Association of Tramadol With All-Cause Mortality Among Patients With Osteoarthritis

Association of Tramadol Versus Codeine Prescriptions with all-cause mortality and cardiovascular diseases among patients with osteoarthritis: a systematic review and meta-analysis of propensity score-matched population-based cohort studies

BACKGROUND

Today, the prescription of tramadol in patients with osteoarthritis (OA) has increased significantly, which can be associated with serious consequences. Contradictory results have been reported regarding the association of tramadol versus codeine with the risk of all-cause mortality (ACM) and cardiovascular diseases (CVD).

METHODS

This systematic review and meta-analysis aimed to evaluate, for the first time, the association of tramadol versus codeine with the risk of ACM and CVD in OA patients for the first time. We searched PubMed, Scopus, Embase, Web of sciences, and Google Scholar with specific keywords and mesh terms to find relevant studies until January 2024. Two independent researchers did the process of searching and screening articles. Cochran's Q and I2 tests evaluated the heterogeneity of the studies. Egger's test was used to evaluate the existence of publication bias.

RESULTS

Seven population-based cohort studies, matched by the propensity score method, including 1,939,293 participants, were reviewed. The study pooled results did not show a significant association between the prescriptions of tramadol versus codeine with increasing the risk of ACM in OA patients. (Hazard ratio (HR): 1.084, 95% confidence interval (95%) CI: 0.883, 1.286, P: 0.56) In addition, the prescription of tramadol versus codeine was not associated with an increased risk of CVD in OA. (HR: 1.025, 95% CI: 0.89, 1.16, P: 0.68, I2 = 37.8%) CONCLUSION: Our systematic review showed that tramadol prescription compared to codeine in OA patients was not associated with an increased risk of ACM and CVD.

Hand Osteoarthritis and Subclinical Cardiovascular Disease in Middle-Aged Women

Objective: To determine subclinical cardiovascular disease (sCVD) in middle-aged women with clinically manifested hand osteoarthritis (HOA) and to improve the characterization of cardiovascular risk in this population. Design: We cross-sectionally evaluated the relationship between HOA and sCVD in 1,803 volunteers from the Mexican Teachers' Cohort. From 2012 to 2016, a subsample from Mexico City, the Northern state Nuevo León, and the Southern states Chiapas and Yucatán was invited for clinical evaluations, during which neurologists examined carotid arteries using ultrasound, and a standardized HOA questionnaire was also administered. HOA was defined as age ≥45 years, hand joint pain, and morning stiffness that lasted no longer than 30 minutes. sCVD was assessed using the intima-media thickness (IMT) and atherosclerotic plaques. Results: Among participants with a mean age of 51 years (±4), 18.4% met the criteria for HOA, and the prevalence of carotid atherosclerosis was 23.1%. After multivariable adjustment, women diagnosed with HOA had a 1.8% (95% confidence interval [CI] 0.3, 3.3) greater mean IMT than those without this joint disease. Similarly, women with HOA had 36% (95% CI 1.01, 1.84) higher odds of carotid atherosclerosis. Conclusions: HOA is associated with sCVD in middle-aged women. This relationship might be due to low-grade chronic inflammation; however, further research is required to clarify the underlying mechanisms.

A Review of Current Approaches to Pain Management in Knee Osteoarthritis with a Focus on Italian Clinical Landscape

The global cases of knee osteoarthritis (KOA) are projected to increase by 74.9% by 2050. Currently, over half of patients remain dissatisfied with their pain relief. This review addresses unmet needs for moderate-to-severe KOA pain; it offers evidence and insights for improved management. Italian experts from the fields of rheumatology, physical medicine and rehabilitation, orthopedics, primary care, and pain therapy have identified several key issues. They emphasized the need for standardized care protocols to address inconsistencies in patient management across different specialties. Early diagnosis is crucial, as cartilage responds better to early protective and structural therapies. Faster access to physiatrist evaluation and reimbursement for physical, rehabilitative, and pharmacological treatments, including intra-articular (IA) therapy, could reduce access disparities. Concerns surround the adverse effects of oral pharmacological treatments, highlighting the need for safer alternatives. Patient satisfaction with corticosteroids and hyaluronic acid-based IA therapies reduces over time and there is no consensus on the optimal IA therapy protocol. Surgery should be reserved for severe symptoms and radiographic KOA evidence, as chronic pain post-surgery poses significant societal and economic burdens. The experts advocate for a multidisciplinary approach, promoting interaction and collaboration between specialists and general practitioners, to enhance KOA care and treatment consistency in Italy.

Osteoarthritis, osteoarthritis treatment and risk of incident dementia: a prospective cohort study based on UK Biobank

BACKGROUND

We aimed to investigate the association between OA and treatment with dementia risk and structural brain abnormalities.

METHODS

We recruited a total of 466,460 individuals from the UK Biobank to investigate the impact of OA on the incidence of dementia. Among the total population, there were 63,081 participants diagnosed with OA. We subsequently categorised the OA patients into medication and surgery groups based on treatment routes. Cox regression models explored the associations between OA/OA treatment and dementia risk, with the results represented as hazard ratios (HRs) and 95% confidence intervals (95% CI). Linear regression models assessed the associations of OA/OA therapy with alterations in cortical structure.

RESULTS

During an average of 11.90 (± 1.01) years of follow-up, 5,627 individuals were diagnosed with all-cause dementia (ACD), including 2,438 AD (Alzheimer's disease), and 1,312 VaD (vascular dementia) cases. Results revealed that OA was associated with the elevated risk of ACD (HR: 1.116; 95% CI: 1.039-1.199) and AD (HR: 1.127; 95% CI: 1.013-1.254). OA therapy lowered the risk of dementia in both medication group (HR: 0.746; 95% CI: 0.652-0.854) and surgery group (HR: 0.841; 95% CI: 0.736-0.960). OA was negatively associated with cortical area, especially precentral, postcentral and temporal regions.

CONCLUSIONS

Osteoarthritis increased the likelihood of developing dementia, and had an association with regional brain atrophy. OA treatment lowered the dementia risk. OA is a promising modifiable risk factor for dementia.

Frequent use of prescription NSAIDs among people with knee or hip osteoarthritis despite contraindications to or precautions with NSAIDs

OBJECTIVE

To describe the use of non-steroidal anti-inflammatory drugs (NSAID), opioids, and physiotherapy (PT) among persons with newly diagnosed knee or hip osteoarthritis (OA) with and without NSAID contraindications or precautions.

DESIGN

We used population-based register data to identify adults aged ≥35 as of January 1, 2014, residing in Skåne region (Sweden) between 2004 and 2013, without a previous knee or hip OA diagnosis. Among this cohort, we identified people with incident knee or hip OA diagnosis between 2014 and 2018 and the presence of contraindications to or precautions for oral NSAIDs at the time of OA diagnosis. We estimated the risk of 1) regular oral NSAID use, 2) regular opioid use, and 3) PT during the first year after diagnosis among those with vs. without contraindications or precautions using confounder-adjusted logistic regression with standardization.

RESULTS

We identified 35,173 persons with newly diagnosed OA, of whom 3257 and 8351 had ≥1 contraindication to oral NSAIDs and ≥1 precaution, respectively. Overall, 27% of individuals used oral NSAIDs (with or without opioids or PT), 10% used opioids, and 57% attended PT. Among patients with contraindications, 21% used oral NSAIDs compared to 31% without (absolute adjusted difference -0.06 (95% CIs: -0.08, -0.05)), 53% vs 59% used PT (adjusted difference -0.03 (-0.05, -0.01)), while 14% vs. 8% had prescribed dispensed opioids (adjusted difference 0.02 (0.01, 0.03)). Similar results were observed for those with precautions.

CONCLUSIONS

We highlight the need for safer treatment options. People with OA and contraindications/precautions to NSAIDs have a higher risk of opioid use, slightly lower risk of PT use, and continue to be prescribed NSAIDs.

Long-term use of prescription opioids for non-cancer pain and mortality: a population-based, propensity-weighted cohort study

OBJECTIVE

The objective of this study was to identify factors associated with long-term opioid use and to assess the association between long-term use and death.

STUDY DESIGN

Retrospective cohort study combining several population-wide databases and covering a population of five million inhabitants, including all adults who were initiated on opioid treatment from 2014 to 2018 for non-cancer pain.

METHODS

We used logistic regression models to identify factors associated with chronic opioid use and carried out survival analyses using multivariable Cox regression modelling for all-cause mortality during follow-up using inverse probability of treatment weighting (IPTW) and propensity scores based on the probability of using opioids chronically.

RESULTS

Among 760,006 patients, 82,423 (10.85%) used opioids for 90 days or more after initiation. Initial therapy characteristics associated with higher risk for long-term use were initiating with long- and short-acting opioids (when compared to tramadol, odds ratio [OR]: 2.63, 95% confidence interval [CI]: 2.57, 2.69 and OR: 1.60, 95%CI: 1.46, 1.76, respectively), using higher daily doses (when compared to 50 morphine milligramme equivalent [MME] or less, prescribing 50 to 89 daily MME, OR: 1.76, 95%CI: 1.65, 1.87; 90 to 119 daily MME, OR: 2.44, 95%CI: 1.99, 3.01; and more than 120 daily MME, OR: 1.77, 95%CI: 1.64, 1.91), and overlapping with gabapentinoids (OR: 2.26, 95%CI: 2.20, 2.32), benzodiazepines (OR: 1.32, 95%CI: 1.30, 1.35), and antipsychotics (OR: 1.21, 95%CI: 1.16, 1.26). After IPTW, chronic opioid use was associated with higher risk of all-cause mortality when compared to short-term use (Hazard Ratio (HR): 1.37, 95%CI: 1.32, 1.42). Sensitivity analyses provided similar results.

CONCLUSION

These findings may help healthcare managers to identify and address patients at higher risk of long-term use and riskier prescription patterns.

Risks of mental disorders among inpatients with burn injury: A nationwide cohort study

OBJECTIVE

This investigation identified the association between burn injuries and the risk of mental disorders in patients with no documented pre-existing psychiatric comorbidities. We also examined the relationship of injury severity and the types of injury with the likelihood of receiving new diagnoses of mental disorders.

METHODS

This population-based retrospective cohort study used administrative data extracted from the Taiwanese National Health Insurance Research Database (NHIRD) between 2000 and 2013. In total, 10,045 burn survivors were matched with a reference cohort of 40,180 patients without burn injuries and were followed to determine if any mental disorder was diagnosed. Patients diagnosed with mental disorders in the five years before study initiation were excluded to ensure incident diagnoses throughout the research duration. Generalized estimating equations in Cox proportional hazard regression models were used for data analysis.

RESULTS

In general, burn injury survivors have a 1.21-fold risk of being diagnosed with new mental disorders relative to patients without burn injuries. Total body surface area (TBSA) of ≧ 30% (aHR: 1.49, 95% CI: 1.36-1.63) and third- or fourth-degree burns (aHR: 1.49, 95% CI: 1.37-1.63) had a significantly greater risk of being diagnosed with mental disorders in comparison to the reference cohort. Patients TBSA 10-29% (aHR: 0.85, 95% CI: 0.77-0.93) and first- or second-degree burn victims (aHR: 0.89, 95% CI: 0.81-0.97) had relatively lower risk of mental disorders than the reference cohort.

CONCLUSION

Burn injuries were associated with an increased risk of mental disorders. Additional research in this field could elucidate this observation, especially if the inherent limitations of the NHIRD can be overcome.

Overview: Chronic Pain and Cannabis-Based Medicines

Chronic pain is primarily conceptualized as a disease in its own right when it is associated with emotional distress and functional impairment. Pathophysiologically, dysfunction of the cortico-mesolimbic connectome is of major importance, with overlapping signals in the nociceptive and stress systems. The endocannabinoid system plays an important role in the central processing of nociceptive signals and regulates the central stress response. Clinically, there is moderate evidence that cannabis-based medicines (CBM) can contribute to a significant reduction in pain, especially the associated pain affect, and improvement in physical function and sleep quality in a proportion of patients with chronic pain. The analgesic effect appears to be largely independent of the cause of pain. In this context, CBM preferentially regulates stress-associated pain processing.

A real-world comparison of circulating tumor cells in breast cancer from China: Novel device, CTC counts and its overall survival

Background

Both CellSearch and CellCollector have been accepted as the proper devices to capture CTC by domestic approval department. However, there is little article about the comparison between these two devices around the world. Herein, we conducted the real-world study to compare with these two devices and to re-verify the efficacy of CTC counts.

Methods

Patients who meet the following points should be included in the analysis. 1. Female, aged 18 years or older; 2. Eastern Cooperative Oncology Group (ECOG) score 0-2; 3. With at least one measurable tumor lesion; 4. Clear immunohistochemistry result; 5. Accept at least one CTC test. Patients were excluded in the analysis if they had a history of malignant tumors, incomplete follow-up information.

Results

536 metastatic breast cancer patients who had been detected for CTC at least once by CellSearch or CellCollector were included in the analysis. CellCollector in vivo CTC detection technology has a higher detection rate than the CellSearch system (69.2% vs 57.4%, P = 0.009). However, the proportion of CTC≥5 detected by CellSearch was higher than CellCollector (37.4% vs 16.3%, P < 0.001). There was a statistically significant difference in overall survival of patients with CTC negative and CTC positive (mOS:49.8 months vs 26.9 months). After 4 weeks of treatment, when CTC decreased by more than 50%, there was a significant difference in survival between the two groups (40.1 months vs 25.8 months, HR = 0.588, 95% CI: 0.350-0.933). In addition, for HER2-positive patients, Patients with CTC HER2 positive had longer overall survival than patients with CTC HER2 negative (median OS: 26.7 months vs 17.3 month, HR = 0.528, 95% CI: 0.269-0.887).

Conclusions

Real-world data indicate that CTC is an independent prognostic factor, and CellCollector and CellSearch have their own advantages in CTC detection.

Comparative safety of tramadol and other opioids following total hip and knee arthroplasty

BACKGROUND

Tramadol is increasingly used to treat acute postoperative pain among older adults following total hip and knee arthroplasty (THA/TKA). However, tramadol has a complex pharmacology and may be no safer than full opioid agonists. We compared the safety of tramadol, oxycodone, and hydrocodone among opioid-naïve older adults following elective THA/TKA.

METHODS

This retrospective cohort included Medicare Fee-for-Service beneficiaries ≥ 65 years with elective THA/TKA between January 1, 2010 and September 30, 2015, 12 months of continuous Parts A and B enrollment, 6 months of continuous Part D enrollment, and no opioid use in the 6 months prior to THA/TKA. Participants initiated single-opioid therapy with tramadol, oxycodone, or hydrocodone within 7 days of discharge from THA/TKA hospitalization, regardless of concurrently administered nonopioid analgesics. Outcomes of interest included all-cause hospitalizations or emergency department visits (serious adverse events (SAEs)) and a composite of 10 surgical- and opioid-related SAEs within 90-days of THA/TKA. The intention-to-treat (ITT) and per-protocol (PP) hazard ratios (HRs) for tramadol versus other opioids were estimated using inverse-probability-of-treatment-weighted pooled logistic regression models.

RESULTS

The study population included 2,697 tramadol, 11,407 oxycodone, and 14,665 hydrocodone initiators. Compared to oxycodone, tramadol increased the rate of all-cause SAEs in ITT analyses only (ITT HR 1.19, 95%CLs, 1.02, 1.41; PP HR 1.05, 95%CLs, 0.86, 1.29). Rates of composite SAEs were not significant across comparisons. Compared to hydrocodone, tramadol increased the rate of all-cause SAEs in the ITT and PP analyses (ITT HR 1.40, 95%CLs, 1.10, 1.76; PP HR 1.34, 95%CLs, 1.03, 1.75), but rates of composite SAEs were not significant across comparisons.

CONCLUSIONS

Postoperative tramadol was associated with increased rates of all-cause SAEs, but not composite SAEs, compared to oxycodone and hydrocodone. Tramadol does not appear to have a superior safety profile and should not be preferentially prescribed to opioid-naïve older adults following THA/TKA.

Weight Loss Induced by Antiobesity Medications and All-Cause Mortality Among Patients With Knee or Hip Osteoarthritis

OBJECTIVE

The current guidelines recommend weight loss for patients with overweight or obesity and knee or hip osteoarthritis (OA); however, there is a paucity of data on the relation of weight loss to death among patients with OA. We aimed to examine the relation of the rate of weight loss induced by antiobesity medications over one year to all-cause mortality among patients with overweight or obesity and knee or hip OA.

METHODS

Using the IQVIA Medical Research Database, we identified people with overweight or obesity and knee or hip OA. We emulated analyses of a hypothetical target trial to assess the effect of slow-to-moderate (2%-10%) or fast (≥10%) weight loss induced by the initiation of antiobesity medications within one year on all-cause mortality and secondary outcomes over five years' follow-up.

RESULTS

Among 6,524 participants, the five-year all-cause mortality rates were 5.3%, 4.0%, and 5.4% for weight gain or stable, slow-to-moderate weight loss, and fast weight loss arms, respectively. Compared with the weight gain or stable arm, hazard ratios of all-cause mortality were 0.72 (95% confidence interval [CI] 0.56-0.92) for the slow-to-moderate weight loss arm and 0.99 (95% CI 0.67-1.44) for the fast weight loss arm. We found dose-response protective effects of weight loss on incident hypertension, type 2 diabetes, and venous thromboembolism but a slightly higher risk of cardiovascular disease, albeit not statistically significant, in the fast rate of weight loss arm than in the weight gain or stable arm and no significant relations of weight loss to the risk of cancer.

CONCLUSION

In this population-based study, a slow-to-moderate, but not fast, rate of weight loss induced by antiobesity medications is associated with a lower risk of all-cause mortality in people with overweight or obesity and knee or hip OA.

Tramadol use before total shoulder arthroplasty: patients have lower risk of complications and resource utilization than those using traditional opioids

BACKGROUND

Evidence continues to mount for the deleterious effects of preoperative opioid use in the setting of total shoulder arthroplasty (TSA). Tramadol, a synthetic opioid with concomitant neurotransmitter effects, has become a popular alternative to traditional opioids, but it has not been well studied in the preoperative setting of TSA. The purpose of this study is to evaluate postsurgical outcomes in TSA for patients with preoperative tramadol use compared with patients using traditional opioids and those who were opioid naïve.

METHODS

Using the IBM Watson Health MarketScan databases, a retrospective cohort study was performed for patients who underwent TSA from 2009 to 2018. Filled pain prescriptions were collected, and prescribing trends were analyzed. Outcomes were compared between 4 patient cohorts defined by preoperative analgesia use-opioid naïve, tramadol, traditional opioids, and combination (opioids and tramadol). Multivariate analysis was used to account for small variations in cohort demographics and comorbidities. Analysis focused on resource utilization and complications. Revision rates at 1 and 3 years postoperatively were also compared.

RESULTS

A total of 29,454 TSA patients were studied, with 8959 available for 3-year postoperative follow-up. Of these, 10,462 (35.5%) were prescribed traditional opioids and 2214 (7.5%) tramadol only. From 2009 to 2018, prescribing trends in the United States demonstrated a significant decrease in the number of patients prescribed preoperative narcotics, whereas the number of patients prescribed preoperative tramadol and those who were opioid naïve significantly increased. Compared with opioid-naïve patients, the traditional opioid cohort had significantly increased odds of resource utilization and complications, whereas the tramadol cohort did not. Specifically, the traditional opioid cohort had an increased risk of prosthetic joint infection compared with both opioid-naïve and tramadol cohorts. The traditional opioid cohort had higher revision rates than opioid-naïve patients at 1 and 3 years, whereas the tramadol cohort did not.

CONCLUSION

Despite a decrease in opioid prescriptions over the study period, many patients in the United States remain on opioids. Although tramadol is not without its own risks, our results suggest that patients taking preoperative tramadol as an alternative to traditional opioids for glenohumeral arthritic pain had a lesser postoperative risk profile, comparable with opioid-naïve patients.

Evidence-Based Review of Nonsurgical Treatments for Knee and Hip Osteoarthritis

Knee and hip osteoarthritis (OA) are highly prevalent joint diseases that lead to chronic pain, disability, and increased mortality. In this review, we provide a summary of nonsurgical treatments available for knee and hip OA that have evidence to support their use. We also provide a summary of the treatments available for knee and hip OA that do not have sufficient evidence to support their use. Treatments covered in this review include pharmacologic and nonpharmacologic modalities. Cite this article as: Misra D, Felson DT. Evidence-based review of nonsurgical treatments for knee and hip osteoarthritis. Eur J Rheumatol. Published online March 25, 2024. doi: 10.5152/ eurjrheum.2024.22096.

Opioid Prescribing by Emergency Physicians: Trends Study of Medicare Part D Prescriber Data 2013-2019

BACKGROUND

Emergency physicians play a critical role in mitigating the opioid epidemic in public health.

OBJECTIVES

To analyze the prescribing of emergency physicians for opioids among Medicare beneficiaries enrolled in the Part D program from 2013 to 2019.

METHODS

We conducted a retrospective, cross-sectional, descriptive analysis of Medicare Part D prescriber data, focusing on opioid claims between 2013 and 2019. The primary outcome variables evaluated included proportion of opioid claims, trends of the most prescribed opioids, cost of opioid claims, and days' supply per claim.

RESULTS

A total of 63,586 emergency physicians were identified over the study period. Opioid prescription by emergency physicians decreased from 14.45% to 11.55%, and the cost spent on opioid drugs declined by 50%. The use of drugs such as hydrocodone-acetaminophen and oxycodone-acetaminophen declined substantially, whereas tramadol and acetaminophen-codeine prescription increased. The opioid prescribing rate and days' supply also decreased.

CONCLUSIONS

The decline in traditional opioid agents such as hydrocodone-acetaminophen was partly offset by an increase in opioids like tramadol, which carry additional potential adverse events. Opioid prescribing rate, average days' supply, and cost of opioid drugs significantly decreased from 2015 to 2019, after a spike in 2015. All regions observed a decrease in emergency physicians, but opioid prescribing rates varied across regions. These trends highlight successful opioid stewardship practices in some areas and the need for further development in others. This information can aid in designing tailored guidelines and policies for emergency physicians to promote effective opioid stewardship practices.

Use of prescribed analgesics before and after exercise therapy and patient education in patients with knee or hip osteoarthritis

The aim of this study was to investigate utilisation patterns of prescribed analgesics before, during, and after an exercise therapy and patient education program among patients with knee or hip osteoarthritis. This cohort study is based on data from the nationwide Good Life with osteoarthritis in Denmark (GLA:D®) patient-register linked with national health registries including data on prescribed analgesics. GLA:D® consists of 8-12 weeks of exercise and patient education. We included 35,549 knee/hip osteoarthritis patients starting the intervention between January 2013 and November 2018. Utilisation patterns the year before, 3 months during, and the year after the intervention were investigated using total dispensed defined daily doses (DDDs) per month per 1000 population as outcome. During the year before the intervention, use of prescribed paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), and opioids increased with 85%, 79% and 22%, respectively. During the intervention, use of paracetamol decreased with 16% with a stable use the following year. Use of NSAIDs and opioids decreased with 38% and 8%, respectively, throughout the intervention and the year after. Sensitivity analyses indicated that the prescription of most analgesics changed over time. For paracetamol, NSAIDs, and opioids, 10% of analgesic users accounted for 45%, 50%, and 70%, respectively, of the total DDDs dispensed during the study period. In general, analgesic use increased the year before the intervention followed by a decrease during the intervention and the year after. A small proportion of analgesic users accounted for half or more of all paracetamol, NSAIDs, and opioids dispensed during the study period.

Prevalence of Nonsteroidal Antiinflammatory Drugs Prescribed for Osteoarthritis: A Systematic Review and Meta-Analysis of Observational Studies

OBJECTIVE

Our systematic review aimed to investigate the proportion of participants with osteoarthritis who were prescribed nonsteroidal antiinflammatory drugs (NSAIDs) by their health care provider.

METHODS

Electronic databases were searched for observational studies reporting NSAID prescribing to participants with diagnosed osteoarthritis of any region. Risk of bias was assessed using a tool designed for observational studies measuring prevalence. Random and fixed-effects meta-analysis was used. Meta-regression investigated study-level factors associated with prescribing. The overall evidence quality was assessed using Grading of Recommendations Assessment, Development, and Evaluation criteria.

RESULTS

Fifty-one studies were included, published between 1989 and 2022, with 6,494,509 participants. The mean age of participants was 64.7 years (95% confidence interval [95% CI] 62.4, 67.0; n = 34 studies). Most studies were from Europe and Central Asia (n = 23 studies), and North America (n = 12 studies). Most studies were judged to be at low risk of bias (75%). Heterogeneity was eliminated when removing studies with a high risk of bias, to give a pooled estimate of NSAIDs prescribing to participants with osteoarthritis of 43.8% (95% CI 36.8, 51.1; moderate quality of evidence). Meta-regression determined that prescribing was associated with year (decreased prescribing over time; P = 0.05) and geographic region (P = 0.03; higher in Europe and Central Asia and in South Asia than in North America) but not with clinical setting.

CONCLUSION

Data from over 6.4 million participants with osteoarthritis between 1989 and 2022 indicate that NSAID prescribing has decreased over time and that prescribing differs between geographic locations.

Hyperlipidemia in immune thrombocytopenia: a retrospective study

BACKGROUND

Immune thrombocytopenia (ITP) is an autoimmune hemorrhagic disease characterized by low platelet count and bleeding manifestations. However, some patients also suffered from atherosclerosis or even infarction. Apart from activated platelets, lipid metabolism takes a large part in the formation of atherosclerosis and metabolic syndrome. The lipid metabolic state in ITP patients is still unknown.

METHODS

We retrospectively reviewed 302 hospitalized ITP patients in our cohort, comparing their blood lipids, bleeding symptoms, metabolic diseases and treatment responses.

RESULTS

We found a high proportion of ITP patients suffered from hyperlipidemia, and other metabolic diseases including cardiovascular or cerebral atherosclerosis or infarction, hypertension, and type 2 diabetes. Hyperlipidemia was associated with severe bleeding and treatment refractoriness in ITP. Statins could alleviate thrombocytopenia and bleeding severity, and facilitate ITP treatment, while improving hyperlipidemia in ITP patients.

CONCLUSIONS

Our present study demonstrated that lipid metabolism might play an indispensable role in ITP pathogenesis and development.

Interactions of Nonsteroidal Antiinflammatory Drugs and Aspirin and Risk of Cardiovascular Disease in Patients With Osteoarthritis

Nonsteroidal antiinf lammatory drugs (NSAIDs) remain the mainstay of the pharmacologic management for relieving osteoarthritis pain, and low-dose aspirin is often prescribed to osteoarthritis patients who are at high risk of cardiovascular disease (CVD). We conducted cohort studies using data from The Health Improvement Network (THIN) database (2000-2019) to assess whether the relationship of initiation of naproxen or ibuprofen vs. initiation of other NSAIDs (excluding both naproxen and ibuprofen), respectively, to the risk of CVD was modified by coprescription of low-dose aspirin among the participants with osteoarthritis. Among participants without coprescription of aspirin, the risk of CVD was lower in naproxen initiators (10.3/1000 person-years) than in other NSAIDs initiators (13.2/1000 person-years; hazard ratio = 0.71, 95% confidence interval: 0.60, 0.85). Among participants with coprescription of aspirin, however, the risk of CVD was higher among naproxen initiators (36.9/1000 person-years) than that among other NSAIDs initiators (34.8/1000 person-years; hazard ratio = 1.48, 95% confidence interval: 1.12, 1.84). The association was significantly modified by coprescription of aspirin (P < 0.001). Similar findings were observed in the association of initiation of ibuprofen vs. other NSAIDs with the risk of CVD, which was significantly modified by coprescription of aspirin (P < 0.001). These findings suggest that osteoarthritis patients and clinicians should be aware of the potential CVD risk of concurrently taking naproxen or ibuprofen and low-dose aspirin.

Comparative Effectiveness of Sodium-Glucose Cotransporter-2 Inhibitors for Recurrent Gout Flares and Gout-Primary Emergency Department Visits and Hospitalizations : A General Population Cohort Study

BACKGROUND

Sodium-glucose cotransporter-2 inhibitors (SGLT2is) decrease serum urate levels, but whether this translates into prevention of recurrent flares among patients with gout and gout-primary emergency department (ED) visits or hospitalizations is unknown.

OBJECTIVE

To compare gout flares and cardiovascular events among patients with gout initiating SGLT2is versus dipeptidyl peptidase 4 inhibitors (DPP-4is), another second-line glucose-lowering agent not associated with serum urate levels or cardiovascular risk.

DESIGN

Propensity score-matched, new-user cohort study.

SETTING

General population database from 1 January 2014 to 30 June 2022.

PARTICIPANTS

Patients with gout and type 2 diabetes.

MEASUREMENTS

The primary outcome was recurrent gout flare counts ascertained by ED, hospitalization, outpatient, and medication dispensing records. Secondary outcomes included myocardial infarction and stroke; genital infection (positive control) and osteoarthritis encounter (negative control) were also assessed. Poisson and Cox proportional hazards regressions were used with 1:1 propensity score matching (primary analysis) and overlap weighting (sensitivity analysis).

RESULTS

After propensity score matching, the flare rate was lower among SGLT2i initiators than DPP-4i initiators (52.4 and 79.7 events per 1000 person-years, respectively), with a rate ratio (RR) of 0.66 (95% CI, 0.57 to 0.75) and a rate difference (RD) of -27.4 (CI, -36.0 to -18.7) per 1000 person-years. The corresponding RR and RD for gout-primary ED visits and hospitalizations were 0.52 (CI, 0.32 to 0.84) and -3.4 (CI, -5.8 to -0.9) per 1000 person-years, respectively. The corresponding hazard ratio (HR) and RD for myocardial infarction were 0.69 (CI, 0.54 to 0.88) and -7.6 (CI, -12.4 to -2.8) per 1000 person-years; the HR for stroke was 0.81 (CI, 0.62 to 1.05). Those who initiated SGLT2is showed higher risk for genital infection (HR, 2.15 [CI, 1.39 to 3.30]) and no altered risk for osteoarthritis encounter (HR, 1.07 [CI, 0.95 to 1.20]). Results were similar when propensity score overlap weighting was applied.

LIMITATION

Participants had concurrent type 2 diabetes.

CONCLUSION

Among patients with gout, SGLT2is may reduce recurrent flares and gout-primary ED visits and hospitalizations and may provide cardiovascular benefits.

PRIMARY FUNDING SOURCE

National Institute of Arthritis and Musculoskeletal and Skin Diseases.

Cell-Based Therapies for Degenerative Musculoskeletal Diseases

Degenerative musculoskeletal diseases (DMDs), including osteoporosis, osteoarthritis, degenerative disc disease, and sarcopenia, present major challenges in the aging population. Patients with DMDs present with pain, functional decline, and reduced exercise tolerance, which result in long-term or permanent deficits in their ability to perform daily activities. Current strategies for dealing with this cluster of diseases focus on relieving pain, but they have a limited capacity to repair function or regenerate tissue. Cell-based therapies have attracted considerable attention in recent years owing to their unique mechanisms of action and remarkable effects on regeneration. In this review, current experimental attempts to use cell-based therapies for DMDs are highlighted, and the modes of action of different cell types and their derivatives, such as exosomes, are generalized. In addition, the latest findings from state-of-the-art clinical trials are reviewed, approaches to improve the efficiency of cell-based therapies are summarized, and unresolved questions and potential future research directions for the translation of cell-based therapies are identified.

System pharmacology analysis to decipher the effect and mechanism of active ingredients combination from Duhuo Jisheng decoction on osteoarthritis in rats

ETHNOPHARMACOLOGY RELEVANCE

Duhuo Jisheng decoction is a traditional Chinese formula that has been widely used in clinical practice to treat osteoarthritis, which has the effects of removing invaded cold and dampness, relieving joint pain. However, it is difficult to determine the effective substances and mechanisms due to assorted herbs and components, and further research is needed.

AIM OF THE STUDY

This study was designed to explore and verify the mechanism and targets of DHJSD in the treatment of OA via network analysis and experiments.

METHOD

In this study, the active ingredients of DHJSD were qualitatively analyzed by UPLC-QDA. Network analysis was used to identify common targets and pathways. Next, we explored the therapeutic mechanism of DHJSD through a rat model of knee osteoarthritis. HE staining was used to judge the establishment of the animal model. ELISA and Western blotting were used to verify the expression of key pathway proteins.

CONCLUSION

In this study, seventeen chemical constituents in DHJSD were identified. According to the network analysis, we obtained the potential associated pathways of action. Then, molecular docking and SPR experiments showed that the sixteen identified components had high binding energies to IL-6. HE staining showed that the high-dose group of DHJSD had an obvious therapeutic effect on model rats. Compared with the model group, the levels of IL-1β, TNF-α, IL-6, MMP3, MMP13, ADAMTS4 and ADAMTS5 in serum and the expression of STAT3 and p-STAT3 protein in administration groups were significantly decreased. This result indicated that the IL-6/STAT3 signaling pathway was one of the important pathways regulated by DHJSD to improve OA.

Prevalence of preoperative opioid usage and its impact on postoperative outcomes: a retrospective cohort study

PURPOSE

Preoperative opioid treatment increases postoperative adverse events. This study was aimed to analyze preoperative opioid prevalence in countries with low opioid consumption. Additionally, the effect of low opioid usage on postoperative outcomes was also investigated.

METHODS

We conducted this single center retrospective cohort analysis in a Japanese university-affiliated hospital to investigate opioid usage and its impact on the duration of postoperative hospitalization and in-hospital mortality. Adult patients who underwent general anesthesia between 2015 and 2020 were included. We extracted the patients' characteristics, surgical information and postoperative outcomes. Subgroup analysis to address opioid dose effect was performed in high and low dose opioid subgroups.

RESULTS

Among 20,306 inpatients, 535 (2.63%) patients used opioids preoperatively. Tramadol was the most frequently used opioid. The median morphine equivalent (MME) dose was 15 mg/day. Median duration of hospitalization was 18 and 9 days in the opioid and non-opioid groups, and in-hospital mortality was 2.06% and 0.42%. Multivariable regression analysis demonstrated that preoperative opioid use was associated with a longer duration of hospitalization and in-hospital mortality. Subgroup analysis demonstrated longer durations of hospitalization in both high (> 30 mg/day MME) and low (≤ 30 mg/day MME) dose opioid groups, while higher in-hospital mortality was seen only in the high dose opioid group.

CONCLUSIONS

Preoperative opioid usage was one-tenth of the United States average. Despite its low prevalence and small dosage, preoperative opioid usage was associated with poor postoperative outcomes. Dedicated perioperative interventions to prevent opioid-associated adverse events should be developed even in countries with low opioid consumption.

The prescription drug monitoring program in a multifactorial approach to the opioid crisis: PDMP data, Pennsylvania, 2016-2020

BACKGROUND

Prescription opioids remain an important contributor to the United States opioid crisis and to the development of opioid use disorder for opioid-naïve individuals. Recent legislative actions, such as the implementation of state prescription drug monitoring programs (PDMPs), aim to reduce opioid morbidity and mortality through enhanced tracking and reporting of prescription data. The primary objective of our study was to describe the opioid prescribing trends in the state of Pennsylvania (PA) as recorded by the PA PDMP following legislative changes in reporting guidelines, and discuss the PDMP's role in a multifactorial approach to opioid harm reduction.

METHODS

State-level opioid prescription data summaries recorded by the PA PDMP for each calendar quarter from August 2016 through March 2020 were collected from the PA Department of Health. Data for oxycodone, hydrocodone, and morphine were analyzed by quarter for total prescription numbers and refills. Prescription lengths, pill quantities, and average morphine milliequivalents (MMEs) were analyzed by quarter for all 14 opioid prescription variants recorded by the PA PDMP. Linear regression was conducted for each group of variables to identify significant differences in prescribing trends.

RESULTS

For total prescriptions dispensed, the number of oxycodone, hydrocodone, and morphine prescriptions decreased by 34.4, 44.6, and 22.3% respectively (p < 0.0001). Refills fluctuated less consistently with general peaks in Q3 of 2017 and Q3 of 2018 (p = 0.2878). The rate of prescribing for all opioid prescription lengths decreased, ranging in frequency from 22 to 30 days (47.5% of prescriptions) to 31+ days of opioids (0.8% of prescriptions) (p < 0.0001). Similarly, decreased prescribing was observed for all prescription amounts, ranging in frequency from 22 to 60 pills (36.6% of prescriptions) to 60-90 pills (14.2% of prescriptions) (p < 0.0001). Overall, the average MME per opioid prescription decreased by 18.9%.

CONCLUSIONS

Per the PA PDMP database, opioid prescribing has decreased significantly in PA from 2016 to 2020. The PDMP database is an important tool for tracking opioid prescribing trends in PA, and PDMPs structured similarly in other states may enhance our ability to understand and influence the trajectory of the U.S. opioid crisis. Further research is needed to determine optimal PDMP policies and practices nationwide.

Opioid Utility and Hospital Outcomes Among Inpatients Admitted With Osteoarthritis and Spine Disorders

OBJECTIVE

The aim of the study is to evaluate opioid analgesic utilization and predictors for adverse events during hospitalization and discharge disposition among patients admitted with osteoarthritis or spine disorders.

DESIGN

This is a retrospective study of 12,747 adult patients admitted to six private community hospitals from 2017 to 2020. Opioid use during hospitalization and risk factors for hospital-acquired adverse events and nonhome discharge were investigated.

RESULTS

The total number of patients using opioids decreased; however, the daily morphine milligram equivalent use for patients on opioids increased from 2017 to 2020. Increased odds of nonhome discharge were associated with older age, Medicaid, Medicare insurance, and increased lengths of stay, increased body mass index, daily morphine milligram equivalent, and electrolyte replacement in the osteoarthritis group. In the spine group, older age, Black race, Medicaid, Medicare, no insurance, increased Charlson Comorbidity Index, lengths of stay, polypharmacy, and heparin use were associated with nonhome discharge. Adverse events were associated with increased age, lengths of stay, Medicare, polypharmacy, antiemetic, and benzodiazepine use in the osteoarthritis group and increased Charlson Comorbidity Index, lengths of stay, and electrolyte replacement in the spine group.

CONCLUSIONS

Despite the decreasing number of patients using opioids over the years, patients on opioids had an increased daily morphine milligram equivalent over the same period.

Pharmaceutical treatment of osteoarthritis

OBJECTIVE

To review the current state of pharmaceutical treatment recommendations for the management of osteoarthritis.

METHOD

A narrative review was drafted to describe treatment guidelines, mechanism of action, pharmacokinetics, and toxicity for nine classes of pharmaceuticals: 1) oral nonsteroidal anti-inflammatory drugs (NSAIDs), 2) topical NSAIDs, 3) COX-2 inhibitors, 4) duloxetine, 5) intra-articular corticosteroids, 6) intra-articular hyaluronic acid, 7) acetaminophen (paracetamol), 8) tramadol, and 9) capsaicin.

RESULTS

In general, oral and topical NSAIDs, including COX-2 inhibitors, are strongly recommended first-line treatments for osteoarthritis due to their ability to improve pain and function but are associated with increased risks in patients with certain comorbidities (e.g., heightened cardiovascular risks). Intra-articular corticosteroid injections are generally recommended for osteoarthritis management and have relatively minor adverse effects. Other treatments, such as capsaicin, tramadol, and acetaminophen, are more controversial, and many updated guidelines offer differing recommendations.

CONCLUSION

The pharmaceutical management of osteoarthritis is a constantly evolving field. Promising treatments are emerging, and medicines that were once considered conventional (e.g., acetaminophen) are gradually becoming less acceptable based on concerns with efficacy and safety. Clinicians need to consider the latest evidence and recommendations to make an informed decision with their patients about how to optimize treatment plans for patients with knee, hip, polyarticular, or hand osteoarthritis.

Tramadol May Increase Risk of Hip Fracture in Older Adults with Post-Traumatic Osteoarthritis

Tramadol, an analgesic widely used for arthritic pain, is known to have adverse effects. This study investigated the association between the long-term use of tramadol for pain control and subsequent hip fractures in patients aged 60 years or older with posttraumatic osteoarthritis. This population-based retrospective cohort study included patients with posttraumatic osteoarthritis who received tramadol for pain control for more than 90 days within a 1-year period. A control cohort was enrolled using propensity score matching. The primary outcome was a new diagnosis of hip fracture requiring surgery. In total, 3093 patients were classified into each cohort. Tramadol use was identified as a risk factor for hip fracture (adjusted hazard ratio (aHR): 1.41; 95% confidence interval (CI): 1.09–1.82; p = 0.008), especially among patients aged 60–70 years (aHR: 2.11; 95% CI: 1.29–3.47; p = 0.003) and among male patients (aHR: 1.83; 95% CI: 1.24–2.70; p = 0.002). This is the first cohort study focusing on the association between long-term tramadol use and hip fracture among older adults with posttraumatic osteoarthritis. Tramadol, as a long-term pain control analgesic for older adults with posttraumatic osteoarthritis, may increase the risk of hip fracture, especially among male patients and those aged 60–70 years.

Recent Advances in Small Molecule Inhibitors for the Treatment of Osteoarthritis

Osteoarthritis refers to a degenerative disease with joint pain as the main symptom, and it is caused by various factors, including fibrosis, chapping, ulcers, and loss of articular cartilage. Traditional treatments can only delay the progression of osteoarthritis, and patients may need joint replacement eventually. As a class of organic compound molecules weighing less than 1000 daltons, small molecule inhibitors can target proteins as the main components of most drugs clinically. Small molecule inhibitors for osteoarthritis are under constant research. In this regard, by reviewing relevant manuscripts, small molecule inhibitors targeting MMPs, ADAMTS, IL-1, TNF, WNT, NF-κB, and other proteins were reviewed. We summarized these small molecule inhibitors with different targets and discussed disease-modifying osteoarthritis drugs based on them. These small molecule inhibitors have good inhibitory effects on osteoarthritis, and this review will provide a reference for the treatment of osteoarthritis.

Chronic low back pain comorbidity count and its impact on exacerbating opioid and non-opioid prescribing behavior

RESEARCH OBJECTIVES

The objective of the study was to determine the characteristics of chronic low back pain (CLBP) comorbidity and its impact on opioid and non-opioid treatments among Chicagoland patients with CLBP.

DESIGN

A retrospective cross-sectional study comparing differences in comorbidity and treatment patterns among Chicagoland patients with CLBP against a matched control arm without chronic low back pain (NCLBP).

SETTING

Academic hospital system outpatient services.

PARTICIPANTS

Using the International Classification of Diseases, 10th Revision codes (ICD 10) 9589 patients were identified with CLBP with a median age of 57 years old and 62.32% female distribution. The NCLBP group comprised 9589 age-, sex-, race-, and region-matched patients.

RESULTS

An increased prevalence across all 17 studied comorbidities was found in CLBP patients as compared to NCLBP patients. CLBP patients carried an average of 3.5 comorbidities compared with 2.4 comorbidities in NCLBP patients. Rheumatoid arthritis (RA), joint arthritis, and obesity had the strongest relationship with CLBP. Additionally, we found that the most prescribed treatment for CLBP were opioids, which ranked above NSAIDs and physical therapy. 56% of CLBP patients were prescribed opioids as compared to 36% of NCLBP patients (Odds Ratio = 2.28, 95% CI: 2.16-2.42). Tramadol was the agent with the strongest relationship to CLBP. CLBP patients were more likely to use two or more opioids concomitantly. The number of total treatments was positively associated with the number of comorbidities in both CLBP and NCLBP patients (Cochran-Armitage trend test p < 0.0001).

CONCLUSIONS

Chronic low back pain patients showed a higher number of comorbidities than their NCLBP counterparts. Comorbidity count trended positively with higher treatment burden with opioids being the most prescribed treatment, often with poly-opioid use, over conservative modalities such as NSAIDs and physical therapy.

Prognostic Factors Related to Clinical Response in 210 Knees Treated by Platelet-Rich Plasma for Osteoarthritis

Many studies have shown the effectiveness of platelet-rich plasma (PRP) in the treatment of knee osteoarthritis. We aimed to determine the factors associated with good or poor response to PRP injections in knee osteoarthritis. This was a prospective observational study. Patients with knee osteoarthritis were recruited from a university hospital. PRP was injected twice at a one-month interval. Pain was assessed on a visual analog scale (VAS) and function was assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Radiographic stage was collected and defined according to the Kellgren-Lawrence classification. Patients were classified as responders if they met the OMERACT-OARSI criteria at 7 months. We included 210 knees. At 7 months, 43.8% were classified as responders. Total WOMAC and VAS were significantly improved between M0 and M7. Physical therapy and a heel-buttock distance >35 cm were the two criteria associated with poor response at M7 by multivariate analysis. Pain VAS at M7 appeared to be lower in patients with osteoarthritis for less than 24 months. No adverse effects were reported. PRP treatment in knee osteoarthritis appears to be well-tolerated and effective, even in patients who reacted poorly to hyaluronic acid. Response was not associated with radiographic stage.

Efficacy and Safety of Tramadol for Knee or Hip Osteoarthritis: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

To examine efficacy and safety of tramadol for knee or hip osteoarthritis (OA).

METHODS

PubMed, Embase, Cochrane Library, and Web of Science were searched up to May 2020 for randomized controlled trials (RCTs) comparing any of the following interventions: tramadol 100 mg/day, 200 mg/day, and 300 mg/day, and placebo for knee or hip OA. Pain and function were measured at or near 12 weeks for efficacy. Gastrointestinal, cardiovascular, and central nervous system (CNS) adverse events (AEs), and withdrawals were measured for safety. Bayesian network meta-analysis was conducted.

RESULTS

Six RCTs (3,611 participants) were included. Tramadol 100 mg/day (standardized mean difference [SMD] -0.16 [95% confidence interval (95% CI) -0.34, 0.00]), 200 mg/day (SMD -0.21 [95% CI -0.37, -0.06]), and 300 mg/day (SMD -0.30 [95% CI -0.48, -0.14]) were statistically more effective than placebo in pain relief, but only tramadol 300 mg/day was better than placebo in functional improvement (SMD -0.24 [95% CI -0.47, -0.03]). Tramadol 100 mg/day (relative risk [RR] 2.29 [95% credible interval (CrI) 1.22, 4.25]), 200 mg/day (RR 4.35 [95% CrI 2.31, 8.01]), and 300 mg/day (RR 6.02 [95% CrI 3.22, 11.1]) involved a higher risk of gastrointestinal AEs. Similarly, tramadol 100-300 mg/day showed a higher risk of CNS AEs and withdrawals. However, the risk of cardiovascular AEs remained unclear.

CONCLUSION

Only tramadol 300 mg/day showed minimal improvement in pain and function but with increasing AEs compared with placebo. Tramadol may not be sufficiently recommended for knee or hip OA based on the presented evidence, especially in patients with the risk of gastrointestinal and CNS AEs.

Gout and Excess Risk of Severe SARS-CoV-2 Infection Among Vaccinated Individuals: A General Population Study

OBJECTIVE

Gout patients often have multiple comorbidities, making them susceptible to SARS-CoV-2 infection and poor outcomes. This study was undertaken to examine the association between gout and the risk of SARS-CoV-2 infection and severe outcomes, especially in patients who have received a SARS-CoV-2 vaccine.

METHODS

We conducted 2 cohort studies using The Health Improvement Network in the UK. Individuals with gout and those without gout from the general population were followed up from December 8, 2020 to October 31, 2021. We estimated the rate difference (RD) and hazard ratio (HR) of SARS-CoV-2 infection and severe outcomes (i.e., hospitalization and death within 30 days after SARS-CoV-2 infection) for individuals with gout versus those without gout using a Cox proportional hazards model according to SARS-CoV-2 vaccination status. We adjusted for potential confounders by using overlap weighting of exposure scores.

RESULTS

Among the vaccinated cohort, 1,955 cases of breakthrough COVID-19 infection occurred in 54,576 individuals with gout (4.68 cases per 1,000 person-months), and 52,468 cases occurred in 1,336,377 individuals without gout (3.76 cases per 1,000 person-months). The partially adjusted RD of breakthrough infection was 0.91 cases per 1,000 person-months (95% confidence interval [95% CI] 0.62-1.20 cases per 1,000 person-months), and the partially adjusted HR was 1.24 (95% CI 1.19-1.30). Gout was also associated with an increased risk of hospitalization (adjusted HR 1.30 [95% CI 1.10-1.53]) and death (adjusted HR 1.36 [95% CI 0.87-2.13]). Women with gout had an increased risk of hospitalization (adjusted HR 1.55 [95% CI 1.15-2.10]) and death (adjusted HR 2.46 [95% CI 1.12-5.41]). Similar associations with gout were observed in the unvaccinated cohort.

CONCLUSION

These general population data suggest that individuals with gout, especially women, have higher risks of SARS-CoV-2 infection and severe outcomes, even when vaccinated.

Chronic opioid use before and after exercise therapy and patient education among patients with knee or hip osteoarthritis

OBJECTIVE

To investigate changes in opioid use after supervised exercise therapy and patient education among knee or hip osteoarthritis patients with chronic opioid use.

METHOD

In this cohort study, we linked data from the Good Life with osteoArthritis in Denmark register (GLA:D®; standardised treatment program for osteoarthritis; January 2013 to November 2018) with national health registries. Among 35,549 patients, 1,262 were classified as chronic opioid users based on amount and temporal distribution of dispensed opioids the year before the intervention. We investigated changes in opioid use, measured as mg oral morphine equivalents (OMEQs), from the year before the intervention to the year after using generalized estimating equations.

RESULTS

We found a 10% decrease in mg OMEQs from the year before to the year after the intervention (incidence rate ratio [IRR]: 0.90, 95% confidence interval [CI]: 0.86, 0.94). Additional analyses suggested this decrease to be mainly attributable to regulatory actions targeting opioid prescribing during the study period (IRR among patients participating in the intervention before: 0.98 [95% CI: 0.89, 1.07] vs after: 0.83 [0.74, 0.93] regulatory actions). In a random general population sample of matched chronic opioid users, a similar opioid use pattern was observed over time, further supporting the impact of regulatory actions on the opioid use in the study population.

CONCLUSION

Among patients with knee or hip osteoarthritis and chronic opioid use, a standardised treatment program did not change opioid use when regulatory changes in opioid prescribing were taken into account.

Comorbidity phenotypes and risk of mortality in patients with osteoarthritis in the UK: a latent class analysis

BACKGROUND

Osteoarthritis (OA) is a common chronic condition but its association with other chronic conditions and mortality is largely unknown. This study aimed to use latent class analysis (LCA) of 30 comorbidities in patients with OA and matched controls without OA to identify clusters of comorbidities and examine the associations between the clusters, opioid use, and mortality.

METHODS

A matched cohort analysis of patients derived from the IQVIA Medical Research Data (IMRD-UK) database between 2000 and 2019. 418,329 patients with newly diagnosed OA were matched to 243,170 patients without OA to identify comorbidity phenotypes. Further analysis investigated the effect of opioid use on mortality in individuals with OA and their matched controls.

RESULTS

The median (interquartile range (IQR)) number of comorbidities was 2 (1-4) and 1 (0-3) in the OA and control groups respectively. LCA identified six comorbidity phenotypes in individuals with and without OA. Clusters with a high prevalence of comorbidities were characterised by hypertension, circulatory, and metabolic diseases. We identified a comorbidity cluster with the aforementioned comorbidities plus a high prevalence of chronic kidney disease, which was associated with twice the hazard of mortality in hand OA with a hazard ratio (HR) (95% CI) of 2.53 (2.05-3.13) compared to the hazard observed in hip/knee OA subtype 1.33 (1.24-1.42). The impact of opioid use in the first 12 months on hazards of mortality was significantly greater for weak opioids and strong opioids across all groups HR (95% CI) ranging from 1.11 (1.07-11.6) to 1.80 (1.69-1.92)). There was however no evidence of association between NSAID use and altered risk of mortality.

CONCLUSION

This study identified six comorbidity clusters in individuals with OA and matched controls within this cohort. Opioid use and comorbidity clusters were differentially associated with the risk of mortality. The analyses may help shape the development of future interventions or health services that take into account the impact of these comorbidity clusters.

Risk of gout flares after COVID-19 vaccination: A case-crossover study

OBJECTIVE

Routine vaccinations are associated with an increased risk of gout flares. We examined the association between COVID-19 vaccination, an immunization program implemented to a large proportion of population, and the risk of gout flares.

METHODS

We conducted a time-stratified case-crossover study among patients with gout who experienced gout flares between December 2020 and September 2021, using data from The Health Improvement Network. We compared the risk of gout flares on each of the seven days on and after the day of COVID-19 vaccination vs. no vaccination during that period using conditional logistic regression. In addition, we performed subgroup analyses stratified by different COVID-19 vaccines (i.e., BNT162b2, hereafter referred to as BNT, and ChAdOx1 nCov-19, hereafter referred to as ChAd).

RESULTS

Among 5,904 patients with gout (mean age: 63·1 years; 85·5% male) who experienced gout flares within one month, the risk of gout flares slightly increased on the second day after COVID-19 vaccination (odds ratio: 1·44; 95% CI: 1·02 to 2·07). The risk of gout flares also slightly increased after receiving COVID-19 vaccine on other remaining days (ORs ranged from 1·03 to 1·22); however, none of them was statistically significant. An increased risk of gout flares on the second day after vaccination was mainly observed for the ChAd vaccine (odds ratio: 1·44; 95% CI: 1·00 to 2·05), but not for BNT vaccine (odds ratio: 1·18; 95% CI: 0·67 to 2·02).

CONCLUSION

COVID-19 vaccination, mainly ChAd vaccination, slightly increases the risk of gout flares on the second day after vaccination. This finding reassures the safety of COVID-19 vaccination for patients with gout.

Societal Cost of Opioid Use in Symptomatic Knee Osteoarthritis Patients in the United States

OBJECTIVE

Symptomatic knee osteoarthritis (SKOA) is a chronic, disabling condition, requiring long-term pain management; over 800,000 SKOA patients in the US use opioids on a prolonged basis. We aimed to characterize the societal economic burden of opioid use in this population.

METHODS

We used the Osteoarthritis Policy Model, a validated computer simulation of SKOA, to estimate the opioid-related lifetime and annual cost generated by the US SKOA population. We included direct medical, lost productivity, criminal justice, and diversion costs. We modeled the SKOA cohort with a mean ± SD age of 54 ± 14 years and Western Ontario and McMaster Universities Osteoarthritis Index pain score of 29 ± 17 (0-100, 100 = worst). We estimated annual costs of strong ($1,381) and weak ($671) opioid regimens using Medicare fee schedules, Red Book, the Federal Supply Schedule, and published literature. The annual lost productivity and criminal justice costs of opioid use disorder (OUD), obtained from published literature, were $11,387 and $4,264, per-person, respectively. The 2015-2016 Medicare Current Beneficiary Survey provided OUD prevalence. We conducted sensitivity analyses to examine the robustness of our estimates to uncertainty in input parameters.

RESULTS

Assuming 5.1% prevalence of prolonged strong opioid use, the total lifetime opioid-related cost generated by the US SKOA population was estimated at $14.0 billion, of which only $7.45 billion (53%) were direct medical costs.

CONCLUSION

Lost productivity, diversion, and criminal justice costs comprise approximately half of opioid-related costs generated by the US SKOA population. Reducing prolonged opioid use may lead to a meaningful reduction in societal costs that can be used for other public health causes.

The Effect of Preoperative Tramadol Use on Postoperative Opioid Prescriptions After Primary Total Hip and Knee Arthroplasty: An Institutional Experience of 11,000 Patients

BACKGROUND

Preoperative opioid use increases opioid consumption postoperatively, but the effect of tramadol is poorly understood.

METHODS

We retrospectively reviewed 11,667 patients undergoing primary unilateral THA and TKA at a single institution. Preoperatively, there were 8,201 opioid-naïve patients (70.3%), 1,315 on tramadol (11.3%), 1,408 on narcotics (12.1%) and 743 on narcotics and tramadol (6.3%). We compared morphine milligram equivalents (MMEs) used during hospitalization, prescribed at discharge, and refilled during the first 90 days. We used multivariate analysis to assess whether preoperative tramadol use was associated with increased number of refills and total refilled MMEs.

RESULTS

Total in-hospital MMEs and daily MMEs was lowest for the opioid naïve patients and significantly increased for the remaining three groups (total in-hospital use: 119, 152, 211, and 196 MMEs, respectively-P < .001) (daily in-hospital use: 66, 74, 100, and 86 MMEs, respectively-P < .001). Opioid refill rate was significantly higher for all patients who were not opioid naïve (32%, 42%, 41%, and 52%, respectively-P < .001). Total MMEs prescribed after discharge was lowest for opioid naïve patients (477, 528, 590 and 658, respectively-P < .001). Logistic and linear regression controlling for age, sex, history of anxiety/depression revealed that THA patients taking tramadol preoperatively were 2.5 times more likely to require post-discharge refills and refilled 80 additional MMEs than opioid naïve patients (P < .001).

CONCLUSION

Tramadol is not recommended for pain beforeTKA or THA, and surgeons and patients should be aware that it is associated with a substantial increase in postoperative opioid use.

Risks of mental disorders among intensive care unit survivors: A nationwide cohort study in Taiwan

OBJECTIVE

This study aimed to investigate the risk of mental disorders among the intensive care unit (ICU) survivors compared with the hospitalized non-ICU and non-hospitalized patients.

METHOD

We extracted data from the Taiwanese National Health Insurance Research Database (NHIRD) to conduct a retrospective cohort study. Multivariate Cox proportional hazard regression models were used to analyze the data. Identified from the NHIRD, we matched 15,918 patients with ICU admissions, 63,672 patients without any inpatient admission (non-inpatient department [non-IPD] cohort), and 63,672 patients admitted to a general ward but not the ICU (non-ICU cohort). The patient records were extracted between the periods of 2000-2015 to identify any occurrence of mental disorders.

RESULTS

During the study period, the overall risk of mental disorder diagnosis was 1.68-fold higher in the ICU cohort than the non-IPD cohort (95% confidence interval (CI): 1.23-1.89, P < 0.001). Alternatively, there were no differences in risks for any mental disorders between the ICU and non-ICU cohorts.

CONCLUSION

Both admissions to the ICU and the general ward cohorts were associated with a higher risk of any mental disorders compared to the general population. Further clinical studies are warranted to confirm this association due to residual or unmeasured risk factors.

Progress in osteoarthritis research by the National Natural Science Foundation of China

Osteoarthritis (OA) in China is gradually becoming an important scientific research area that has had a significant impact on research and development (R&D) activities in the OA field worldwide. This article summarizes the R&D progress related to OA in China in recent years. The National Natural Science Foundation of China (NSFC) is a national funding institution for basic research and plays a critical role in promoting and supporting Chinese scholars' R&D activities. We collected and analyzed information on NSFC funding in the field of OA from 2010 to 2019, including the amount, the level and the program categories of the funded projects. The data fully demonstrate the important and positive role of the NSFC in supporting free exploration, cultivating research teams and young talent, and boosting OA R&D. In this article, we outline and discuss hot topics in focused areas, key advances in this field and the prospects for progress in OA research in China.

Body surface area affected by psoriasis and the risk for psoriatic arthritis: a prospective population-based cohort study

OBJECTIVE

Increasing psoriasis severity has been associated with comorbidities including cardiovascular disease. The objective of this study was to examine the association of psoriasis severity with the development of PsA.

METHODS

A prospective population-based cohort study was performed within The Health Improvement Network, a UK medical record database. Patients aged 25-60 years with a code for psoriasis were randomly selected between 2008 and 2011. Questionnaires were sent to their general practitioners to confirm the diagnosis of psoriasis and provide the patient's approximate body surface area (BSA). Incidence of PsA was calculated by BSA, and Cox proportional hazard ratios were used to examine the risk of developing PsA by BSA category after adjusting for other covariates.

RESULTS

Among 10 474 questionnaires sent, 9987 (95%) were returned, 9069 (91%) had confirmed psoriasis, and BSA was provided for 8881 patients: 52% had mild psoriasis, 36% moderate psoriasis and 12% severe psoriasis. The mean age was 46, and 49% were female. Mean follow-up time was 4.2 years (s.d. 2.1); the incidence of PsA was 5.4 cases per 1000 person-years. After adjusting for age and sex, BSA >10% [hazard ratio (HR) 2.01, 95% CI: 1.29, 3.13], BSA 3-10% (HR 1.44, 95% CI: 1.02, 2.03), obesity (HR 1.64, 95% CI: 1.19, 2.26) and depression (HR 1.68, 95% CI: 1.21, 2.33) were associated with incident PsA.

CONCLUSIONS

In this large prospective cohort study, BSA assessed by general practitioners was a strong predictor of developing PsA, and obesity and depression were additive risk factors.

Tramadol Use in United States Emergency Departments 2007-2018

BACKGROUND

Amidst the opioid epidemic, there has been an increasing focus on opioid utilization in U.S. emergency departments (EDs). Compared with other opioids, little is known about the use of tramadol over the past decade. Tramadol has uncertain efficacy and a concerning adverse effect profile compared with traditional opioids.

OBJECTIVE

Our aim was to describe trends in tramadol use in U.S. EDs between 2007 and 2018.

METHODS

We analyzed the National Hospital Ambulatory Medical Care Survey from 2007 to 2018 to examine ED visits by patients 18 years or older in which tramadol was administered or prescribed. We examined trends in demographics and resource utilization and compared these trends with those of traditional opioids. Survey-weighted analyses were conducted to provide national-level estimates.

RESULTS

Between 2007 and 2018, ED visits in which tramadol was used increased 70.6%, from 1.7% of all ED visits in 2007 to 2.9% in 2018. The largest increases were noted among patients aged 55 through 64 years and 65 years and older. Diagnostic resource utilization increased across the study period. Overall opioid utilization during the study period decreased from 28.4% in 2007 to 17.9% in 2018 (p < 0.001). The use of other specific opioids declined or remained stable between 2007 and 2018.

CONCLUSIONS

Although the use of traditional opioids decreased from 2007 to 2018, the use of tramadol increased. Increases were largest among older patients, who may be more susceptible to the adverse effects associated with this medication. Further research in the appropriate use of tramadol in the ED setting is warranted.

Association of tramadol with all-cause mortality, cardiovascular diseases, venous thromboembolism, and hip fractures among patients with osteoarthritis: a population-based study

Background

The use of tramadol among osteoarthritis (OA) patients has been increasing rapidly around the world, but population-based studies on its safety profile among OA patients are scarce. We sought to determine if tramadol use in OA patients is associated with increased risks of all-cause mortality, cardiovascular diseases (CVD), venous thromboembolism (VTE), and hip fractures compared with commonly prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) or codeine.

Methods

Using administrative health datasets from British Columbia, Canada, we conducted a sequential propensity score-matched cohort study among all OA patients between 2005 and 2013. The tramadol cohort (i.e., tramadol initiation) was matched with four comparator cohorts (i.e., initiation of naproxen, diclofenac, cyclooxygenase-2 [Cox-2] inhibitors, or codeine). Outcomes are all-cause mortality, first-ever CVD, VTE, and hip fractures within the year after the treatment initiation. Patients were followed until they either experienced an event, left the province, or the 1-year follow-up period ended, whichever occurred first. Cox proportional hazard models were used to estimate hazard ratios after adjusting for competing risk of death.

Results

Overall, 100,358 OA patients were included (mean age: 68 years, 63% females). All-cause mortality was higher for tramadol compared to NSAIDs with rate differences (RDs/1000 person-years, 95% CI) ranging from 3.3 (0.0–6.7) to 8.1 (4.9–11.4) and hazard ratios (HRs, 95% CI) ranging from 1.2 (1.0–1.4) to 1.5 (1.3–1.8). For CVD, no differences were observed between tramadol and NSAIDs. Tramadol had a higher risk of VTE compared to diclofenac, with RD/1000 person-years (95% CI) of 2.2 (0.7–3.7) and HR (95% CI) of 1.7 (1.3–2.2). Tramadol also had a higher risk of hip fractures compared to diclofenac and Cox-2 inhibitors with RDs/1000 person-years (95% CI) of 1.9 (0.4–3.4) and 1.7 (0.2–3.3), respectively, and HRs (95% CI) of 1.6 (1.2–2.0) and 1.4 (1.1–1.9), respectively. No differences were observed between tramadol and NSAIDs for all events.

Conclusions

OA patients initiating tramadol have an increased risk of mortality, VTE, and hip fractures within 1 year compared with commonly prescribed NSAIDs, but not with codeine.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02764-3.

Less Well-Known Consequences of the Long-Term Use of Opioid Analgesics: A Comprehensive Literature Review

BACKGROUND

The adverse effects of short-term opioid analgesics are well known and acknowledged; however, the spectrum of the sequelae of long-term use seems less clear. Some effects may remain undetected but still have the potential to cause harm and reduce patients' quality of life.

OBJECTIVE

To review the literature on the adverse effects of long-term opioid therapy.

METHODS

We performed a quasi-systematic search, analyzing articles published in the MEDLINE database between January 2000 and March 2021 that identified adverse effects of opioids used for chronic pain treatment.

RESULTS

Growing evidence indicates that there are multiple serious adverse effects of opioid treatment. Long-term opioid use may have significant effects on the endocrine, immune, cardiovascular, respiratory, gastrointestinal, and neural systems. Studies show that long-term opioid treatment increases the risk of fractures, infections, cardiovascular complications, sleep-disordered breathing, bowel dysfunction, overdose, and mortality. Opioids may potentially affect cancer development. Most consequences of the long-term use of opioids have been identified in studies of patients with non-malignant pain.

CONCLUSION

Studies indicate that long-term use of opioids increases the risk of drug-related events in a significant number of patients. Clinicians should be aware of these complications associated with prescribing opioids, discuss them with patients, prevent complications, if possible, and diagnose them early and manage adequately. More human studies are needed to assess the risk, including trials with individual opioids, because they have different adverse effect profiles.

Association of Metformin Use With Risk of Venous Thromboembolism in Adults With Type 2 Diabetes: A General-Population-Based Cohort Study

Metformin is hypothesized to protect against the risk of venous thromboembolism (VTE); however, there is a paucity of data supporting this hypothesis. Among individuals aged 40-90 years with a diagnosis of type 2 diabetes in the Health Improvement Network database (2000-2019), we compared the risks of incident VTE, pulmonary embolism, and deep vein thrombosis among metformin initiators with those among sulfonylurea initiators. Individuals were followed from their first prescription refill to an incident VTE, drug discontinuation, switching or augmenting, plan disenrollment, or the end of the study, whichever occurred first. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using the Cox model, adjusting for confounders using inverse probability of treatment weighting. Among 117,472 initiators of metformin and 13,835 initiators of sulfonylureas, 555 (1.3/1,000 person-years) and 75 (2.1/1,000 person-years) VTE cases occurred in each group, respectively. The multivariable-adjusted HR was 0.65 (95% CI: 0.51, 0.84). The corresponding risks for pulmonary embolism (adjusted HR = 0.71, 95% CI: 0.50, 1.01) and deep vein thrombosis (adjusted HR = 0.64, 95% CI: 0.48, 0.87) were also lower in metformin initiators than in sulfonylurea initiators. Our study provided empirical evidence to support a lower risk of VTE after initiation of metformin as compared with sulfonylureas among patients with type 2 diabetes.

Worse health‐related quality of life, impaired functioning and psychiatric comorbidities are associated with excess mortality in patients with severe chronic pain

Background

Severe chronic pain that interferes with daily activities is associated with an increased risk of mortality. We assessed the overall mortality of tertiary chronic pain patients in comparison with the general population, with a special aim to analyse the association of health‐related quality of life (HRQoL) and its dimensions with the risk of death.

Methods

In this prospective observational follow‐up study, patients with non‐cancer chronic pain attended an outpatient multidisciplinary pain management (MPM) episode in a tertiary pain clinic in 2004–2012 and were followed until May 2019. Mortality between the patients and the general population was compared with standardized mortality ratios (SMR) in different age groups. Causes of death and comorbidities were compared among the deceased. Association of mortality and HRQoL and its dimensions, measured with the 15D instrument, was studied with Cox proportional hazards model.

Results

During a mean of 10.4‐year follow‐up of 1498 patients, 296 died. The SMR in the youngest age group (18–49 years) was significantly higher than that of the general population: 2.6 for males and 2.9 for females. Even elderly females (60–69 years) had elevated mortality (SMR 2.3). Low baseline HRQoL at the time of MPM, as well as poor ratings in the psychosocial dimensions of HRQoL, was associated with an increased risk of death.

Conclusions

Our results support the role of HRQoL measurement by a validated instrument such as the 15D in capturing both the physical and the psychological symptom burden, and consequently, an elevated risk of death, in patients with chronic pain.

Significance

Severe chronic pain is associated with elevated mortality. In patients in chronic pain under 50 years old, the mortality was 2.5–3 times higher than in the general population. Psychological distress appears to contribute to the increased mortality. Regular follow‐up by health‐related quality of life (HRQoL) measurement could be useful in identifying patients in chronic pain who are in need of intensive symptom management and to prevent early death.