A naturalistic study of the determinants of health related quality of life improvement in osteoarthritic patients treated with non-specific non-steroidal anti-inflammatory drugs

Low-dose SoluMatrix diclofenac in patients with osteoarthritis pain: impact on quality of life in a controlled trial

Low-dose SoluMatrix diclofenac was developed to provide effective pain relief for osteoarthritis pain. We evaluated the effects of SoluMatrix diclofenac on health-related quality of life (HRQoL) measures in patients with osteoarthritis, hypothesizing that SoluMatrix-treated patients would experience significant improvement compared with placebo. In this 12-week, phase 3 randomized controlled trial, 305 patients with osteoarthritis of the hip or knee received SoluMatrix diclofenac 35 mg three times (TID) or twice (BID) daily or placebo. Measures included HRQoL, assessed by Short Form 36 (SF-36, version 2), and pain, stiffness, and physical function, assessed by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at baseline and at week 12. Descriptive statistics were calculated for mean changes from baseline; inferential statistics compared treatment groups with placebo. SoluMatrix diclofenac 35 mg BID (6.2 [0.75]; P = 0.0048) or TID (6.6 [0.80]; P = 0.0014) produced large improvements in the SF-36 physical component summary (PCS) scores at week 12 (least squares mean change from baseline [SE]) compared with placebo (3.5 [0.78]). Minimum clinically important differences were observed in six out of eight SF-36 domains among patients in SoluMatrix diclofenac groups and five out of eight domains in the placebo group; treatment with SoluMatrix diclofenac 35 mg TID produced significant improvements (P ≤ 0.03) in five out of eight domains versus placebo. SoluMatrix diclofenac 35 mg TID significantly improved responses to 23 out of 24 questions in the WOMAC versus placebo (P ≤ 0.0334). Low-dose SoluMatrix diclofenac 35 mg TID and BID significantly improved HRQoL, pain, stiffness, and physical function in patients with osteoarthritis of the hip or knee.

Safe prescription recommendations for non steroidal anti-inflammatory drugs: consensus document ellaborated by nominated experts of three scientific associations (SER-SEC-AEG)

This article outlines key recommendations for the appropriate prescription of non steroidal anti-inflammatory drugs to patients with different musculoskeletal problems. These recommendations are based on current scientific evidence, and takes into consideration gastrointestinal and cardiovascular safety issues. The recommendations have been agreed on by experts from three scientific societies (Spanish Society of Rheumatology [SER], Spanish Association of Gastroenterology [AEG] and Spanish Society of Cardiology [SEC]), following a two-round Delphi methodology. Areas that have been taken into account encompass: efficiency, cardiovascular risk, gastrointestinal risk, liver risk, renal risk, inflammatory bowel disease, anemia, post-operative pain, and prevention strategies. We propose a patient management algorithm that summarizes the main aspects of the recommendations.

ICRS Recommendation Document: Patient-Reported Outcome Instruments for Use in Patients with Articular Cartilage Defects

OBJECTIVE

The purpose of this article is to describe and recommend patient-reported outcome instruments for use in patients with articular cartilage lesions undergoing cartilage repair interventions.

METHODS

Nonsystematic literature search identifying measures addressing pain and function evaluated for validity and psychometric properties in patients with articular cartilage lesions.

RESULTS

The knee-specific instruments, titled the International Knee Documentation Committee Subjective Knee Form and the Knee injury and Osteoarthritis and Outcome Score, both fulfill the basic requirements for reliability, validity, and responsiveness in cartilage repair patients. A major difference between them is that the former results in a single score and the latter results in 5 subscores. A single score is preferred for simplicity's sake, whereas subscores allow for evaluation of separate constructs at all levels according to the International Classification of Functioning.

CONCLUSIONS

Because there is no obvious superiority of either instrument at this time, both outcome measures are recommended for use in cartilage repair. Rescaling of the Lysholm Scoring Scale has been suggested, and confirmatory longitudinal studies are needed prior to recommending this scale for use in cartilage repair. Inclusion of a generic measure is feasible in cartilage repair studies and allows analysis of health-related quality of life and health economic outcomes. The Marx or Tegner Activity Rating Scales are feasible and have been evaluated in patients with knee injuries. However, activity measures require age and sex adjustment, and data are lacking in people with cartilage repair.

Treatment of chronic non-malignant pain in the elderly: safety considerations

Non-malignant pain in the elderly is frequently under-treated, with physicians appearing to be uncertain concerning how best to achieve optimum management of this common problem in individual cases. The aim of this review is to provide a brief overview and discuss the variety of interacting factors that contribute to the continuing under-treatment of chronic non-malignant pain in the older population. The central objective is to encourage safer and more effective pain management in a population that is highly vulnerable to painful conditions and to the consequences of poorly treated pain. Under-treatment of pain as experienced by the elderly is largely a consequence of uncertainties that arise within a complex environment that is underscored and exacerbated by the progressive and rapid aging of the global population. Uncertainties include the optimum management of pain in geriatric syndromes, frailty and dementia, and their impact on diagnosis, pain assessment and choices of treatment modalities. There is an inadequate evidence base for pharmacological interventions in older persons with respect to pharmacokinetic and pharmacodynamic changes that occur with aging. In this review, the prevalence of chronic pain and the incidence of adverse drug reactions are identified as factors that encourage conservatism in prescribing, as are major predictors of adverse drug reactions, i.e. aging, inappropriate combinations of medications and polypharmacy. The major classes of analgesic drugs are summarized with reference to their mechanisms of action, analgesic properties and known adverse effects. Although all medications have associated risks, the use of analgesics in managing persistent pain in elderly people is widely supported and guided on the basis of clinical experience and consensus among specialists in geriatrics and pain management. It is concluded that the absence of trial data, specific to the elderly, is substantially offset by information based on clinical experience and expert consensus statements. Used appropriately, analgesic and adjuvant treatments can and should be employed to relieve persistent pain in the expanding elderly population.

Burden of premenstrual dysphoric disorder on health-related quality of life

OBJECTIVE

The purpose of this study was to document the burden of premenstrual dysphoric disorder (PMDD) on health-related quality of life (HRQoL) in comparison to the U.S. general population and specific chronic health conditions.

METHODS

The disease burden that PMDD placed on HRQoL was estimated by comparing SF-12v2 scores between women who were identified as being at risk for PMDD with those observed in the general U.S. female population. Additional comparisons were made to several chronic health conditions. Regression methods were used to estimate SF-12v2 normative values from the general population sample and statistically adjust them to match age and the presence of disease comorbidity of the PMDD patient group. Significance tests were used to compare the means across samples.

RESULTS

After adjusting for multiple comparisons, six SF-12v2 scales and two summary measures of PMDD were significantly below the adjusted U.S. general population norms. Both summary measures of PMDD had mean differences greater than 3 points below the norm (threshold for clinical meaningful difference). The burden of PMDD was greater on mental/emotional HRQoL domains than on physical HRQoL. The HRQoL burden of PMDD was (1) greater than that of chronic back pain in bodily pain and mental health (MH) scales and greater than type 2 diabetes and hypertension in bodily pain scale while comparable in all other scales of the three conditions, (2) comparable to osteoarthritis and rheumatoid arthritis in all scales, and (3) less burden than depression in vitality and MH scales and mental component summary measure while comparable in other scales.

CONCLUSIONS

PMDD is associated with substantial burden on both physical and mental aspects of HRQoL.

Health-related quality of life in patients with osteoarthritis after total knee replacement: factors influencing outcomes at 36 months of follow-up

OBJECTIVES

(1) To evaluate health-related quality of life (HRQL) in patients with severe osteoarthritis (OA) undergoing total knee replacement (TKR) and (2) to identify the influence of sociodemographic, clinical, intra-operative and postoperative variables on HRQL at 36 months after TKR.

DESIGN

Prospective study with a 36-month follow-up. Preoperative interviews were carried out with 90 in-patients. The disease-specific Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire was used to measure the health status. Sociodemographic, clinical, intra-operative degree of difficulty, in-patient and postoperative data were collected. Associations were analyzed using linear regression models.

RESULTS

Of the 90 potentially eligible patients, 67 (54 females, mean age 74.83, standard deviation [SD] 5.57) completed follow-up assessment. There were significant differences between preoperative and postoperative WOMAC pain, stiffness and function scores (P<0.001, P=0.005 and P<0.001, respectively). Variables retained in each of the models explained between 15% and 23% (R(2) adjusted) of the variability of each WOMAC dimension. Higher preoperative WOMAC scores were associated with greater postoperative improvement (P<0.001). Chronic musculoskeletal pain unrelated to knee OA was associated with higher WOMAC pain, stiffness and function dimension scores (P=0.004, P=0.029 and P=0.005, respectively). Severe (Class III) obesity (body mass index [BMI] 35-39.9) was associated with more pain (P=0.049).

CONCLUSIONS

In patients with severe OA, HRQL significantly improved at 36 months after TKR, especially in the pain dimension. Lower preoperative WOMAC scores, chronic pain unrelated to knee OA, and severe obesity negatively influenced postoperative WOMAC scores. This disease-specific questionnaire may help to identify patients at increased risk of negative outcomes after surgery.

Flurbiprofen in the symptomatic management of rheumatoid arthritis: a valuable alternative

BACKGROUND

The withdrawal of certain cyclooxygenase-2 selective drugs and the availability of over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) have increased the pressure for researching and prescribing conventional NSAIDs with a favourable efficacy/tolerance ratio in inflammatory diseases, particularly rheumatoid arthritis. The aim of this comprehensive meta-analysis was to evaluate the absolute and relative efficacy and safety of flurbiprofen in the management of rheumatoid arthritis.

METHODS

A systematic and exhaustive bibliographic research of published literature has been performed. The inclusion criteria are summarised as follows: randomised trial and rheumatoid arthritis and flurbiprofen and oral administration and anti-inflammatory doses from 100 to 300 mg and (placebo or aspirin or indomethacin or naproxen or ibuprofen or ketoprofen) and (articular pain or stiffness or swelling or mobility or patient/physician reported efficacy or tolerance or gastrointestinal (GI) tolerance). Studies were conducted from January 1975 to January 2006. Analyses have been stratified by comparisons and outcomes. Publication bias and robustness have been extensively investigated.

RESULTS

Fourteen studies, accounting for 1103 patient-years, have been included in the quantitative review. The mean daily doses administrated were 200 mg flurbiprofen, 4000 mg aspirin, 150 indomethacin, 750 mg naproxen and 1800 mg ibuprofen. Flurbiprofen was superior to placebo for all outcomes, and superior to three of four other NSAIDs in terms of formal symptomatic measures (pain, stiffness and swelling). Several patients or physicians reported the efficacy of flurbiprofen as superior to indomethacin and naproxen, while its safety, and particularly its GI tolerance were better compared with aspirin and indomethacin. Sensitivity analyses have reported a sufficient robustness against systematic publication bias assumptions.

CONCLUSION

This meta-analysis has shown that flurbiprofen is an interesting alternative to commonly prescribed NSAIDs in the symptomatic management of rheumatoid arthritis, especially given its favourable efficacy/tolerance ratio.

Health-related quality of life and costs in patients with osteoarthritis on waiting list for total knee replacement

OBJECTIVES

To determine: (1) health-related quality of life (HRQL) in patients with severe osteoarthritis (OA) on a waiting list (WL) for total knee replacement (TKR) and to compare it with general Spanish reference population values (RPVs); (2) the influence of sociodemographic and clinical variables on HRQL dimensions and (3) the use and cost of resources related to knee OA.

METHODS

Cross-sectional study. HRQL was measured by Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Medical Outcomes Study 36 Item Short Form Health Survey (SF-36) questionnaires. Sociodemographic and disease characteristics, body mass index, pharmacological treatment and the cost and use of economic resources related to knee OA during the 6-months previous to baseline were recorded. Relationships were analyzed using linear regression models.

RESULTS

One hundred consecutive outpatients (71 female, mean age 71+/-6.89 years, mean disease duration 11.84+/-10.52 years) were included. Patients showed worse HRQL measured by SF-36 than the reference population, mainly in physical function, physical role and bodily pain dimensions (P<0.05). A low number of visits to physicians were recorded (mean 0.62+/-1.04). Total mean direct medical costs were 200.24 euro (95%CI 167.08-233.40) and total mean direct non-medical costs were 1234.87 euro (95%CI 812.74-1657.00).

CONCLUSIONS

The HRQL of patients on a WL is worse than that of the reference population. The main costs of these patients were on non-medical resources, mainly due to functional limitations and loss of autonomy. The results suggest little compliance with knee OA management guidelines.