The evaluation of antirheumatic drugs

Sensitivity of effect variables in rheumatoid arthritis: a meta-analysis of 130 placebo controlled NSAID trials

In a meta-analysis of placebo controlled NSAID trials, the sensitivity of the effect variables was calculated as the correlation coefficient and as the difference between drug and placebo, divided by the placebo group standard deviation. The patient's global evaluation was the most sensitive variable overall. Pain was more sensitive than Ritchie's index. Several variables may be omitted from clinical trials, especially if two active drugs are being compared. For example, the best maximum estimate for the difference in ESR between NSAIDs and placebo was 1.0 mm/hr (95% confidence interval -1.5 to 3.4 mm/hr), and for joint size 0.44% (-1.0 to 1.9%), corresponding to a quarter of a millimeter for each of the 10 joints usually measured. It is suggested to record only the patient's global evaluation, pain, and morning stiffness.

Methodology and overt and hidden bias in reports of 196 double-blind trials of nonsteroidal antiinflammatory drugs in rheumatoid arthritis

Important design aspects were decreasingly reported in NSAID trials over the years, whereas the quality of statistical analysis improved. In half of the trials, the effect variables in the methods and results sections were not the same, and the interpretation of the erythrocyte sedimentation rate in the reports seemed to depend on whether a significant difference was found. Statistically significant results appeared in 93 reports (47%). In 73 trials they favored only the new drug, and in 8 only the active control. All 39 trials with a significant difference in side effects favored the new drug. Choice of dose, multiple comparisons, wrong calculation, subgroup and within-groups analyses, wrong sampling units (in 63% of trials for effect variables, in 23% for side effects), change in measurement scale before analysis, baseline difference, and selective reporting of significant results were some of the verified or possible causes for the large proportion of results that favored the new drug. Doubtful or invalid statements were found in 76% of the conclusions or abstracts. Bias consistently favored the new drug in 81 trials, and the control in only one trial. It is not obvious how a reliable meta-analysis could be done in these trials.

Long-term experience with piroxicam in osteoarthritis

The long-term efficacy and safety of piroxicam 20 mg once daily in the treatment of osteoarthritis was evaluated in 30 patients--eight for three to five years, seven for six years, and 15 for more than seven years--for a total mean duration of six years. More than 93 percent (28/30) reported feeling well at the last visit, while 12 said they were either asymptomatic or had only mild symptoms. Total joint pain scores, total joint swelling and specific functional activity levels improved and remained improved throughout the study period. Side effects were relatively frequent but mostly in the mild to moderate class (159/166) and these were mostly gastrointestinal. Patients preferred remaining on the drug for a mean of six years rather than changing to alternative therapies made available to them.

Clinical assessment of disease activity in rheumatoid arthritis

A new experimental design was developed to study the value of clinical parameters of disease activity in patients with rheumatoid arthritis. Ten patients with classical rheumatoid arthritis were examined by five senior doctors in a department of medical rheumatology. In spite of an attempt to make the clinical examination as uniform as possible the inter-observer variation among the doctors was greater than the variation among the patients, for the following parameters: joint pain at rest, joint tenderness and joint swelling. An acceptable inter-observer variation in relation to patient variation was found for 1) a combined registration of joint pain at rest or on movement, 2) duration of morning stiffness, 3) grip strength, 4) subjective well-being as indicated on a visual analogue scale, 5) fingertip--palm distance, and 6) maximum flexion-extension in elbows, wrists and knees. The variation from morning to afternoon and from day to day was negligible. It is concluded that registration of elaborated articular scores is useless in the daily routine in rheumatological departments when different doctors examine the patients.

Continued use of non-steroidal anti-inflammatory drugs: an index of clinical efficacy

1 A double-blind entry to a trial of an active non-steroidal anti-inflammatory drug, flurbiprofen against placebo was undertaken until 100 patients with classical rheumatoid arthritis had been allocated to each treatment. 2 Each patient was given a long-term supply of drug and was asked to vary their own dosage within simple limits, according to the severity of their symptoms. They were instructed to return immediately they felt dissatisfied with their medication either on account of side-effect or of lack of effect. 3 The length of time that patients remained satisfied with their drug was used as the sole measure of efficacy of the drug. At 2 weeks there were only 30% remaining on placebo and by 4 months no patients remained satisfied with the inactive drug. Forty-three per cent were satisfied with flurbiprofen at the end of 1 year. 4 Clearly compliance with anti-rheumatic drugs is better if the drugs are effective and there is no long-term placebo response in rheumatoid arthritis.

Mefenamic acid: an under-rated antirheumatic?

A double-blind crossover study was carried out in 18 patients with classical rheumatoid arthritis to assess the effectiveness of mefenamic acid (500 mg t.d.s.) compared with placebo or indomethacin (25 mg q.d.s.). Each treatment was given for 1 week and subjective and objective assessments were carried out at the end of each period. Results showed that both mefenamic acid and indomethacin were significantly better than placebo in most parameters. Although duration of morning stiffness and patient preference favoured indomethacin it was considered that there was no demonstrable difference of any clinical significance between the two active medications.

Serum immunoreactive gastrin: specificity for rheumatoid arthritis, bimodality of distribution, and failure of effect of anti-inflammatory drugs

A significant rise in immunoreactive gastrin in a proportion of patients with rheumatoid arthritis is confirmed. Such a rise does not seem to occur in other inflammatory or tissue destructive diseases. The patients with raised immunoreactive gastrin appear to form a separate population but the factors determining this separation remain obscure. Anti-inflammatory drugs, at least during short-term administration have no influence on immunoreactive gastrin concentrations.

Clinical assessment of azapropazone in rheumatoid arthritis

Azapropazone was investigated in a 2-week double-blind clinical out-patient trial against placebo in 23 patients with definite rheumatoid arthritis. The drug was given at a dose of 1200 mg. per day before food. At this dose level the drug was shown to have an antirheumatic effect in terms of pain relief, articular tenderness and duration of morning stiffness.