SHOULD NONSTEROIDAL ANTI-INFLAMMATORY DRUGS BE USED TO TREAT OSTEOARTHRITIS?

Osteoarthritis

The clinical appearance and radiological pattern of osteoarthritis have been identified in the skeletons of dinosaurs some 50-70 million years old, and in Egyptian mummies, and in ancient skeletons in England. Osteoarthritis patterns of joint involvement, often referred to as primary osteoarthritis, can be seen in the hands, spinal facet joints, hips, knees and feet, but can also be termed secondary osteoarthritis when seen in any joint that has had trauma, sepsis, surgery or metabolic insult. The prevalence of osteoarthritis increases with age. The histology and pathophysiology both demonstrate an inflammatory process. While there have been studies of genetic predisposition, the basic cause of primary osteoarthritis has not been determined.

Improved clinical outcome measures of knee pain and function with concurrent resolution of subchondral Bone Marrow Edema Lesion and joint effusion in an osteoarthritic patient following Pentosan Polysulphate Sodium treatment: a case report

Background

At present, there are no registered products for the treatment of subchondral Bone Marrow Edema Lesion (BML) and associated knee pain. Patients who do not respond to current anti-inflammatory therapies are left with limited treatment options, and may resort to operative management with Total Knee Arthroplasty (TKA). We report the use of Pentosan Polysulphate Sodium (PPS) for the treatment of BMLs of the knee.

Case presentation

We report the case of a 70-year-old female with knee osteoarthritis presenting with a high level of knee pain, scoring 8 on the Numerical Rating Scale (NRS), and functional limitation demonstrating a poor Lysholm Knee Score of 37. MRI scans of the knee revealed subchondral BML in the medial femoral condyle and medial tibial plateau. The patient was administered a course of Pentosan Polysulphate Sodium (PPS) intramuscularly twice weekly, for 3 weeks. MRI scans 2 weeks post-treatment showed complete resolution of the bone marrow edema at the medial femoral condyle and medial tibial plateau with concomitant recovery from pain (NRS pain score of 0), and a 43% improvement of the Lysholm Knee Score. In addition, marked reduction in joint effusion was also demonstrated in the MRI scan post PPS therapy.

Conclusion

The MRI interpretations demonstrate improved clinical outcome measures ensuing therapeutic intervention with PPS, and warranting further investigation into the efficacy of PPS in the treatment of BML associated pain and dysfunction in the osteoarthritic population via randomized controlled trial, or equivalent rigorous methodological technique.

Effects of pentosan polysulfate in osteoarthritis of the knee: A randomized, double-blind, placebo-controlled pilot study

BACKGROUND

Recent recommendations from the Group for the Respect of Excellence and Ethics in Science for the clinical assessment of the effects of disease-modifying osteoarthritis (OA) drugs suggest that improvement in joint space narrowing, pain, and function relative to a control group should be the primary end points.

OBJECTIVE

The aim of this study was to assess the ability of sodium pentosan polysulfate (NaPPS) to improve pain and function in patients with OA of the knee.

METHODS

This randomized, double-blind, placebo-controlled pilot study was performed at the Queen Elizabeth II Medical Centre, Perth, Australia. Patients aged ≥18 years with OA of the knee were randomly assigned to receive NaPPS 3 mg/kg or Ringer's solution (control), IM QW for 4 weeks. Efficacy was assessed at enrollment and weekly during the 4 weeks of treatment and at weeks 8, 12, 16, and 24. Seven direct clinical assessments were made, including intensity of early morning joint stiffness, pain at rest, and pain on walking. A 10-cm visual analog scale (VAS) was used to assess pain at rest and on walking and early morning joint stiffness. Response was defined as a change from baseline in VAS score ≥2 cm. Function was assessed using the 10-cm VAS to rate 13 activities of daily living (ADLs), including stair climbing and domestic chores. Patient global assessment of the overall effectiveness of the study drug comprised a 4-point Likert scale (0 = not effective to 3 = maximally effective). An aggregate score for all ADL functions was calculated as the mean change from baseline score of all of the ADLs as determined at 4, 8, 12, 16, and 24 weeks after commencement of the study. For tolerability monitoring, hematology and biochemistry were used, and patients were questioned about adverse events at each visit.

RESULTS

A total of 114 patients were enrolled (83 women, 31 men; mean [SD] age, 63.3 [1.5] years; NaPPS group, 54 patients; control group, 60 patients). Significant differences in scores of 3 of the 7 direct clinical assessments were found between the 2 groups (duration of joint stiffness at 4, 8, 12, and 16 weeks [all, P:5 0.015]; pain at rest at 8, 12, 16, and 24 weeks [all, P ≤ 0.017]; and patient global assessment at 4, 8, 12, 16, and 24 weeks [all, P <- 0.006]). The rates of trial continuation were higher in the NaPPS group compared with those in the control group at 8, 12, and 24 weeks (all, P < 0.05). Mean scores for 3 of 13 ADLs were significantly higher in the NaPPS group compared with those in the control group at weeks 8 and 12 (all, P ≤ 0.03). On combining all of the ADL scores, functional improvement from baseline was found at weeks 8 and 12 in the NaPPS group (both, P = 0.02). Mild bruising at the injection site occurred in <1% of patients in both treatment groups.

CONCLUSIONS

In this pilot study, 4 weekly injections of NaPPS were associated with significantly improved duration of joint stiffness and pain at rest compared with controls for 20 weeks after the cessation of treatment, and significantly improved pain on walking and overall function for 8 weeks after the cessation of treatment in these patients with OA of the knee.

Proceedings of the "Arthritis, Agriculture, and Rural Life: state of the art research, practices, and applications" conference, West Lafayette, Indiana, May 11-13, 2011

This article presents proceedings of the first national conference to assemble professionals to address the issue of arthritis in agriculture. The "Arthritis, Agriculture, and Rural Life: State of the Art Research, Practices, and Applications" conference, May 11-13, 2011, at the Purdue University Beck Agricultural Center in West Lafayette, Indiana, focused on increasing awareness and education in the prevention, effects, care, and treatment of arthritis specific to farmers. Presentations included a contextualizing keynote and sessions addressing the prevention and treatment of arthritis in agriculture, including topics such as traditional arthritis therapies, alternative treatments, assistive technology, and ergonomic techniques and modifications. Participants discussed particular issues on a field trip to several Purdue University research farms addressing ergonomics. The conference concluded with a farmer panel, where attendees heard personal stories from farmers suffering from the effects of arthritis.

WITHDRAWN: Analgesia and non-aspirin, non-steroidal anti-inflammatory drugs for osteoarthritis of the hip

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) have been widely used as a pharmacologic treatment to relieve pain for patients with OA of the hip. However, these agents are associated with significant toxicity, particularly in the elderly population (age > 65 years).

OBJECTIVES

To review all randomized trials of analgesics and anti-inflammatory therapy in osteoarthritis (OA) of the hip. To determine which non-steroidal, anti-inflammatory drug (NSAID) is the most effective, and which NSAID is the most toxic.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Group's trials register, the Cochrane Controlled Trials Register and MEDLINE up to August 1994. Reference lists of all trials were also manually searched.

SELECTION CRITERIA

All randomized controlled trials comparing non-steroidal anti-inflammatory drugs (NSAIDs) and/or analgesics in patients with Osteoarthritis. The trials selected for inclusion were identified by one reviewer (TT) and rechecked by a second (MH).

DATA COLLECTION AND ANALYSIS

Qualitative assessments were performed using a quality scoring system designed for NSAID trials in rheumatoid arthritis. Both the design and analysis aspects of the trials were evaluated, each aspect being rated on a scale of 0 to 8. A quantitative method, which calculates the ratio of improvement produced by one NSAID to that produced by another, was used to rate the relative efficacy of different NSAIDs with respect to pain relief. Toxicity comparisons were made according to the reviewer findings. All quality assessments were carried out independently by two reviewers (TT, BS). All data abstraction was carried out by one reviewer (TT) and rechecked by two other reviewers (BS, GW). A consensus was reached on discrepancies.

MAIN RESULTS

Forty-three trials were identified, and of these, 39 evaluated NSAIDs, while four evaluated only analgesics. The median design and analysis scores were two and four respectively. Six NSAIDs were included in at least five trials. Of these, indomethacin was rated more effective in five of its seven comparisons, but more toxic in seven of 12 comparisons. Only five of the 29 (17%) NSAID comparisons found statistically significant differences in efficacy. Of the 43 RCTs identified only 17 had statistical data available for future pooling for this meta-analysis. In the case where data was missing, authors of the trials will be contacted for inclusion of data in future reviews.

AUTHORS' CONCLUSIONS

NSAID trials in patients with OA of the hip appear to be weakened by the lack of standardization of case definition of OA, and also by the lack of standardization of outcome assessments. No clear recommendations for the choice of specific NSAID therapy in hip OA can be offered at this time based on this analysis.

Pandemonium over painkillers persists

Chronic non-cancer pain remains under-treated. Five years ago it was highlighted that more research was needed into the safety and efficacy of NSAIDs and opioid drugs in older people (Cowan, 2002). Concerns remain over NSAID-induced pathology and now there are safety concerns over the continued use of supposedly safer COX-2 agents. There also remain concerns over the problematic use of opioids, including the potential for psychological and physical dependence. While more research is still needed to inform prescribing for older people, it is also apparent that we still need long-term studies of commonly used pain medications for the whole spectrum of age groups. Data derived from such studies would inform nurse prescribing.

Nutritional considerations in joint health

Osteoarthritis, a debilitating joint disorder, is the most common form of arthritis in the United States, where it affects an estimated 21 million people. In 2004, the direct and indirect health care costs associated with all forms of arthritis were approximately 86 billion dollars. Joint discomfort from osteoarthritis and other joint disorders may reduce physical activity in individuals experiencing this condition, resulting in energy imbalance and weight gain. Increased weight can exacerbate existing problems, as additional stress on joints stimulates risk of additional joint disorders. Dietitians play a role in preventing or reversing the problem of joint disorders by promoting nutrient-rich diets that support joint health through improvement in cartilage metabolism. In addition, counseling individuals on weight management and active lifestyles are key strategies for the management of joint health.

Chronic non-cancer pain in older people: current evidence for prescribing

Chronic pain is a serious problem for many older people, yet its management in this population is often less than satisfactory. The high incidence of toxicity and side effects with some medications and irrational fears of opioid dependence are significant barriers to effective pain management. In this article, the research evidence relating to these issues is examined, and their impact on nurse prescribing considered. More studies are needed to assess the veracity of opposing arguments, and to support effective assessment and prescribing by nurses.

Iatrogenic cost factors incorporating mild and moderate adverse events in the economic comparison of aceclofenac and other NSAIDs

OBJECTIVE

To perform a modelled economic analysis of the efficacy and tolerability of aceclofenac in comparison with those of other nonsteroidal antiinflammatory drugs (NSAIDs) used in the treatment of common arthritic disorders including osteoarthritis, rheumatoid arthritis and ankylosing spondylitis.

DESIGN

A decision analytical model was constructed to represent the clinical and economic consequences of NSAID treatment. Probabilities of noncompliance, lack of efficacy and incidence of adverse events were obtained from comparative randomised double-blind clinical trials. Local unit treatment costs were used and an expert panel was convened to estimate resource use. Both classical foldback analysis and bootstrap methods were used to compute point estimates and 95% confidence limits of costs for NSAID treatment.

PATIENTS AND INTERVENTIONS

Data were obtained from 12 randomised double-blind clinical trials included in an earlier meta-analysis.

MAIN OUTCOME MEASURES

Total costs to the healthcare provider, including NSAID treatment costs (drug acquisition costs and physician visits for prescription) and iatrogenic costs (substitution treatment costs for patients not achieving clinical efficacy and costs of medical visits, treatment, diagnostic tests and hospital stays associated with adverse events) and the iatrogenic cost factor (ICF) were used as the primary outcome measures.

RESULTS

Means and 95% confidence intervals revealed no statistically significant differences in total costs between aceclofenac and other NSAIDs, with the exception of piroxicam, despite substantial differences in drug acquisition costs. The ICF for aceclofenac was lower than that for all other comparators, and differences in ICF between aceclofenac 200 mg/day and diclofenac 150 mg/day, indomethacin 100 mg/day, naproxen 1000 mg/day, tenoxicam 20 mg/day or ketoprofen 150 mg/day were statistically significant.

CONCLUSION

These results show that the comparative overall costs of NSAIDs bears little relation to drug acquisition cost, and that the ICF is one of the most important determinants of overall costs.

Novel strategies for the treatment of osteoarthritis

Osteoarthritis is a worldwide heterogeneous group of conditions that leads to joint symptoms, which are associated with defective integrity of articular cartilage, in addition to related changes in the underlying bone at the joint margins. The prevalence of the disease after the age of 65 years, is about 60% in men and 70% in women. The aetiology of osteoarthritis is multifactorial, with the end result being mechanical joint failure and varying degrees of loss of joint function. The pathophysiological events associated with osteoarthritis are beginning to be understood. Essential inflammatory cytokines, such as IL-1beta and TNF-alpha, are involved initiating a vicious cycle of catabolic and degradative events in cartilage, mediated by metalloproteinases, which degrade cartilage extracellular matrix. The role of inflammation in the pathophysiology and progression of early osteoarthritis is supported further by the observation that C-reactive protein levels are raised in women with early knee osteoarthritis and higher levels predict those whose disease will progress. The synovium from osteoarthritis joints stains for IL-1beta and TNF-alpha. Nitric oxide, which exerts pro-inflammatory effects, is released during inflammation. Cartilage from patients with rheumatoid arthritis and osteoarthritis spontaneously produces nitric oxide in vitro. In experimental osteoarthritis, nitric oxide induces chondrocyte apoptosis, thus contributing to cartilage degradation. Hence unregulated nitric oxide production in humans plays a part in the pathophysiology of the disease. These recent observations suggest that therapy can now be targeted at specific sites of pathophysiological pathways involved in the pathogenesis of osteoarthritis. The novel strategies under consideration for the treatment of osteoarthritis can be divided into five main areas. These are COX-2 inhibitors, nitric oxide synthesis inhibitors and anti-oxidants, chondrocyte and bone growth promoters, metalloproteinase and cytokine inhibitors and gene therapy.

Knee pain and joint loading in subjects with osteoarthritis of the knee

Although treatments for osteoarthritis of the knee are often directed at relieving pain, pain may cause patients to alter how they perform activities to decrease the loads on the joints. The knee-adduction moment is a major determinant of the load distribution between the medial and lateral plateaus. Therefore, the interrelationship between pain and the external knee-adduction moment during walking may be especially important for understanding mechanical factors related to the progression of medial tibiofemoral osteoarthritis. Fifty-three subjects with symptomatic radiographic evidence of osteoarthritis of the knee were studied. These subjects were a subset of those enrolled in a double-blind study in which gait analysis and radiographic and clinical evaluations were performed after a 2-week washout of anti-inflammatory and analgesic treatment. The subjects then took a nonsteroidal anti-inflammatory drug, acetaminophen, or placebo for 2 weeks, and the gait and clinical evaluations were repeated. The change in the peak external adduction moment between the two evaluations was inversely correlated with the change in pain (R = 0.48, p < 0.001) and was significantly different between those whose pain increased (n = 7), decreased (n = 18), or remained unchanged (n = 28) (p = 0.009). Those with increased pain had a significant decrease in the peak external adduction (p = 0.005) and flexion moments (p = 0.023). In contrast, the subjects with decreased pain tended to have an increase in the peak external adduction moment (p = 0.095) and had a significant increase in the peak external extension moment (p = 0.017). The subjects whose pain was unchanged had no significant change in the peak external adduction (p = 0.757), flexion (p = 0.234), or extension (p = 0.465) moments. Thus, decreases in pain among patients with medial tibiofemoral osteoarthritis were related to increased loading of the degenerative portion of the joints. Additional long-term prospective studies are needed to determine whether increased loading during walking actually results in accelerated progression of the disease.

Analgesia and non-aspirin, non-steroidal anti-inflammatory drugs for osteoarthritis of the hip

OBJECTIVES

To review all randomized trials of analgesics and anti-inflammatory therapy in osteoarthritis (OA) of the hip. To determine which non-steroidal, anti-inflammatory drug (NSAID) is the most effective, and which NSAID is the most toxic.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Group's trials register, the Cochrane Controlled Trials Register and Medline up to August 1994. Reference lists of all trials were also manually searched.

SELECTION CRITERIA

All randomized controlled trials comparing non-steroidal anti-inflammatory drugs (NSAIDs) and/or analgesics in patients with Osteoarthritis. The trials selected for inclusion were identified by one reviewer (TT) and rechecked by a second (MH).

DATA COLLECTION AND ANALYSIS

Qualitative assessments were performed using a quality scoring system designed for NSAID trials in rheumatoid arthritis. Both the design and analysis aspects of the trials were evaluated, each aspect being rated on a scale of 0 to 8. A quantitative method, which calculates the ratio of improvement produced by one NSAID to that produced by another, was used to rate the relative efficacy of different NSAIDs with respect to pain relief. Toxicity comparisons were made according to the reviewer findings. All quality assessments were carried out independently by two reviewers (TT, BS). All data abstraction was carried out by one reviewer (TT) and rechecked by two other reviewers (BS, GW). A consensus was reached on discrepancies.

MAIN RESULTS

Forty-three trials were identified, and of these, 39 evaluated NSAIDs, while four evaluated only analgesics. The median design and analysis scores were two and four respectively. Six NSAIDs were included in at least five trials. Of these, indomethacin was rated more effective in five of its seven comparisons, but more toxic in seven of 12 comparisons. Only five of the 29 (17%) NSAID comparisons found statistically significant differences in efficacy. Of the 43 RCTs identified only 17 had statistical data available for future pooling for this meta-analysis. In the case where data was missing, authors of the trials will be contacted for inclusion of data in future reviews.

REVIEWER'S CONCLUSIONS

NSAID trials in patients with OA of the hip appear to be weakened by the lack of standardization of case definition of OA, and also by the lack of standardization of outcome assessments. No clear recommendations for the choice of specific NSAID therapy in hip OA can be offered at this time based on this analysis.

The pathobiology of osteoarthritis and the rationale for the use of pentosan polysulfate for its treatment

OBJECTIVES

Structure-modifying osteoarthritis (OA) drugs (SMOADs) may be defined as agents that reverse, retard, or stabilize the underlying pathology of OA, thereby providing symptomatic relief in the long-term. The objective of this review was to evaluate the literature on sodium pentosan polysulfate (NaPPS) and calcium pentosan polysulfate (CaPPS), with respect to the pathobiology of OA to ascertain whether these agents should be classified as SMOADs.

METHODS

Published studies on NaPPS and CaPPS were selected on the basis of their relevance to the known pathobiology of OA, which also was reviewed.

RESULTS

Both NaPPS and CaPPS exhibit a wide range of pharmacological activities. Of significance was the ability of these agents to support chondrocyte anabolic activities and attenuate catabolic events responsible for loss of components of the cartilage extracellular matrix in OA joints. Although some of the anti-catabolic activities may be mediated through direct enzyme inhibition, NaPPS and CaPPS also have been shown to enter chondrocytes and bind to promoter proteins and alter gene expression of matrix metalloproteinases and possibly other mediators. In rat models of arthritis, NaPPS and CaPPS reduced joint swelling and inflammatory mediator levels in pouch fluids. Moreover, synoviocyte biosynthesis of high-molecular-weight hyaluronan, which is diminished in OA, was normalized when these cells were incubated with NaPPS and CaPPS or after intraarticular injection of NaPPS into arthritic joints. In rabbit, canine, and ovine models of OA, NaPPS and CaPPS preserved cartilage integrity, proteoglycan synthesis, and reduced matrix metalloproteinase activity. NaPPS and CaPPS stimulated the release of tissue plasminogen activator (t-PA), superoxide dismutase, and lipases from vascular endothelium while concomitantly decreasing plasma levels of the endogenous plasminogen activator inhibitor PAI-1. The net thrombolytic and lipolytic effects exhibited by NaPPS and CaPPS may serve to improve blood flow through subchondral capillaries of OA joints and improve bone cell nutrition. In geriatric OA dogs, NaPPS and CaPPS reduced symptoms, as well as normalized their thrombolytic status, threshold for platelet activation, and plasma triglyceride levels. These hematologic parameters were shown to be abnormal in OA animals before drug treatment. Similar outcomes were observed in OA patients when CaPPS or NaPPS were given orally or parenterally in both open and double-blind trials.

CONCLUSIONS

The data presented in this review support the contention that NaPPS and CaPPS should be classified as SMOADs. However, additional long-term clinical studies employing methods of assessing joint structural changes will be needed to confirm this view.

Patient-related risk factors for early revision of total hip replacements. A population register-based case-control study of 674 revised hips

In this population register-based, matched case-control study, we assessed patient-related factors and early risk of revision after total hip replacement (THR). Information was obtained via a mall survey among patients reported to the Norwegian Arthroplasty Register during the period 1987-1993. The study included 674 revised hips, as cases, and 1,343 hips with a primary operation only, as controls. Completed questionnaires were received from 81% of the 2,017 individual cases and controls. We identified a set of patient-related factors associated with poor THR prognosis. Increasing weight was a risk factor among male patients older than 67 years who were more than 1.77 m tall (p = 0.01). Smoking had no overall effect, but former heavy smokers had an increased risk of 2.8 compared to never-smokers. Alcohol intake was associated with an increased risk of dislocation. Revision due to infection was commoner among patients taking anti-diabetic drugs (OR = 14) than among patients taking no medication. An increased overall revision risk was found among patients using systemic steroids (OR = 2.8) or local pulmonary steroids (OR = 6.0). The risk also increased in male patients performing regular exercise before the primary operation (OR = 2.6), and in female patients of working-age doing heavy work (OR = 1.9).

Chronic pain: osteoarthritis and cancer

Osteoarthritis and cancer pain are two types of chronic pain commonly seen in small animal practice. The management of osteoarthritic pain consists of both pharmacologic therapy and nonpharmacologic strategies, including exercise control, dietary management and surgical therapy. Nonsteroidal antiinflammatory drugs are commonly used, although there is still controversy about their effect on the underlying pathologic processes of osteoarthritis. Despite a lack of well-designed clinical trials, chondroprotective drugs and neutraceuticals have gained popularity. Cancer pain can result from direct tumor invasion, paraneoplastic syndromes or diagnostic and therapeutic procedures, including surgery, chemotherapy and radiation. Treatment of cancer pain consists of definitive or palliative therapy and management of therapy induced pain. Analgesic therapy should be based on the World Health Organization's three step analgesic ladder for the administration of analgesia to cancer patients.

Guidelines for the medical management of osteoarthritis. Part I. Osteoarthritis of the hip. American College of Rheumatology

Treatment of patients with OA of the hip should be individualized and tailored to the severity of the disease. In individuals with mildly symptomatic disease, treatment may be limited to patient education, physical and occupational therapy, other nonpharmacologic modalities, and drug therapy with a non-opioid oral analgesic. In patients who are unresponsive to this treatment regimen, the use of an NSAID in addition to nonpharmacologic therapy is appropriate unless it is medically contraindicated. Patients with severe symptomatic OA of the hip require an aggressive approach to decreasing pain, increasing mobility, and improving function; such patients may benefit from orthopedic consultation and evaluation for osteotomy or total joint arthroplasty.