Identification of pain categories associated with change in pain in patients receiving placebo: data from two phase 3 randomized clinical trials in symptomatic knee osteoarthritis

Pathological tissue formation and degradation biomarkers correlate with patient reported pain outcomes: an explorative study

Background

The lack of disease modifying drugs in Osteoarthritis (OA) may be attributed to the difficulty in robust response based on patient-reported outcomes (PROs) linked to drug mechanism of action. Joint tissue turnover biomarkers are associated with disease progression. A subset of patients has elevated serum levels of CRP metabolite (CRPM). This explorative study investigates the associations between PROs and joint tissue turnover markers in patients with high or low CRPM.

Methods

Serum of 146 knee OA patients of the New York Inflammation cohort and 21 healthy donors were assessed for biomarkers of collagen degradation (C1M, C2M, C3M, C4M), formation (PRO-C1, PRO-C2, PRO-C3, PRO-C4), and CRPM. Mean (SD) age was 62.5 (10.1); BMI, 26.6 (3.6); 62% women; and, 67.6% had symptomatic OA. WOMAC pain, stiffness, function, and total were recorded at baseline and at two-year follow-up. Associations were adjusted for race, sex, age, BMI, and NSAID.

Results

There was no difference in markers between donors and patients. C2M correlated with the WOMAC scores in all CRPM groups. Significant correlations were observed between PROs and PRO-C4, C1M, and C3M in the CRPMhigh group. The best predictive models for improvement were found for function and total with AUCs of 0.74 (p ​< ​0.01) and 0.78 (p ​< ​0.01). The best predictive models for worsening were found for function and total with AUCs of 0.84 (p ​< ​0.01) and 0.80 (p ​< ​0.05).

Conclusion

We hypothesize that collagen markers are prognostic tools for segregating patient populations in clinical trials.

Associations between single-question Visual Analogue Scale pain score and weight-bearing and non–weight-bearing domains of Western Ontario and McMaster Universities Arthritis Index pain: data from 2 phase 3 clinical trials

A cross-sectional study demonstrating a moderate Visual Analogue Scale/WOMAC pain scale agreement with scale discordance driven by non–weight-bearing properties of Western Ontario and McMaster Universities Arthritis Index pain and increasing with the Kellgren–Lawrence grade.

Introduction:

Visual Analogue Scale (VAS) and the pain subscale of the Western Ontario and McMaster Universities Arthritis Index (WOMAC) are commonly used measuring tools of osteoarthritis (OA) pain.

Objectives:

The objective of this cross-sectional study was to explore the associations between single-question VAS pain and the weight-bearing and non–weight-bearing domains of WOMAC pain.

Methods:

Data from 2093 patients with OA participating in 2 phase 3 clinical trials were included for post hoc analyses. Univariate Pearson correlations and comparison of r values were made using z statistics obtained using the Fisher r to z test for all items of the VAS pain scale, the WOMAC pain subscale, the weight-bearing and non–weight-bearing constructs of WOMAC pain subscale, and by subgroups of WOMAC pain quintiles and Kellgren–Lawrence grades.

Results:

The correlations between VAS pain and WOMAC pain were significant (r = 0.67, P < 0.001) with a slope of 0.57 (95% confidence interval [CI]: 0.54–0.61). A similar correlation was found for weight-bearing pain (r = 0.68, P < 0.001, slope: 0.62 (95% CI: 0.59–0.65) but significantly lower for non–weight-bearing pain (r = 0.55, P < 0.001, slope: 0.49 (95% CI: 0.46–0.52). The degree of disagreement between the 2 instruments seemed to be lesser in the extreme ends of the scales, and the observed association between Kellgren–Lawrence grade and disagreement between VAS and WOMAC was driven by non–weight-bearing pain.

Conclusion:

In conclusion, VAS pain and WOMAC pain subscale correlation was found to be moderate and the VAS pain scale correlated more accurately with the WOMAC pain weight-bearing questions. This constitutes novel insight into patient with OA pain reporting.

Effects of physical exercise and body weight on disease-specific outcomes of people with rheumatic and musculoskeletal diseases (RMDs): systematic reviews and meta-analyses informing the 2021 EULAR recommendations for lifestyle improvements in people with RMDs

BACKGROUND

A European League Against Rheumatism (EULAR) taskforce was convened to develop recommendations for lifestyle behaviours in rheumatic and musculoskeletal diseases (RMDs). This paper reviews the literature on the effects of physical exercise and body weight on disease-specific outcomes of people with RMDs.

METHODS

Three systematic reviews were conducted to summarise evidence related to exercise and weight in seven RMDs: osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, axial spondyloarthritis (axSpA), psoriatic arthritis, systemic sclerosis and gout. Systematic reviews and original studies were included if they assessed exercise or weight in one of the above RMDs, and reported results regarding disease-specific outcomes (eg, pain, function, joint damage). Systematic reviews were only included if published between 2013-2018. Search strategies were implemented in the Medline, Embase, Cochrane Library of systematic reviews and CENTRAL databases.

RESULTS

236 articles on exercise and 181 articles on weight were included. Exercise interventions resulted in improvements in outcomes such as pain and function across all the RMDs, although the size of the effect varied by RMD and intervention. Disease activity was not influenced by exercise, other than in axSpA. Increased body weight was associated with worse outcomes for the majority of RMDs and outcomes assessed. In general, study quality was moderate for the literature on exercise and body weight in RMDs, although there was large heterogeneity between studies.

CONCLUSION

The current literature supports recommending exercise and the maintenance of a healthy body weight for people with RMDs.

The Effectiveness of Single Injection of Platelet-Rich Plasma for Knee Osteoarthritis Combined with Meniscus Injury: A Randomized Trial

Objectives : To explore the effectiveness of single injection of platelet-rich plasma with rehabilitation therapy for knee osteoarthritis combined with meniscus injury. Methods : Forty patients who met the inclusion criteria were randomly assigned to a rehabilitation group (REH group, 20 cases) receiving rehabilitation training, and a platelet-rich plasma group (PRP group, 20 cases) receiving an ultrasound-guided single injection of PRP in combination with rehabilitation training. Rehabilitation training in the two groups lasted for 2 weeks, and the patients were evaluated using the short-form McGill pain questionnaire (SF-MPQ), Western Ontario McMaster Universities index (WOMAC score), and infrared thermography (knee-joint mean temperature) before treatment, at 1 week, 1 month and 6 months after treatment. Results : Two patients were lost to follow-up in both the PRP group and the REH group. Significant reductions in pain scores, WOMAC scores and knee temperature were observed at 1 week and 1 month after treatment in both groups (p < 0.05). Significant lower SF-MPQ scores were observed in the PRP group than in the REH group at 6 months followup (p < 0.01). Similarly, the mean knee temperature was significantly lower in the PRP group than in the REH group at 6 months follow-up (p < 0.01). No severe complications occurred in either group. Conclusions: Compared to rehabilitation therapy alone, single injection of platelet-rich plasma in combination with rehabilitation therapy has beneficial effect on pain, knee function and mean knee temperature in patients with KOA combined with meniscus injury. Single injection of platelet-rich plasma combined with rehabilitation therapy has a good short-term effectiveness.

Safety and efficacy of a single intra-articular injection of a novel enhanced protein solution (JTA-004) compared to hylan G-F 20 in symptomatic knee osteoarthritis: a randomized, double-blind, controlled phase II/III study

Background

New minimally invasive treatments are vital to delay joint replacement surgery in patients with knee osteoarthritis. This study was designed to select the most effective among three formulations of an enhanced protein solution containing clonidine, hyaluronic acid, and human plasma (JTA-004), and compare the safety and efficacy of intra-articular administration of the selected formulation with a reference treatment (hyaluronic acid) in symptomatic knee osteoarthritis patients.

Methods

In this two-stage, double-blind, phase II/III study conducted in 12 Belgian centers, 50–79-year-old patients with primary knee osteoarthritis were randomized (1:1:1:1) to receive one dose of one of three JTA-004 formulations (differing in clonidine concentration [50 or 100 μg/ml] and volume [2 or 4 ml]) or the reference treatment (hylan G-F 20). Patients were evaluated using Western Ontario McMaster Universities (WOMAC®) Scores and the Short-Form health survey up to 6 months post-injection (Month 6). Drug consumption and safety were evaluated.

Results

Among 164 treated patients, 147 completed the study. The JTA-004 formulation containing 200 μg clonidine and 20 mg hyaluronic acid in 2 ml (JTA-200/2) was selected based on interim results at Month 6. The difference in adjusted mean change in WOMAC Pain Subscale Score from baseline (JTA-200/2 minus reference group) at Month 6 was − 9.49 mm; statistical superiority of JTA-200/2 over the reference was not demonstrated. No statistically significant differences in adjusted mean changes from baseline between JTA-200/2 and reference groups were observed for Pain, Physical Function and Stiffness Subscales WOMAC Scores, Total WOMAC Score, and Well-being Score at any timepoint, although JTA-200/2 induced larger improvements in WOMAC Scores than the reference. Statistically significantly larger improvements in WOMAC Pain Subscale Scores for JTA-004 versus the reference were observed in post-hoc analyses on pooled data from all JTA-004 formulations at Month 6 (p = 0.030) and Month 3 (p = 0.014). All JTA-004 formulations had clinically acceptable safety profiles.

Conclusions

This study provided preliminary evidence of the safety of intra-articular injection of JTA-004 in knee osteoarthritis patients. Phase III randomized controlled trials with larger sample sizes are needed to evaluate the efficacy of JTA-004 in knee osteoarthritis.

Trial registration

Clinicaltrials.gov/identifier NCT02740231;  clinicaltrialsregister.eu/identifier 2015–002117-30. Retrospectively registered 13/4/2016.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04750-3.

Co-existing patterns of MRI lesions were differentially associated with knee pain at rest and on joint loading: a within-person knee-matched case-controls study

BACKGROUND

To assess the association of co-existing MRI lesions with knee pain at rest or on joint loading.

METHODS

We included participants from Osteoarthritis Initiative whose pain score, measured by WOMAC sub-scales, differed by ≥1 point at rest (in bed at night, sitting/lying down) or on joint loading (walking, stairs) between two knees. Cartilage morphology, bone marrow lesions, meniscus extrusion, meniscus morphology, Hoffa's synovitis and synovitis-effusion were assessed using the compartment-specific MRI Osteoarthritis Knee Score. We performed latent class analyses to identify subgroups of co-existing MRI lesions and fitted a conditional logistic regression model to examine their associations with knee pain.

RESULTS

Among 130 eligible participants, we identified five subgroups of knees according to patterns of co-existing MRI lesions: I. minimal lesions; II. mild lesions; III. moderate morphological lesions; IV. moderate multiple reactive lesions; and V. severe lesions. Compared with subgroup I, the odds ratios (ORs) and 95% confidence intervals (CI) of greater pain in bed at night were 1.6 (0.3, 7.2), 2.2 (0.5, 9.5), 6.2 (1.3, 29.6) and 11.2 (2.1, 59.2) for subgroups II-V, respectively. A similar association was observed between aforementioned subgroups and pain with sitting/lying down. The ORs (95% CI) of greater pain with walking were 1.0 (reference), 1.7 (0.5, 6.1), 0.7 (0.2, 2.3), 5.0 (1.4, 18.6) and 7.9 (2.0, 31.5) for subgroup I-V, respectively. The corresponding analysis for pain on stairs showed similar results.

CONCLUSIONS

Distinct patterns of co-existing MRI lesions have different implications for the pathogenesis of osteoarthritic knee pain occurring with/without joint loading.

Osteoarthritis phenotypes and novel therapeutic targets

The success of disease-modifying osteoarthritis drug (DMOAD) development is still elusive. While there have been successes in preclinical and early clinical studies, phase 3 clinical trials have failed so far and there is still no approved, widely available DMOAD on the market. The latest research suggests that, among other causes, poor trial outcomes might be explained by the fact that osteoarthritis (OA) is a heterogeneous disease with distinct phenotypes. OA trials might be more successful if they would address and target a specific phenotype. The increasing availability of advanced techniques to detect particular OA characteristics expands the possibilities to distinguish between such potential OA phenotypes. Magnetic resonance imaging is among the key imaging techniques to stratify and monitor patients with changes in bone, cartilage and inflammation. Biochemical markers have mainly used as secondary parameters and could further delineate phenotypes. Moreover, post-hoc analyses of trial data have suggested the existence of distinct pain phenotypes and their relevance in the design of clinical trials. Although ongoing work in the field supports the concept of OA heterogeneity, this has not yet resulted in more effective treatment options. This paper reviews the current knowledge about potential OA phenotypes and suggests that combining patient clinical data, quantitative imaging, biochemical markers and utilizing data-driven approaches in patient selection and efficacy assessment will allow for more successful development of effective DMOADs.