to the recency of use of acetaminophen and/or an acetaminophen-codeine combination. Patients were classified as current (0-90 days preceding index date), recent (91-180 days), or past (181-365 days) acetaminophen users, or nonusers (longer than 365 days), with nonusers representing the reference category. Conditional logistic regression was estimated to calculate odds ratios (ORs) and 95% confidence intervals (CIs). Of the 36,754 patients with osteoarthritis and newly prescribed NSAIDs, the incidence rate of ACCEs was 117.6 per 10,000 person-years. No significant association between exposure to acetaminophen-containing medications and ACCEs was observed in current (OR 1.22, 95% CI 0.96-1.55), recent (OR 1.12, 95% CI 0.80-1.55), or past users (OR 1.13, 95% CI 0.86-1.48). A secondary analysis evaluating exposure to acetaminophen monotherapy or acetaminophen-codeine combination therapy showed similar results for current users.

CONCLUSION

Our findings indicate that no association can be made between the use of acetaminophen and/or an acetaminophen-codeine combination and the occurrence of ACCEs. This information contributes to support clinicians in the choice of acetaminophen therapy for osteoarthritis-related pain, especially in those patients presenting with cerebrovascular and cardiovascular morbidities or related risk factors.

Pain Relief for an Osteoarthritic Knee in the Elderly: A Practical Guide

In view of the increasing prevalence of knee osteoarthritis (OA) in the population worldwide, optimal management is critical to decrease the burden of this condition and minimize disability and personal suffering. Current care is based on a sequence of non-pharmacological, pharmacological, and surgical modalities, targeted to improving pain and function in the elderly population. The aim of this article is to provide a practical view of the efficacy of therapeutic options available along with clinically relevant considerations on the management of knee OA in this demographic group.

From painkiller to empathy killer: acetaminophen (paracetamol) reduces empathy for pain

Simulation theories of empathy hypothesize that empathizing with others' pain shares some common psychological computations with the processing of one's own pain. Support for this perspective has largely relied on functional neuroimaging evidence of an overlap between activations during the experience of physical pain and empathy for other people's pain. Here, we extend the functional overlap perspective to the neurochemical level and test whether a common physical painkiller, acetaminophen (paracetamol), can reduce empathy for another's pain. In two double-blind placebo-controlled experiments, participants rated perceived pain, personal distress and empathic concern in response to reading scenarios about another's physical or social pain, witnessing ostracism in the lab, or visualizing another study participant receiving painful noise blasts. As hypothesized, acetaminophen reduced empathy in response to others' pain. Acetaminophen also reduced the unpleasantness of noise blasts delivered to the participant, which mediated acetaminophen's effects on empathy. Together, these findings suggest that the physical painkiller acetaminophen reduces empathy for pain and provide a new perspective on the neurochemical bases of empathy. Because empathy regulates prosocial and antisocial behavior, these drug-induced reductions in empathy raise concerns about the broader social side effects of acetaminophen, which is taken by almost a quarter of adults in the United States each week.

Current research on pharmacologic and regenerative therapies for osteoarthritis

Osteoarthritis (OA) is a degenerative joint disorder commonly encountered in clinical practice, and is the leading cause of disability in elderly people. Due to the poor self-healing capacity of articular cartilage and lack of specific diagnostic biomarkers, OA is a challenging disease with limited treatment options. Traditional pharmacologic therapies such as acetaminophen, non-steroidal anti-inflammatory drugs, and opioids are effective in relieving pain but are incapable of reversing cartilage damage and are frequently associated with adverse events. Current research focuses on the development of new OA drugs (such as sprifermin/recombinant human fibroblast growth factor-18, tanezumab/monoclonal antibody against β-nerve growth factor), which aims for more effectiveness and less incidence of adverse effects than the traditional ones. Furthermore, regenerative therapies (such as autologous chondrocyte implantation (ACI), new generation of matrix-induced ACI, cell-free scaffolds, induced pluripotent stem cells (iPS cells or iPSCs), and endogenous cell homing) are also emerging as promising alternatives as they have potential to enhance cartilage repair, and ultimately restore healthy tissue. However, despite currently available therapies and research advances, there remain unmet medical needs in the treatment of OA. This review highlights current research progress on pharmacologic and regenerative therapies for OA including key advances and potential limitations.

Pharmacogenetics of analgesic drugs

• Individual variability in pain perception and differences in the efficacy of analgesic drugs are complex phenomena and are partly genetically predetermined.

• Analgesics act in various ways on the peripheral and central pain pathways and are regarded as one of the most valuable but equally dangerous groups of medications.

• While pharmacokinetic properties of drugs, metabolism in particular, have been scrutinised by genotype–phenotype correlation studies, the clinical significance of inherited variants in genes governing pharmacodynamics of analgesics remains largely unexplored (apart from the µ-opioid receptor).

• Lack of replication of the findings from one study to another makes meaningful personalised analgesic regime still a distant future.

• This narrative review will focus on findings related to pharmacogenetics of commonly used analgesic medications and highlight authors’ views on future clinical implications of pharmacogenetics in the context of pharmacological treatment of chronic pain.

Anti-arthritic agents: progress and potential

Osteoarthritis and rheumatoid arthritis are the two most common types of arthritis. Cartilage breakdown is a key feature of both diseases which contributes to the pain and joint deformity experienced by patients. Therefore, anti-arthritis drugs are of great importance. The aim of this review is to present recent progress in studies of various agents against osteoarthritis and rheumatoid arthritis. The structures and activities of anti-arthritic agents, which used in medical practice or are in development, are presented and discussed. The effects and mechanisms of action of opioids, glucocorticoids, non-steroidal anti-inflammatory drugs, disease-modifying anti-rheumatic drugs, natural products derived from plants, nutraceuticals, and a number of new and perspective agents are considered. Various perspective targets for the treatment of osteoarthritis and rheumatoid arthritis are also discussed. Trials of good quality are needed to draw solid conclusions regarding efficacy of many of the studied agents. Unfortunately, to date, there is no pharmacologic agent proven to prevent the progression of both diseases, and there is an urgent need for further development of better anti-arthritic agents.

Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials

OBJECTIVE

To investigate the efficacy and safety of paracetamol (acetaminophen) in the management of spinal pain and osteoarthritis of the hip or knee.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline, Embase, AMED, CINAHL, Web of Science, LILACS, International Pharmaceutical Abstracts, and Cochrane Central Register of Controlled Trials from inception to December 2014.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials comparing the efficacy and safety of paracetamol with placebo for spinal pain (neck or low back pain) and osteoarthritis of the hip or knee.

DATA EXTRACTION

Two independent reviewers extracted data on pain, disability, and quality of life. Secondary outcomes were adverse effects, patient adherence, and use of rescue medication. Pain and disability scores were converted to a scale of 0 (no pain or disability) to 100 (worst possible pain or disability). We calculated weighted mean differences or risk ratios and 95% confidence intervals using a random effects model. The Cochrane Collaboration's tool was used for assessing risk of bias, and the GRADE approach was used to evaluate the quality of evidence and summarise conclusions.

RESULTS

12 reports (13 randomised trials) were included. There was "high quality" evidence that paracetamol is ineffective for reducing pain intensity (weighted mean difference -0.5, 95% confidence interval -2.9 to 1.9) and disability (0.4, -1.7 to 2.5) or improving quality of life (0.4, -0.9 to 1.7) in the short term in people with low back pain. For hip or knee osteoarthritis there was "high quality" evidence that paracetamol provides a significant, although not clinically important, effect on pain (-3.7, -5.5 to -1.9) and disability (-2.9, -4.9 to -0.9) in the short term. The number of patients reporting any adverse event (risk ratio 1.0, 95% confidence interval 0.9 to 1.1), any serious adverse event (1.2, 0.7 to 2.1), or withdrawn from the study because of adverse events (1.2, 0.9 to 1.5) was similar in the paracetamol and placebo groups. Patient adherence to treatment (1.0, 0.9 to 1.1) and use of rescue medication (0.7, 0.4 to 1.3) was also similar between groups. "High quality" evidence showed that patients taking paracetamol are nearly four times more likely to have abnormal results on liver function tests (3.8, 1.9 to 7.4), but the clinical importance of this effect is uncertain.

CONCLUSIONS

Paracetamol is ineffective in the treatment of low back pain and provides minimal short term benefit for people with osteoarthritis. These results support the reconsideration of recommendations to use paracetamol for patients with low back pain and osteoarthritis of the hip or knee in clinical practice guidelines.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42013006367.

Relative benefit-risk comparing diclofenac to other traditional non-steroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors in patients with osteoarthritis or rheumatoid arthritis: a network meta-analysis

INTRODUCTION

There is argument over the benefits and risks of drugs for treating chronic musculoskeletal pain. This study compared the efficacy, safety, and tolerability of diclofenac, ibuprofen, naproxen, celecoxib, and etoricoxib for patients with pain caused by osteoarthritis (OA) or rheumatoid arthritis (RA).

METHODS

A systematic literature review used Medline and EMBASE to identify randomised controlled trials. Efficacy outcomes assessed included: pain relief measured by visual analogue scale (VAS); Western Ontario McMaster Universities Arthritis Index (WOMAC) VAS or WOMAC Likert scale; physical functioning measured by WOMAC VAS or Likert scale; and patient global assessment (PGA) of disease severity measured on VAS or 5-point Likert scale. Safety outcomes included: Antiplatelet Trialists' Collaboration (APTC), major cardiovascular (CV) and major upper gastrointestinal (GI) events, and withdrawals. Data for each outcome were synthesized by a Bayesian network meta-analysis (NMA). For efficacy assessments, labelled doses for OA treatment were used for the base case while labelled doses for RA treatment were also included in the sensitivity analysis. Pooled data across dose ranges were used for safety.

RESULTS

Efficacy, safety, and tolerability data were found for 146,524 patients in 176 studies included in the NMA. Diclofenac (150 mg/day) was likely to be more effective in alleviating pain than celecoxib (200 mg/day), naproxen (1000 mg/day), and ibuprofen (2400 mg/day), and similar to etoricoxib (60 mg/day); a lower dose of diclofenac (100 mg/day) was comparable to all other treatments in alleviating pain. Improved physical function with diclofenac (100 and 150 mg/day) was mostly comparable to all other treatments. PGA with diclofenac (100 and 150 mg/day) was likely to be more effective or comparable to all other treatments. All active treatments were similar for APTC and major CV events. Major upper GI events with diclofenac were lower compared to naproxen and ibuprofen, comparable to celecoxib, and higher than etoricoxib. Risk of withdrawal with diclofenac was lower compared to ibuprofen, similar to celecoxib and naproxen, and higher than etoricoxib.

CONCLUSIONS

The benefit-risk profile of diclofenac was comparable to other treatments used for pain relief in OA and RA; benefits and risks vary in individuals and need consideration when making treatment decisions.

Safe prescribing of non-steroidal anti-inflammatory drugs in patients with osteoarthritis--an expert consensus addressing benefits as well as gastrointestinal and cardiovascular risks

BACKGROUND

There are several guidelines addressing the issues around the use of NSAIDs. However, none has specifically addressed the upper versus lower gastrointestinal (GI) risk of COX-2 selective and non-selective compounds nor the interaction at both the GI and cardiovascular (CV) level of either class of drugs with low-dose aspirin. This Consensus paper aims to develop statements and guidance devoted to these specific issues through a review of current evidence by a multidisciplinary group of experts.

METHODS

A modified Delphi consensus process was adopted to determine the level of agreement with each statement and to determine the level of agreement with the strength of evidence to be assigned to the statement.

RESULTS

For patients with both low GI and CV risks, any non-selective NSAID (ns-NSAID) alone may be acceptable. For those with low GI and high CV risk, naproxen may be preferred because of its potential lower CV risk compared with other ns-NSAIDs or COX-2 selective inhibitors, but celecoxib at the lowest approved dose (200 mg once daily) may be acceptable. In patients with high GI risk, if CV risk is low, a COX-2 selective inhibitor alone or ns-NSAID with a proton pump inhibitor appears to offer similar protection from upper GI events. However, only celecoxib will reduce mucosal harm throughout the entire GI tract. When both GI and CV risks are high, the optimal strategy is to avoid NSAID therapy, if at all possible.

CONCLUSIONS

Time is now ripe for offering patients with osteoarthritis the safest and most cost-effective therapeutic option, thus preventing serious adverse events which could have important quality of life and resource use implications. Please see related article: http://dx.doi.org/10.1186/s12916-015-0291-x.

Use of Opioid Analgesics in Older Australians

OBJECTIVE

To identify potential medication management issues associated with opioid use in older Australians.

DESIGN

Retrospective cross-sectional review of the utilization of analgesics in 19,581 people who underwent a medication review in Australia between 2010 and 2012.

SUBJECTS

Australian residents living in the community deemed at risk for adverse medication outcomes or any resident living fulltime in an aged care facility.

METHODS

Patient characteristics in those taking regularly dosed opioids and not and those taking opioid doses >120 mg and ≤120 mg MEQ/day were compared. Multivariable binary logistic regression was used to analyze the association between regular opioid and high dose opioid usage and key variables. Additionally, medication management issues associated with opioids were identified.

RESULTS

Opioids were taken by 31.8% of patients, with 22.1% taking them regularly. Several major medication management issues were identified. There was suboptimal use of multimodal analgesia, particularly a low use of non-opioid analgesics, in patients taking regular opioids. There was extensive use (45%) of concurrent anxiolytics/hypnotics among those taking regular opioid analgesics. Laxative use in those prescribed opioids regularly was low (60%). Additionally, almost 12% of patients were taking doses of opioid that exceeded Australian recommendations.

CONCLUSIONS

A significant evidence to practice gap exists regarding the use of opioids amongst older Australians. These findings highlight the need for a quick reference guide to support prescribers in making appropriate decisions regarding pain management in older patients with persistent pain. This should also be combined with patient and caregiver education about the importance of regular acetaminophen to manage persistent pain.

Persistent nonmalignant pain management using nonsteroidal anti-inflammatory drugs in older patients and use of inappropriate adjuvant medications

Objective

Due to the high risk of life-threatening side effects, nonsteroidal anti-inflammatory drugs (NSAIDs) are not favored for treating persistent nonmalignant pain in the elderly. We report national prescription trends with determinants of NSAIDs prescription for persistent nonmalignant pain among older patients (age 65 and over) in the US outpatient setting.

Methods

A cross-sectional analysis was performed using National Ambulatory Medical Care Survey data. Prescriptions for NSAIDs, opioids, and adjuvant agents were identified using five-digit National Ambulatory Medical Care Survey drug codes.

Results

About 89% of the 206,879,848 weighted visits in the US from 2000 to 2007 recorded NSAIDs prescriptions in patients (mean age =75.4 years). Most NSAIDs users had Medicare (75%), and about 25% were prescribed with adjuvant medications considered inappropriate for their age. Compared to men, women were 1.79 times more likely to be prescribed NSAIDs.

Conclusion

The high percentage of NSAIDs prescription in older patients is alarming. We recommend investigating the appropriateness of the high prevalence of NSAIDs use among older patients reported in our study.

A systematic review of the effectiveness of stroke self-management programs for improving function and participation outcomes: self-management programs for stroke survivors

PURPOSE

A systematic review of stroke self-management programs was conducted to: (i) identify how many and what self-management support strategies were included in stroke self-management interventions and (ii) describe whether self-management programs effectively improved outcomes, focusing specifically on function and participation outcomes.

METHODS

Twelve databases were searched for the years 1986-2012 to identify self-management programs for stroke survivors. Pre-post, quasi-experimental and randomized controlled trial study designs were included. Descriptive information about the intervention was scrutinized to identify what self-management support strategies were present in the intervention and comparisons were made between programs using a group versus a one-to-one format. All outcomes were included and categorized.

RESULTS

The most prominent strategies identified in our review were goal setting and follow-up, and an individualized approach using structured information and professional support. There are indications that self-management programs can significantly increase participation and functional ability. However, the high level of clinical heterogeneity in program delivery, outcomes and level of stroke severity made it impossible to conduct a meta-analysis. Further examination of individual self-management support strategies, such as linking rehabilitation goal setting to post-acute self-management programs, the inclusion of family members and the contribution of peer-support is warranted.

IMPLICATIONS FOR REHABILITATION

Self-management programs for stroke survivors. Linking post-acute self-management programs to rehabilitation goal setting could improve outcomes. Involving family members in self-management programs may benefit stroke survivors.

Comparative effectiveness of pharmacologic interventions for knee osteoarthritis: a systematic review and network meta-analysis

BACKGROUND

The relative efficacy of available treatments of knee osteoarthritis (OA) must be determined for rational treatment algorithms to be formulated.

PURPOSE

To examine the efficacy of treatments of primary knee OA using a network meta-analysis design, which estimates relative effects of all treatments against each other.

DATA SOURCES

MEDLINE, EMBASE, Web of Science, Google Scholar, Cochrane Central Register of Controlled Trials from inception through 15 August 2014, and unpublished data.

STUDY SELECTION

Randomized trials of adults with knee OA comparing 2 or more of the following: acetaminophen, diclofenac, ibuprofen, naproxen, celecoxib, intra-articular (IA) corticosteroids, IA hyaluronic acid, oral placebo, and IA placebo.

DATA EXTRACTION

Two reviewers independently abstracted study data and assessed study quality. Standardized mean differences were calculated for pain, function, and stiffness at 3-month follow-up.

DATA SYNTHESIS

Network meta-analysis was performed using a Bayesian random-effects model; 137 studies comprising 33,243 participants were identified. For pain, all interventions significantly outperformed oral placebo, with effect sizes from 0.63 (95% credible interval [CrI], 0.39 to 0.88) for the most efficacious treatment (hyaluronic acid) to 0.18 (CrI, 0.04 to 0.33) for the least efficacious treatment (acetaminophen). For function, all interventions except IA corticosteroids were significantly superior to oral placebo. For stiffness, most of the treatments did not significantly differ from one another.

LIMITATION

Lack of long-term data, inadequate reporting of safety data, possible publication bias, and few head-to-head comparisons.

CONCLUSION

This method allowed comparison of common treatments of knee OA according to their relative efficacy. Intra-articular treatments were superior to nonsteroidal anti-inflammatory drugs, possibly because of the integrated IA placebo effect. Small but robust differences were observed between active treatments. All treatments except acetaminophen showed clinically significant improvement from baseline pain. This information, along with the safety profiles and relative costs of included treatments, will be helpful for individualized patient care decisions.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality.

Efficacy and safety of ginger in osteoarthritis patients: a meta-analysis of randomized placebo-controlled trials

The aim of this study was to assess the clinical efficacy and safety of oral ginger for symptomatic treatment of osteoarthritis (OA) by carrying out a systematic literature search followed by meta-analyses on selected studies. Inclusion criteria were randomized controlled trials (RCTs) comparing oral ginger treatment with placebo in OA patients aged >18 years. Outcomes were reduction in pain and reduction in disability. Harm was assessed as withdrawals due to adverse events. The efficacy effect size was estimated using Hedges' standardized mean difference (SMD), and safety by risk ratio (RR). Standard random-effects meta-analysis was used, and inconsistency was evaluated by the I-squared index (I(2)). Out of 122 retrieved references, 117 were discarded, leaving five trials (593 patients) for meta-analyses. The majority reported relevant randomization procedures and blinding, but an inadequate intention-to-treat (ITT) analysis. Following ginger intake, a statistically significant pain reduction SMD = -0.30 ([95% CI: [(-0.50, -0.09)], P = 0.005]) with a low degree of inconsistency among trials (I(2) = 27%), and a statistically significant reduction in disability SMD = -0.22 ([95% CI: ([-0.39, -0.04)]; P = 0.01; I(2) = 0%]) were seen, both in favor of ginger. Patients given ginger were more than twice as likely to discontinue treatment compared to placebo ([RR = 2.33; 95% CI: (1.04, 5.22)]; P = 0.04; I(2) = 0%]). Ginger was modestly efficacious and reasonably safe for treatment of OA. We judged the evidence to be of moderate quality, based on the small number of participants and inadequate ITT populations. Prospero: CRD42011001777.

Commentary on recent therapeutic guidelines for osteoarthritis

BACKGROUND

Despite availability of international evidence-based guidelines for osteoarthritis (OA) management, agreement on the different treatment modalities is lacking.

METHOD

A symposium of European and US OA experts was held within the framework of the Annual European Congress of Rheumatology to discuss and compare guidelines and recommendations for the treatment of knee OA and to reach a consensus for management, particularly for areas in which there is no clear consensus: non-pharmacological therapy; efficacy and safety of analgesics and non-steroidal anti-inflammatory drugs (NSAIDs); intra-articular (i.a.) hyaluronates (HA); and the role of chondroitin sulfate (CS) and/or glucosamine sulfate (GS).

RESULTS

All guidelines reviewed agree that knee OA is a progressive disease of the joint whose management requires non-pharmacological and pharmacological approaches. Discrepancies between guidelines are few and mostly reflect heterogeneity of expert panels involved, geographical differences in the availability of pharmacotherapies, and heterogeneity of the studies included. Panels chosen for guideline development should include experts with real clinical experience in drug use and patient management. Implementation of agreed guidelines can be thwarted by drug availability and reimbursement plans, resulting in optimal OA treatment being jeopardized, HA and symptomatic slow-acting drugs for osteoarthritis (SySADOAs) being clear examples of drugs whose availability and prescription can greatly vary geographically. In addition, primary care providers, often responsible for OA management (at least in early disease), may not adhere to clinical care guidelines, particularly for non-pharmacological OA treatment.

CONCLUSION

Harmonization of the recommendations for knee OA treatment is challenging but feasible, as shown by the step-by-step therapeutic algorithm developed by the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). More easily disseminated and implemented guidance for OA treatment in the primary care setting is key to improved management of OA.

Management of persistent pain in the older patient: a clinical review

IMPORTANCE

Persistent pain is highly prevalent, costly, and frequently disabling in later life.

OBJECTIVE

To describe barriers to the management of persistent pain among older adults, summarize current management approaches, including pharmacologic and nonpharmacologic modalities; present rehabilitative approaches; and highlight aspects of the patient-physician relationship that can help to improve treatment outcomes. This review is relevant for physicians who seek an age-appropriate approach to delivering pain care for the older adult.

EVIDENCE ACQUISITION

Search of MEDLINE and the Cochrane database from January 1990 through May 2014, using the search terms older adults, senior, ages 65 and above, elderly, and aged along with non-cancer pain, chronic pain, persistent pain, pain management, intractable pain, and refractory pain to identify English-language peer-reviewed systematic reviews, meta-analyses, Cochrane reviews, consensus statements, and guidelines relevant to the management of persistent pain in older adults.

FINDINGS

Of the 92 identified studies, 35 evaluated pharmacologic interventions, whereas 57 examined nonpharmacologic modalities; the majority (n = 50) focused on older adults with osteoarthritis. This evidence base supports a stepwise approach with acetaminophen as first-line therapy. If treatment goals are not met, a trial of a topical nonsteroidal anti-inflammatory drug, tramadol, or both is recommended. Oral nonsteroidal anti-inflammatory drugs are not recommended for long-term use. Careful surveillance to monitor for toxicity and efficacy is critical, given that advancing age increases risk for adverse effects. A multimodal approach is strongly recommended-emphasizing a combination of both pharmacologic and nonpharmacologic treatments to include physical and occupational rehabilitation, as well as cognitive-behavioral and movement-based interventions. An integrated pain management approach is ideally achieved by cultivating a strong therapeutic alliance between the older patient and the physician.

CONCLUSIONS AND RELEVANCE

Treatment planning for persistent pain in later life requires a clear understanding of the patient's treatment goals and expectations, comorbidities, and cognitive and functional status, as well as coordinating community resources and family support when available. A combination of pharmacologic, nonpharmacologic, and rehabilitative approaches in addition to a strong therapeutic alliance between the patient and physician is essential in setting, adjusting, and achieving realistic goals of therapy.

An algorithm recommendation for the management of knee osteoarthritis in Europe and internationally: a report from a task force of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO)

OBJECTIVES

Existing practice guidelines for osteoarthritis (OA) analyze the evidence behind each proposed treatment but do not prioritize the interventions in a given sequence. The objective was to develop a treatment algorithm recommendation that is easier to interpret for the prescribing physician based on the available evidence and that is applicable in Europe and internationally. The knee was used as the model OA joint.

METHODS

ESCEO assembled a task force of 13 international experts (rheumatologists, clinical epidemiologists, and clinical scientists). Existing guidelines were reviewed; all interventions listed and recent evidence were retrieved using established databases. A first schematic flow chart with treatment prioritization was discussed in a 1-day meeting and shaped to the treatment algorithm. Fine-tuning occurred by electronic communication and three consultation rounds until consensus.

RESULTS

Basic principles consist of the need for a combined pharmacological and non-pharmacological treatment with a core set of initial measures, including information access/education, weight loss if overweight, and an appropriate exercise program. Four multimodal steps are then established. Step 1 consists of background therapy, either non-pharmacological (referral to a physical therapist for re-alignment treatment if needed and sequential introduction of further physical interventions initially and at any time thereafter) or pharmacological. The latter consists of chronic Symptomatic Slow-Acting Drugs for OA (e.g., prescription glucosamine sulfate and/or chondroitin sulfate) with paracetamol at-need; topical NSAIDs are added in the still symptomatic patient. Step 2 consists of the advanced pharmacological management in the persistent symptomatic patient and is centered on the use of oral COX-2 selective or non-selective NSAIDs, chosen based on concomitant risk factors, with intra-articular corticosteroids or hyaluronate for further symptom relief if insufficient. In Step 3, the last pharmacological attempts before surgery are represented by weak opioids and other central analgesics. Finally, Step 4 consists of end-stage disease management and surgery, with classical opioids as a difficult-to-manage alternative when surgery is contraindicated.

CONCLUSIONS

The proposed treatment algorithm may represent a new framework for the development of future guidelines for the management of OA, more easily accessible to physicians.

Changes in opioid and other analgesic use 1995-2010: repeated cross-sectional analysis of dispensed prescribing for a large geographical population in Scotland

BACKGROUND

Despite recent concerns about increasing rates of analgesic prescribing, detailed epidemiological studies are lacking. We identified and described changes in the pattern of community-dispensed prescriptions to the Tayside population, Scotland, between 31st March 1995 (n = 301,020) and 31st March 2010 (n = 311,881).

METHODS

Repeated cross-sectional analysis of patient-level population data on dispensed analgesics, stratified by sociodemographic variables; logistic regression to identify factors associated with strong opioid dispensing in 2010.

RESULTS

The proportion of people currently dispensed any analgesic increased in 2010 (17.9%) compared with 1995 (15.7%). This increase was not equal across drug classes, with paracetamol, opioids and gabapentin/pregabalin showing an increase, but others showing a decrease. Weak opioids were less commonly dispensed in 2010 (8.2% vs. 8.4%) but dispensing of strong opioids increased 18-fold (3.6% vs. 0.2%), including a five-fold increase of morphine, fentanyl or oxycodone (0.75% vs. 0.15%). People receiving more non-analgesic drugs (odds ratio 20.7 if dispensed >14 non-analgesic medications vs. those dispensed <4) and those living in more deprived areas (OR 1.63 most deprived vs. most affluent) were more likely to receive a strong opioid in 2010.

CONCLUSIONS

Analgesic use rose modestly between 1995 and 2010, but with larger changes within individual classes, only partly reflecting evidence-based guidance. Dispensing of strong opioids increased dramatically, largely driven by tramadol, although other strong opioids tripled. Polypharmacy and socio-economic deprivation were strongly associated with strong opioid use. Research is needed to establish the causes, benefits and harms of the increase in analgesic, and especially strong opioid use.

The efficacy and tolerability of glucosamine sulfate in the treatment of knee osteoarthritis: A randomized, double-blind, placebo-controlled trial

BACKGROUND

Osteoarthritis (OA) is the most common form of arthritis and is often associated with disability and impaired quality of life.

OBJECTIVE

The aim of the study was to assess the efficacy and tolerability of glucosamine sulfate (GS) in the treatment of knee OA.

METHODS

Consecutive outpatients affected by primary monolateral or bilateral knee OA were enrolled in this double-blind, double-dummy, prospective, randomized, placebo-controlled trial. One group received GS 1500 mg QD for 12 weeks, and the other group received placebo QD for 12 weeks. The treatment period was followed by a 12-week treatment-free observation phase. Each patient was examined at baseline and at weeks 4, 8, 12, 16, 20, and 24. The primary efficacy criteria were pain at rest and during movement, assessed on a visual analog scale (VAS) of 0 to 100 mm. The secondary criteria included the Western Ontario and McMaster Universities (WOMAC) index for total pain score (W-TPS), total stiffness score (W-TSS), and total physical function score (W-TPFS). VAS, W-TPS, W-TSS, and W-TPFS were evaluated at baseline and at weeks 4, 8, 12, 16, 20, and 24. Analgesic drug consumption (ie, acetaminophen or NSAIDs) was also assessed.

RESULTS

Patient demographics were similar in the GS and placebo groups. Of 60 randomized patients (30 per group), 56 completed the study (28 treated with GS and 28 who received placebo). Statistically significant improvements in symptomatic knee OA were observed, as measured by differences in resting pain at weeks 8, 12, and 16 (all, P < 0.05 vs placebo) and in pain during movement at weeks 12 and 16 (both, P < 0.05). W-TPS was lower with GS than placebo at weeks 8, 12, and 16 (all, P < 0.01), and at week 20 (P < 0.05). W-TSS was also lower with GS than placebo at weeks 8, 12, 16, and 20 (all, P < 0.05). W-TPFS was lower with GS than placebo at weeks 8 (P < 0.05), 12 (P < 0.01), 16 (P < 0.05), and 20 (P < 0.05). Drug consumption was lower in the GS group than the placebo group at weeks 8, 12, 16, and 20 (all, P < 0.05). The incidence of adverse events was 36.7% with GS and 40.0% with placebo.

CONCLUSIONS

GS 1500 mg QD PO for 12 weeks was associated with statistically significant reductions in pain and improvements in functioning, with decreased analgesic consumption, compared with baseline and placebo in these patients with knee OA. A carryover effect was detected after treatment ended.

The efficacy of duloxetine, non-steroidal anti-inflammatory drugs, and opioids in osteoarthritis: a systematic literature review and meta-analysis

BACKGROUND

This meta-analysis assessed the efficacy of duloxetine versus other oral treatments used after failure of acetaminophen for management of patients with osteoarthritis.

METHODS

A systematic literature review of English language articles was performed in PUBMED, EMBASE, MedLine In-Process, Cochrane Library, and ClinicalTrials.gov between January 1985 and March 2013. Randomized controlled trials of duloxetine and all oral non-steroidal anti-inflammatory drugs and opioids were included if treatment was ≥12 weeks and the Western Ontario and McMaster Universities Index (WOMAC) total score was available. Studies were assessed for quality using the assessment tool from the National Institute for Health and Clinical Excellence guidelines for single technology appraisal submissions.WOMAC baseline and change from baseline total scores were extracted and standardized. A frequentist meta-analysis, meta-regression, and indirect comparison were performed using the DerSimonian-Laird and Bucher methods. Bayesian analyses with and without adjustment for study-level covariates were performed using noninformative priors.

RESULTS

Thirty-two publications reported 34 trials (2 publications each reported 2 trials) that met inclusion criteria. The analyses found all treatments except oxycodone (frequentist) and hydromorphone (frequentist and Bayesian) to be more effective than placebo. Indirect comparisons to duloxetine found no significant differences for most of the compounds. Some analyses showed evidence of a difference with duloxetine for etoricoxib (better), tramadol and oxycodone (worse), but without consistent results between analyses. Forest plots revealed positive trends in overall efficacy improvement with baseline scores. Adjusting for baseline, the probability duloxetine is superior to other treatments ranges between 15% to 100%.Limitations of this study include the low number of studies included in the analyses, the inclusion of only English language publications, and possible ecological fallacy associated with patient level characteristics.

CONCLUSIONS

This analysis suggests no difference between duloxetine and other post-first line oral treatments for osteoarthritis (OA) in total WOMAC score after approximately 12 weeks of treatment. Significant results for 3 compounds (1 better and 2 worse) were not consistent across performed analyses.

A systematic review of the effect of paracetamol on blood pressure in hypertensive and non-hypertensive subjects

AIM

To review current evidence on the effect of paracetamol on blood pressure (BP), the quality of the previous studies and the validity of the results, and to summarize these findings.

METHODS

A systematic literature review was performed by searching PubMed, the Cochrane library and EMBASE for publications between the years 1963 and 2012.

RESULTS

We identified three case reports, seven prospective observational trials, six randomized controlled trials, one commentary and two reviews. Some, but not all, of the observational studies, which included over 147 000 patients, showed an increased risk of hypertension with paracetamol use. The randomized studies were generally small and the results were inconsistent. Three studies, which included 104 patients, showed an increase of systolic BP by ~4 mmHg, two studies, which included 27 patients, reported no change in BP and one study, which included 21 patients, reported a fall in BP although no placebo arm was included for comparison.

CONCLUSIONS

The overall effect of paracetamol on BP is unclear. Given that paracetamol is often suggested as a safer alternative to non-steroidal anti-inflammatory drugs (NSAIDs), it would seem that further prospective evidence is now needed to address the effect of paracetamol on BP. This would be best done with larger studies in relevant cohorts using BP measured by ambulatory BP monitoring as the primary endpoint.

Knee osteoarthritis related pain: a narrative review of diagnosis and treatment

BACKGROUND

Osteoarthritis is a common progressive joint disease, involving not only the joint lining but also cartilage, ligaments, and bone. For the last ten years, majority of published review articles were not specific to osteoarthritis of the knee, and strength of evidence and clinical guidelines were not appropriately summarized.

OBJECTIVES

To appraise the literature by summarizing the findings of current evidence and clinical guidelines on the diagnosis and treatment of knee osteoarthritis pain.

METHODOLOGY

English journal articles that focused on knee osteoarthritis related pain were searched via PubMed (1 January 2002 - 26 August 2012) and Physiotherapy Evidence Database (PEDro) databases, using the terms 'knee', 'osteoarthritis' and 'pain'. In addition, reference lists from identified articles and related book chapters were included as comprehensive overviews.

RESULTS

For knee osteoarthritis, the highest diagnostic accuracy can be achieved by presence of pain and five or more clinical or laboratory criteria plus osteophytes. Some inconsistencies in the recommendations and findings were found between the clinical guidelines and systematic reviews. Generally, paracetamol, oral and topical non-steroidal anti-inflammatory drugs, opioids, corticosteroid injections and physical therapy techniques, such as therapeutic exercises, joint manual therapy and transcutaneous electrical nerve stimulation, can help reduce pain and improve function. Patient education programs and weight reduction for overweight patients are important to be considered.

CONCLUSIONS

Some inconsistencies in the recommendations and findings were found between the clinical guidelines and systematic reviews. However, it is likely that a combination of pharmacological and non-pharmacological treatments is most effective in treating patients with knee osteoarthritis.

Clinical management of patients with hip and knee osteoarthritis: patient satisfaction with treatment switch

Hip and knee osteoarthritis (OA) is a common cause of disability, with great quality of life and economic impact, hence the need for effective treatment. Patient satisfaction with treatment is a measure of therapeutic effectiveness and may be used to assess treatment switch in OA patients. A 3-month multicenter, prospective, epidemiologic, non-interventional study was conducted in patients with hip and/or knee OA to assess therapeutic efficacy in patients requiring treatment switch due to lack of effectiveness and/or tolerability in primary care settings. Therapeutic effectiveness was assessed by patient satisfaction using the osteoARthritis Treatment Satisfaction (ARTS) scale. The 3-month disease change [by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and a pain visual analog scale (VAS)] and its correlation with treatment satisfaction were also assessed, as well as patient gastrointestinal (GI) and cardiovascular (CV) profiles. 5,976 patients were analyzed (mean age 68.8 years, 65.1 % female). 67 and 61.8 % showed high GI and CV risk, respectively. The proportion of patients on acetaminophen treatment during the study decreased from 74.8 % at baseline to 23.9 %, while the proportion on non-steroidal anti-inflammatory drugs (NSAIDs) increased from 59.8 to 85.8 %. At 3 months, the standardized (0-100) overall ARTS score increased from 57.7 to 71.6 (p < 0.0001), while disease severity decreased. There was a significant (p < 0.0001) negative association between the ARTS, and the WOMAC and VAS scores. Treatment switching from acetaminophen to NSAIDs as a consequence of poor effectiveness and/or tolerability resulted in increased patient satisfaction with treatment and lower OA severity.

Cost-effectiveness analyses of osteoarthritis oral therapies: a systematic review

BACKGROUND

Cost-effectiveness analyses (CEAs) have been performed for oral non-disease-altering osteoarthritis (OA) treatments for well over a decade. During that period the methods for performing these analyses have evolved as pharmacoeconomic methods have advanced, new treatments have been introduced, and the knowledge of associated adverse events (AEs) has improved.

OBJECTIVE

The objective of this systematic review was to trace the development of CEAs for oral non-disease-altering treatments in OA.

METHODS

A systematic search for CEAs of OA oral treatments was performed of the English-language medical literature using the following databases: PubMed, EMBASE, MEDLINE In-Process, EconLit, and Cochrane. Key requirements for inclusion were that the population described patients with OA or arthritis and that the analysis reported at least one incremental cost-effectiveness ratio. Each identified publication was assessed for inclusion. Thirteen characteristics and all AEs appearing in each included CEA were extracted and organized. Reference lists from these CEAs were also searched. A chronology of key CEAs in the field was compiled, noting the characteristics that advanced the state of the art in modeling oral OA treatments.

RESULTS

Thirty publications of 28 CEAs were identified and evaluated. Developments in CEAs included an expanded set of comparators that broadened from non-steroidal anti-inflammatory drugs (NSAIDs) only to NSAIDs plus gastroprotective agents, cyclooxygenase-2 inhibitors, and opioids. In turn, AEs expanded from gastrointestinal (GI) events to also include cardiovascular (CV) and neurological events. Efficacy, which initially was presumed to be equivalent for all treatments, evolved to treatment-specific efficacies. Decision-tree analyses were generally replaced by Markov models or, occasionally, stochastic or discrete event simulation. Finally, outcomes have progressed from GI-centric measures to also include quality-adjusted life-years.

CONCLUSION

Methods used by CEAs of oral non-disease-altering OA treatments have evolved in response to changing treatments with different safety profiles and efficacies as well as technical advances in the application of decision science to health care.

Piroxicam-β-cyclodextrin: a GI safer piroxicam

Although NSAIDs are very effective drugs, their use is associated with a broad spectrum of adverse reactions in the liver, kidney, cardiovascular (CV) system, skin and gut. Gastrointestinal (GI) side effects are the most common and constitute a wide clinical spectrum ranging from dyspepsia, heartburn and abdominal discomfort to more serious events such as peptic ulcer with life-threatening complications of bleeding and perforation. The appreciation that CV risk is also increased further complicates the choices of physicians prescribing anti-inflammatory therapy. Despite prevention strategies should be implemented in patients at risk, gastroprotection is often underused and adherence to treatment is generally poor. A more appealing approach would be therefore to develop drugs that are devoid of or have reduced GI toxicity. Gastro-duodenal mucosa possesses many defensive mechanisms and NSAIDs have a deleterious effect on most of them. This results in a mucosa less able to cope with even a reduced acid load. NSAIDs cause gastro-duodenal damage, by two main mechanisms: a physiochemical disruption of the gastric mucosal barrier and systemic inhibition of gastric mucosal protection, through inhibition of cyclooxygenase (COX, PG endoperoxide G/H synthase) activity of the GI mucosa. However, against a background of COX inhibition by anti-inflammatory doses of NSAIDs, their physicochemical properties, in particular their acidity, underlie the topical effect leading to short-term damage. It has been shown that esterification of acidic NSAIDs suppresses their gastrotoxicity without adversely affecting anti-inflammatory activity. Another way to develop NSAIDs with better GI tolerability is to complex these molecules with cyclodextrins (CDs), giving rise to so-called “inclusion complexes” that can have physical, chemical and biological properties very different from either those of the drug or the cyclodextrin. Complexation of NSAIDs with β-cyclodextrin potentially leads to a more rapid onset of action after oral administration and improved GI tolerability because of minimization of the drug gastric effects. One such drug, piroxicam-β-cyclodextrin (PBC), has been used in Europe for 25 years. Preclinical and clinical pharmacology of PBC do show that the β-cyclodextrin inclusion complex of piroxicam is better tolerated from the upper GI tract than free piroxicam, while retaining all the analgesic and anti-inflammatory properties of the parent compound. In addition, the drug is endowed with a quick absorption rate, which translates into a faster onset of analgesic activity, an effect confirmed in several clinical studies. An analysis of the available trials show that PBC has a GI safety profile, which is better than that displayed by uncomplexed piroxicam. Being an inclusion complex of piroxicam, whose CV safety has been pointed out by several observational studies, PBC should be viewed as a CV safe anti-inflmmatory compound and a GI safer alternative to piroxicam. As a consequence, it should be considered as a useful addition to our therapeutic armamentarium.

Adverse effects associated with non-opioid and opioid treatment in patients with chronic pain

Chronic pain is a debilitating condition that is associated with many common diseases; this places a major burden on the healthcare system. There are currently numerous analgesic agents available for the treatment of chronic pain. In general, the oral non-opioid analgesic, paracetamol, is recommended for the initial treatment of mild to moderate pain. Therapeutic doses of paracetamol do not appear to result in hepatotoxicity, although overdose may lead to acute liver failure. Current data suggest that paracetamol has acceptable gastrointestinal tolerability. Another class of non-opioid analgesic with confirmed efficacy for the treatment of chronic mild to moderate pain are non-steroidal anti-inflammatory drugs (NSAIDs), although this efficacy is offset by the potential of adverse gastrointestinal events. In particular, non-selective NSAIDs, also known as cyclooxygenase (COX) inhibitors, carry an increased risk of serious upper gastrointestinal complications, including ulcers, perforation and bleeding. The introduction of COX-2 inhibitors provided a NSAID-based option with improved gastrointestinal safety, but increased risk of cardiovascular effects. Opioids are powerful analgesic agents used to treat moderate to severe chronic pain. However, treatment with opioids is associated with a number of common adverse effects, including constipation, nausea or vomiting, pruritus, somnolence or cognitive impairment, dry mouth, tolerance or dependence and urinary retention. Although there are multiple strategies in place to manage adverse events that arise from both non-opioid and opioid analgesic therapy, a better understanding of the mechanisms involved in the development of specific drug-related adverse effects is required along with proper prescribing practices and adequate physician/patient education. Balanced against the adverse effects of pain management medications, there is a need to be mindful of the widespread, often serious, adverse consequences of poorly managed pain itself.

The modern pharmacology of paracetamol: therapeutic actions, mechanism of action, metabolism, toxicity and recent pharmacological findings

Paracetamol is used worldwide for its analgesic and antipyretic actions. It has a spectrum of action similar to that of NSAIDs and resembles particularly the COX-2 selective inhibitors. Paracetamol is, on average, a weaker analgesic than NSAIDs or COX-2 selective inhibitors but is often preferred because of its better tolerance. Despite the similarities to NSAIDs, the mode of action of paracetamol has been uncertain, but it is now generally accepted that it inhibits COX-1 and COX-2 through metabolism by the peroxidase function of these isoenzymes. This results in inhibition of phenoxyl radical formation from a critical tyrosine residue essential for the cyclooxygenase activity of COX-1 and COX-2 and prostaglandin (PG) synthesis. Paracetamol shows selectivity for inhibition of the synthesis of PGs and related factors when low levels of arachidonic acid and peroxides are available but conversely, it has little activity at substantial levels of arachidonic acid and peroxides. The result is that paracetamol does not suppress the severe inflammation of rheumatoid arthritis and acute gout but does inhibit the lesser inflammation resulting from extraction of teeth and is also active in a variety of inflammatory tests in experimental animals. Paracetamol often appears to have COX-2 selectivity. The apparent COX-2 selectivity of action of paracetamol is shown by its poor anti-platelet activity and good gastrointestinal tolerance. Unlike both non-selective NSAIDs and selective COX-2 inhibitors, paracetamol inhibits other peroxidase enzymes including myeloperoxidase. Inhibition of myeloperoxidase involves paracetamol oxidation and concomitant decreased formation of halogenating oxidants (e.g. hypochlorous acid, hypobromous acid) that may be associated with multiple inflammatory pathologies including atherosclerosis and rheumatic diseases. Paracetamol may, therefore, slow the development of these diseases. Paracetamol, NSAIDs and selective COX-2 inhibitors all have central and peripheral effects. As is the case with the NSAIDs, including the selective COX-2 inhibitors, the analgesic effects of paracetamol are reduced by inhibitors of many endogenous neurotransmitter systems including serotonergic, opioid and cannabinoid systems. There is considerable debate about the hepatotoxicity of therapeutic doses of paracetamol. Much of the toxicity may result from overuse of combinations of paracetamol with opioids which are widely used, particularly in USA.

Pharmacologic treatment of hand-, knee- and hip-osteoarthritis

Osteoarthritis (OA) is a joint disease of high prevalence and affects > 90 % of the population, depending on several risk factors. Symptomatic OA is less frequent, but requires an individually tailored therapeutic regimen consisting of non-pharmacological and pharmacological treatment modalities. Pharmacologic therapy, however, is mainly limited to analgetic and anti-inflammatory agents; structure modifying remedies do not exist. The therapeutic approach to hand-, knee- and hip-OA is basically similar and differs only at some minor points. Generally, topical agents or paracetamol are recommended as first-line agents. If unsuccessful oral non-steroidal anti-inflammatory drugs (NSAIDs) or COX-2-selctive inhibitors should be introduced. Tramadol is an option in the case patients will not respond satisfactorily to NSAIDs. Glucosamine and chondroitine sulphate are no longer recommended in knee and hip OA, but chondroitine might be efficient in treating hand OA. Oral NSAIDs should be prescribed with caution due to potential side effects. Opioids are not recommended as their benefits are outweighed by an increased risk for serious adverse events.

The young osteoarthritic knee: dilemmas in management

As a result of increasing life expectancies, continuing physical careers, lifestyles into later life and rising obesity levels, the number of younger patients presenting with osteoarthritis (OA) of the knee is increasing. When conservative management options have been exhausted, the challenge for the orthopedic surgeon is to offer a procedure that will relieve symptoms and allow a return to a high level of function but not compromise future surgery that may be required as disease progresses or prostheses fail and require revision. We discuss the options available to this group of patients and the relative benefits and potential negative points of each. Total knee replacement (TKR) in the young patient is associated with high risk of early failure and the need for future revision surgery. After TKR, most surgeons advise limitation of sporting activities. If osteoarthritis is limited to only one compartment in the knee there may be surgical options other than TKR. Osteotomy above or below the knee may be considered and works by redirecting the load passing through the joint into the relatively unaffected compartment. A unicompartmental knee replacement (UKR) or patella-femoral joint (PFJ) replacement only replaces the articular surfaces in the affected compartment, leaving the unaffected compartments untouched with better preservation of the soft tissues. Which of these options is best for a particular patient depends upon the patient's symptoms, precise pathology, lifestyle, and expectations.

Shoulder osteoarthritis

Osteoarthritis (OA) is the most frequent cause of disability in the USA, affecting up to 32.8% of patients over the age of sixty. Treatment of shoulder OA is often controversial and includes both nonoperative and surgical modalities. Nonoperative modalities should be utilized before operative treatment is considered, particularly for patients with mild-to-moderate OA or when pain and functional limitations are modest despite more advanced radiographic changes. If conservative options fail, surgical treatment should be considered. Although different surgical procedures are available, as in other joints affected by severe OA, the most effective treatment is joint arthroplasty. The aim of this work is to give an overview of the currently available treatments of shoulder OA.

Pharmaceutical therapy for osteoarthritis

There are a variety of oral and topical pharmaceutical agents for the treatment of osteoarthritis. To date there is no pharmacologic agent proved to prevent disease progression. This article focuses primarily on the medications used for symptomatic relief and palliation of pain. The article reviews the medications' mechanisms of action and the available efficacy literature, as well as indications, contraindications, and common adverse effects.

Treatment satisfaction after switching to another therapy in Spanish orthopaedic clinic outpatients with knee or hip osteoarthritis previously refractory to paracetamol

BACKGROUND AND OBJECTIVE

Hip and knee osteoarthritis is highly prevalent in the elderly, and the incidence is estimated to increase in the coming decades. Prior to surgery, symptomatic treatment, starting with non-pharmacological therapies, should be prescribed. Paracetamol (acetaminophen) is the recommended first pharmacological treatment for osteoarthritis. If paracetamol is ineffective, non-steroidal anti-inflammatory drug (NSAID) treatment is indicated. The superiority of NSAIDs over paracetamol has been demonstrated in several studies. Furthermore, the assessment of patient satisfaction could be an adequate indicator of the quality of care given and is likely related to the evolution of the condition and the therapeutic regimen. The objective of this study was to assess the satisfaction of patients diagnosed with hip and/or knee osteoarthritis who had been previously treated with paracetamol and switched to NSAID treatment due to a lack of effectiveness by paracetamol.

METHODS

An observational, prospective, multicentre and comparative study was conducted in 2009 among patients diagnosed with hip and knee OA who visited outpatient orthopaedic clinics. The evaluation of treatment effectiveness was carried out using a patient-based visual analogue scale (VAS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The satisfaction regarding change of treatment due to a lack of effectiveness and/or the presence of adverse effects was evaluated using the osteoARthritis Treatment Satisfaction (ARTS) questionnaire.

RESULTS

A total of 2437 patients were evaluated (knee OA: 1438 [59%]; hip OA: 621 [25.5%]; knee and hip OA: 124 [5.1%]; and without OA location registered: 254 [10.4%]). The study findings showed an increase in patient satisfaction after abandoning the use of paracetamol to treat OA. Statistically significant increases in both overall satisfaction mean (from 57.7 [SD 13.5] to 71.3 [SD 12.0]) and in each of the four domains of the ARTS questionnaire were observed (p < 0.0001 in all cases). According to the WOMAC and a VAS, treatment effectiveness increased significantly after 3 months (p < 0.0001) and significant correlations with satisfaction were observed (r = -0.32 and r = -0.29, respectively; p < 0.0001). The mean (SD) change in global satisfaction in patients treated with NSAIDs was 14.9 (15.5) versus 7.2 (14.4) for patients treated with non-NSAIDs (p < 0.0001). Patients taking NSAID treatment showed substantially more improvement over those taking non-NSAID treatment.

CONCLUSION

NSAIDs relieve pain due to OA in paracetamol-resistant patients and improve treatment effectiveness and patient satisfaction with treatment. Furthermore, paracetamol-refractory subjects under conventional medical treatment with NSAIDs experienced the drug as more effective and also tended to be more satisfied with treatment than those treated with non-NSAIDs.

Treatment satisfaction after switching to another therapy in Spanish orthopaedic clinic outpatients with knee or hip osteoarthritis previously refractory to paracetamol

BACKGROUND AND OBJECTIVE

Hip and knee osteoarthritis is highly prevalent in the elderly, and the incidence is estimated to increase in the coming decades. Prior to surgery, symptomatic treatment, starting with non-pharmacological therapies, should be prescribed. Paracetamol (acetaminophen) is the recommended first pharmacological treatment for osteoarthritis. If paracetamol is ineffective, non-steroidal anti-inflammatory drug (NSAID) treatment is indicated. The superiority of NSAIDs over paracetamol has been demonstrated in several studies. Furthermore, the assessment of patient satisfaction could be an adequate indicator of the quality of care given and is likely related to the evolution of the condition and the therapeutic regimen. The objective of this study was to assess the satisfaction of patients diagnosed with hip and/or knee osteoarthritis who had been previously treated with paracetamol and switched to NSAID treatment due to a lack of effectiveness by paracetamol.

METHODS

An observational, prospective, multicentre and comparative study was conducted in 2009 among patients diagnosed with hip and knee OA who visited outpatient orthopaedic clinics. The evaluation of treatment effectiveness was carried out using a patient-based visual analogue scale (VAS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The satisfaction regarding change of treatment due to a lack of effectiveness and/or the presence of adverse effects was evaluated using the osteoARthritis Treatment Satisfaction (ARTS) questionnaire.

RESULTS

A total of 2437 patients were evaluated (knee OA: 1438 [59%]; hip OA: 621 [25.5%]; knee and hip OA: 124 [5.1%]; and without OA location registered: 254 [10.4%]). The study findings showed an increase in patient satisfaction after abandoning the use of paracetamol to treat OA. Statistically significant increases in both overall satisfaction mean (from 57.7 [SD 13.5] to 71.3 [SD 12.0]) and in each of the four domains of the ARTS questionnaire were observed (p < 0.0001 in all cases). According to the WOMAC and a VAS, treatment effectiveness increased significantly after 3 months (p < 0.0001) and significant correlations with satisfaction were observed (r = -0.32 and r = -0.29, respectively; p < 0.0001). The mean (SD) change in global satisfaction in patients treated with NSAIDs was 14.9 (15.5) versus 7.2 (14.4) for patients treated with non-NSAIDs (p < 0.0001). Patients taking NSAID treatment showed substantially more improvement over those taking non-NSAID treatment.

CONCLUSION

NSAIDs relieve pain due to OA in paracetamol-resistant patients and improve treatment effectiveness and patient satisfaction with treatment. Furthermore, paracetamol-refractory subjects under conventional medical treatment with NSAIDs experienced the drug as more effective and also tended to be more satisfied with treatment than those treated with non-NSAIDs.

Pharmacologic Management of Osteoarthritis-Related Pain in Older Adults: A Review Shows that Many Drug Therapies Provide Small-to-Modest Pain Relief

Because pain is a common and debilitating symptom of osteoarthritis in older adults, the authors reviewed data on the efficacy and safety of commonly used oral, topical, and intraarticular drug therapies in this population. A search of several databases found that most studies have focused on knee osteoarthritis and reported only short-term outcomes. Also, treatment efficacy was found to vary by drug class; the smallest effect was observed with acetaminophen and the largest with opioids and viscosupplements. Acetaminophen and topical agents had the best safety profiles, whereas oral nonsteroidal antiinflammatory drugs and opioids had the worst. Little data were available on patients ages 75 years old and older and on patients from diverse racial and ethnic groups. Most drug therapies gave mild-to-moderate pain relief; their long-term safety and efficacy and their effects in diverse populations (particularly older adults) remain undetermined.

Efficacy of balneotherapy on pain, function and quality of life in patients with osteoarthritis of the knee

The aims of this study were to evaluate whether balneotherapy with mineral sulphate-bicarbonate-calcium water could determine substantial symptomatic improvement, and to detect any changes in the quality of life (QoL) of patients with symptomatic knee osteoarthritis (OA). This was a prospective randomized, single blind controlled trial. Sixty outpatients with primary bilateral knee OA, according to ACR criteria, were included in the study and randomized to one of two groups: group I (30 patients) was treated with a daily sulphate-bicarbonate-calcium mineral water bath; group II (30 patients), the control group, continued their regular outpatient care routine. At baseline, after 15 days and after 12 weeks, patients were evaluated by Visual Analogue Scale (VAS) for spontaneous pain, Lequesne and Womac Index for gonarthrosis, SF-36, Arthritis Impact Measurement Scale (AIMS) and symptomatic drugs consumption. We observed a significant improvement of all parameters at the end of the cycle of balneotherapy which persisted throughout the follow-up period, whereas in the control group no significant differences were noted. This symptomatic effect was confirmed by the significant reduction of symptomatic drugs consumption. The differences between the two groups were significant for all considered parameters already from the 15th day and persisted during follow-up. Tolerability of balneotherapy seemed to be good, with light and transitory side effects. Our results confirm that the beneficial effects of balneotherapy in patients with knee OA last over time, with positive effects on the painful symptomatology, a significant improvement on functional capacities and QoL. Balneotherapy can represent a useful backup to pharmacological treatment of knee OA or a valid alternative for patients who do not tolerate pharmacological treatments.

Controlled release formulation of oxycodone in patients with moderate to severe chronic osteoarthritis: a critical review of the literature

Osteoarthritis (OA) is a physically and emotionally debilitating disease that predominantly affects the aging adult population. Current pharmacologic treatment options primarily consist of nonsteroidal anti-inflammatory drugs and/or acetaminophen, but associated side effects, analgesic limitations, especially in the elderly, and the need for around-the-clock analgesia have led physicians to search for alternative analgesics. Opioids have shown effectiveness at mitigating both chronic cancer and noncancer pain, and their ability to be placed into controlled release (CR) formulations suggests that they may prove efficacious for OA patients. One formulation, oxycodone CR, has shown effectiveness in cancer pain patients and in some trials of noncancer low back pain. In this review, the objective was to synthesize the reported findings by researchers in this field and present an up-to-date look at the efficacy, safety, and tolerability of oxycodone CR in OA patients. Public literature databases were searched using specific keywords (eg, oxycodone CR) for studies assessing the efficacy and safety profile of oxycodone CR and its use in patients with OA. A total of eleven articles that matched the criteria were identified, which included three placebo-controlled trials, six comparative trials, one pharmacokinetic study in the elderly, and one long-term safety trial. Analysis of the studies revealed that oxycodone CR is reasonably efficacious, safe, and tolerable when used to manage moderate to severe chronic OA pain, with similar side effects to that of other opioids.

Current considerations for the treatment of severe chronic pain: the potential for tapentadol

Studies suggest that around 20% of adults in Europe experience chronic pain, which not only has a considerable impact on their quality of life but also imposes a substantial economic burden on society. More than one-third of these people feel that their pain is inadequately managed. A range of analgesic drugs is currently available, but recent guidelines recommend that NSAIDs and COX-2 inhibitors should be prescribed cautiously. Although the short-term efficacy of opioids is good, adverse events are common and doses are frequently limited by tolerability problems. There is a perceived need for improved pharmacological treatment options. Currently, many treatment decisions are based solely on pain intensity. However, chronic pain is multifactorial and this apaproach ignores the fact that different causative mechanisms may be involved. The presence of more than one causative mechanism means that chronic pain can seldom be controlled by a single agent. Therefore, combining drugs with different analgesic actions increases the probability of interrupting the pain signal, but is often associated with an increased risk of drug/drug interactions, low compliance and increased side effects. Tapentadol combines μ-opioid receptor agonism and noradrenaline reuptake inhibition in a single molecule, with both mechanisms contributing to its analgesic effects. Preclinical testing has shown that μ-opioid agonism is primarily responsible for analgesia in acute pain, whereas noradrenaline reuptake inhibition is more important in chronic pain. In clinical trials in patients with chronic pain, the efficacy of tapentadol was similar to that of oxycodone, but it produced significantly fewer gastrointestinal side-effects and treatment discontinuations. Pain relief remained stable throughout a 1-year safety study. Thus, tapentadol could possibly overcome some of the limitations of currently available analgesics for the treatment of chronic pain.

Glenohumeral joint preservation: a review of management options for young, active patients with osteoarthritis

The management of osteoarthritis of the shoulder in young, active patients is a challenge, and the optimal treatment has yet to be completely established. Many of these patients wish to maintain a high level of activity, and arthroplasty may not be a practical treatment option. It is these patients who may be excellent candidates for joint-preservation procedures in an effort to avoid or delay joint replacement. Several palliative and restorative techniques are currently optional. Joint debridement has shown good results and a combination of arthroscopic debridement with a capsular release, humeral osteoplasty, and transcapsular axillary nerve decompression seems promising when humeral osteophytes are present. Currently, microfracture seems the most studied reparative treatment modality available. Other techniques, such as autologous chondrocyte implantation and osteochondral transfers, have reportedly shown potential but are currently mainly still investigational procedures. This paper gives an overview of the currently available joint preserving surgical techniques for glenohumeral osteoarthritis.

HZT-501 (DUEXIS(®); ibuprofen 800 mg/famotidine 26.6 mg) gastrointestinal protection in the treatment of the signs and symptoms of rheumatoid arthritis and osteoarthritis

Arthritis affects nearly 50 million people in the USA and, with the aging of the population, the prevalence is expected to rise. While NSAIDs are very effective in relieving pain associated with osteoarthritis (OA) and rheumatoid arthritis (RA), they are associated with side effects, including gastrointestinal (GI) toxicity, which may manifest as dyspepsia, ulcers and/or bleeding. A number of approaches have been employed in an effort to either completely avoid or reduce the risk of GI toxicities associated with NSAID use. Two new products combining an NSAID with a gastroprotective agent have recently been approved and other agents are in the pipeline. Patient adherence to prescribed gastroprotective therapy is known to be poor, often resulting in an increased risk of GI events in patients taking NSAIDs. These newer combination products may fulfill an important need for many patients who need to receive NSAIDs for the pain of OA and RA, but who are also at risk of upper GI events. This article reviews preclinical and clinical results for a new fixed-dose combination of ibuprofen and famotidine, DUEXIS(®) (HZT-501), which has recently been approved in the USA for the relief of signs and symptoms of RA and OA and to decrease the risk of developing upper GI ulcers.

Management of the Retired Athlete with Osteoarthritis of the Knee

PURPOSE

Osteoarthritis of the knee is a complex interaction of biological, mechanical, and biochemical factors that are further complicated by injury, which accelerates pathological processes within the joint. As a result, athletes, particularly those with a history of knee injury, have an earlier onset and higher prevalence of osteoarthritis that would be expected based on their age. This can present a clinical dilemma to the physician managing the patient who, despite the presence of radiologically confirmed disease, has few symptoms and wishes to maintain an active lifestyle.

METHODS

We reviewed meta-analyses and systematic reviews of randomized controlled trials about clinical management of knee osteoarthritis with special interest on effect sizes.

RESULTS

Numerous management options have undergone the rigor of clinical trials and subsequently have been summarized in meta-analyses and systematic reviews, the results of which offer evidence regarding varying degrees of effect. Based on the available evidence, most summaries and clinical practice guidelines suggest a regimen of patient education, self-management, weight control, and exercise supported by individualized pain management strategies. Other noninvasive or less invasive strategies are available that have varying degrees of effect.

CONCLUSIONS

Although the evidence supporting many of the clinical management options might be considered modest, those effects are sufficient to permit an active lifestyle and have, given the prevalence of the disease, a public health impact.

A comparison of the therapeutic efficacy of diclofenac in osteoarthritis: a systematic review of randomised controlled trials

OBJECTIVE

Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) commonly prescribed for pain relief in osteoarthritis (OA). The relative efficacy of diclofenac compared to other pain relief medications used in OA (e.g., alternative NSAIDs, cyclooxygenase type 2 [COX-2] inhibitors) is uncertain. The objective of this systematic review is to compare the current evidence on efficacy of diclofenac versus other pain relief medications.

RESEARCH DESIGN AND METHODS

A systematic literature search was carried out for randomised, well controlled clinical trials comparing the efficacy of diclofenac with other pain relief medications in OA (reviews, meta-analyses and n = 1 trials were excluded). The databases searched were EMBASE, Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, and Ovid MEDLINE Daily Update. Articles were included from 1999 onwards. Retrieved articles were discussed by comparator medication.

RESULTS

Of the 263 articles identified in the literature search, 37 were eventually included in this review. These were comparisons with the selective COX-2 inhibitors etoricoxib, celecoxib, lumiracoxib and rofecoxib; comparisons with the NSAIDs aceclofenac, dexketoprofen, etodolac, lornoxicam, meloxicam, nabumetone and nimesulide; and comparisons to acetaminophen, tramadol, diacerein, oxaceprol, oral hydrolytic enzyme therapies, Chinese herbal remedies and castor oil supplementation. Overall, in the majority of the trials at therapeutic doses diclofenac provided similar efficacy to comparator treatments; and in general diclofenac was able to support its position as a reference medication of choice for OA trials.

CONCLUSIONS

The efficacy of diclofenac is largely unchallenged in that it remains as effective as newer pain relief medications employed in OA. A review of the available data demonstrates that diclofenac continues to provide physicians with a benchmark pharmacological treatment for OA.

Pharmacological modulation of central nociception in the management of chronic musculoskeletal pain

SUMMARY Chronic musculoskeletal pain, defined as pain lasting beyond the usual healing time of 6 weeks to 3 months, is a very common condition. It adversely affects the quality of life of patients and has a significant economic impact on our society. There is an ever increasing understanding of the pathophysiology of chronic pain. This has resulted in the effective use of various medications aimed at modulating both central and peripheral sensitizations. There are also new agents being developed based on fundamental research. The pharmacological agents used in the modulation of central nociception in chronic musculoskeletal pain are reviewed in this article.

"It looks after me": how older patients make decisions about analgesics for osteoarthritis

OBJECTIVE

To explore the key motivators behind selection of analgesics (nonsteroidal antiinflammatory drugs [NSAIDs], acetaminophen, and complementary medications [CMs]) by patients with osteoarthritis (OA).

METHODS

We performed a qualitative study in which in-depth semistructured interviews were conducted with 15 OA patients recruited from 4 general practices in Sydney, Australia. Patients were ages ≥65 years, and were currently taking or had recently taken an NSAID for OA.

RESULTS

Three key themes emerged from the data: reliance, routine, and pill load. Patients were strongly reliant upon NSAIDs because they consistently satisfied their needs. By contrast, they were much less reliant upon acetaminophen because of uncertainty or skepticism about its effectiveness. They were not reliant upon CMs but were willing to take them indefinitely because they were perceived as being without risk. Many patients took an NSAID as well as CMs as part of a "daily routine." By contrast, patients had difficulty developing a routine around using acetaminophen at the recommended maximum dose because of the implicit frequency of dosing required and an aversion to the associated "pill load."

CONCLUSION

The results highlight the importance of exploring the perceptions and preferences of patients with regard to analgesics for OA. Clinician advice regarding analgesia for OA should take account of the possible reliance of the patient upon an NSAID, their medicine routines, and their potential concern about the pill load associated, in particular, with acetaminophen.