Clinical comorbidities, treatment patterns, and direct medical costs of patients with osteoarthritis in usual care: a retrospective claims database analysis

Association of peri-operative prescription of non-steroidal anti-inflammatory drugs with continued prescription of opioids after total knee arthroplasty: a retrospective claims-based cohort study

Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the mainstays of multimodal pain management. While effective for acute pain control, recent pre-clinical evidence has raised concerns regarding an association between NSAIDs and chronic pain and potential opioid use. Our objective was to explore the association between peri-operative use of prescription NSAIDs and the need for continued opioid prescriptions lasting 90-180 days in previously opioid-naïve patients undergoing total knee arthroplasty. A database of health claims in the USA was used to identify all opioid-naïve adult patients who underwent primary knee arthroplasty between January 2010 and October 2021. We evaluated the magnitude of association between peri-operative prescription NSAID claims and claims for opioids at 90 days postoperatively using multivariable logistic regression models. Secondary outcomes included: the magnitude of association between peri-operative NSAID prescription and claims for opioids at 180 days postoperatively; and identifying other potential factors associated with opioid claims at 90 days postoperatively. After risk adjustment using multivariable logistic regression models in the 789,736-patient cohort, the adjusted odds ratio (95%CI) for a continuous claim of opioids at 90 and 180 days postoperatively among patients with a peri-operative NSAID prescription within 30 days was 1.32 (1.30-1.35), p < 0.001; and 1.12 (1.10-1.15), p < 0.001, respectively. This estimate of effect remained robust at 90 days after accounting for known potential confounders, including pre-existing knee pain and acute postoperative pain severity. Similar analysis of other pain medications (e.g. paracetamol) did not detect such an association. This population-based cohort study suggests that peri-operative prescription NSAID use may be associated with continued opioid prescription claims at 90 and 180 days after knee arthroplasty, even after adjusting for other observed covariates for continuous opioid claims. These novel findings can inform clinical decision-making for post-surgical pain management, risk-benefit discussions with patients and future research.

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.

Discrepancies in ICD-9/ICD-10-based codes used to identify three common diseases in cancer patients in real-world settings and their implications for disease classification in breast cancer patients and patients without cancer: a literature review and descriptive study

Background

International Classification of Diseases, Ninth/Tenth revisions, clinical modification (ICD-9-CM, ICD-10-CM) are frequently used in the U.S. by health insurers and disease registries, and are often recorded in electronic medical records. Due to their widespread use, ICD-based codes are a valuable source of data for epidemiology studies, but there are challenges related to their accuracy and reliability. This study aims to 1) identify ICD-9/ICD-10-based codes reported in literature/web sources to identify three common diseases in elderly patients with cancer (anemia, hypertension, arthritis), 2) compare codes identified in the literature/web search to SEER-Medicare's 27 CCW Chronic Conditions Algorithm ("gold-standard") to determine their discordance, and 3) determine sensitivity of the literature/web search codes compared to the gold standard.

Methods

A literature search was performed (Embase, Medline) to find sources reporting ICD codes for at least one disease of interest. Articles were screened in two levels (title/abstract; full text). Analysis was performed in SAS Version 9.4.

Results

Of 106 references identified, 29 were included that reported 884 codes (155 anemia, 80 hypertension, 649 arthritis). Overall discordance between the gold standard and literature/web search code list was 32.9% (22.2% for ICD-9; 35.7% for ICD-10). The gold standard contained codes not found in literature/web sources, including codes for hypertensive retinopathy/encephalopathy, Page Kidney, spondylosis/spondylitis, juvenile arthritis, thalassemia, sickle cell disorder, autoimmune anemias, and erythroblastopenia. Among a cohort of non-cancer patients (N=684,376), the gold standard identified an additional 129 patients with anemia, 33,683 with arthritis, and 510 with hypertension compared to the literature/web search. Among a cohort of breast cancer patients (N=303,103), the gold standard identified an additional 59 patients with anemia, 10,993 with arthritis, and 163 with hypertension. Sensitivity of the literature/web search code list was 91.38-99.96% for non-cancer patients, and 93.01-99.96% for breast cancer patients.

Conclusion

Discrepancies in codes used to identify three common diseases resulted in variable differences in disease classification. In all cases, the gold standard captured patients missed using the literature/web search codes. Researchers should use standardized, validated coding algorithms when available to increase consistency in research and reduce risk of misclassification, which can significantly alter the findings of a study.

The impact of moderate to severe osteoarthritis on the physical performance and quality of life: a cross-sectional study in Greek patients (PONOS study)

BACKGROUND

Osteoarthritis (OA) represents a leading cause of disability with limited data available for the Greek patients.

OBJECTIVES

To evaluate the impact of moderate to severe symptomatic hip/knee OA under treatment on physical performance and quality of life.

METHODS

A non-interventional, cross-sectional, epidemiological study of patients with moderate/severe OA, recruited in a single visit from 9 expert sites in Athens, Greece. Assessments were based on commonly used outcome scales: the Hip disability and Osteoarthritis Outcome Score (HOOS), the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the EuroQol-5-Dimensions 3-levels questionnaire (EQ-5D-3L).

RESULTS

One hundred sixty-four patients were included in the analysis. Most of the patients were females (78.7%), with a mean age of 70.5 ± 10.2 years. Comorbidities were reported by 87.2% of patients with hypertension being the most frequently reported (53.7%), followed by dyslipidemia (31.1%), obesity (24.4%) and diabetes mellitus (23.2%). Paracetamol was the most common treatment (96%), followed by NSAIDs (75%), opioids (50%) and locally applied medications (42.7%). Both hip and knee OA patients showed substantial deterioration in health-related quality of life (QoL) and health status as reflected by the HOOS/KOOS (Function in sport and recreation was the most impaired subscale, followed by Hip- or Knee-related QoL). The mean EQ-5D-3L index score was 0.396 ± 0.319 and the mean EQ-VAS score was 52.1 ± 1.9. When compared indirectly to the local population norms our OA population had worse QoL indices.

CONCLUSION

Our findings suggest the functional disability and impaired QoL of Greek patients with moderate/severe hip/knee OA under treatment emphasizing the need for novel treatments that will reduce the burden of the disease.

Demographics are no clinically relevant predictors of patient-reported knee osteoarthritis symptoms - Comprehensive multivariate analysis

Aims & objectives

In clinical practice, arthroplasties are predominantly indicated by clinical and radiological assessment of osteoarthritis. Pain and function are individually considered, but a comprehensive analysis of differences in symptom reporting by pre-operative factors is lacking. In the present study, we determined differences in patient reported outcome measures between demographic groups among patients admitted to total knee arthroplasty.

Materials & methods

Between 2010 and 2019, we collected pre-operative Oxford Knee Scores, Western Ontario and McMaster University Osteoarthritis Index, quality of life in 2555 patients undergoing primary, osteoarthritis-indicated total knee arthroplasty at Patients were categorized by sex, age (<70, 70-80, >80 years), body mass index (BMI <25, 25-30, 30-35, >35 kg/m2), American Society of Anesthesiologists -classification (ASA 1, 2, ≥3) and Charnley score (A, B1, B2, C). Symptom scores (median, IQR) were compared using bivariate and multivariate methods.

Results

The cohort was 60% female, 70.0 years old (69.4-70.1), and BMI was 28.9 kg/m2 (29.6-30.0). As compared to bivariate analyses, between-group differences in multivariate analyses were consistently smaller. BMI and sex remain significant predictors after adjustment for age, ASA, and Charnley. Age, ASA, and Charnley were no independent predictors of symptom scores. A group of patients (30%) reported no physical dysfunction, and less symptom severity in pain and stiffness.

Conclusion

This study is the first to show that differences in symptom reporting between demographic groups are partly colinear, and are negligible for prediction of symptoms. Lastly, for a significant proportion of patients, patient-reported outcome measures do not adequately present disease severity.

Inhibition of anandamide breakdown reduces pain and restores LTP and monoamine levels in the rat hippocampus via the CB1 receptor following osteoarthritis

Chronic pain is a persistent, complex condition that contributes to impaired mood, anxiety and emotional problems. Osteoarthritis (OA) is one of the major causes of chronic pain in adults and elderly people. A substantial body of evidence demonstrate that hippocampal neural circuits, especially monoamine dopamine and serotonin levels, contributes to negative affect and avoidance motivation experienced during pain. Current pharmacological strategies for OA patients are unsatisfying and the endocannabinoid system modulation might represent an alternative for the treatment of OA-related pain. In the present study, we used a rat model of osteoarthritis induced by intra-articular injection of sodium monoiodoacetate to assess, 28 days post-induction, the contribution of endocannabinoid system on the possible alteration in pain perception and affective behavior, in LTP and monoamine levels in the lateral entorhinal cortex-dentate gyrus pathway. The results show that OA-related chronic pain induces working memory impairment and depressive-like behavior appearance, diminishes LTP, decreases dopamine levels and increases serotonin levels in the rat dentate gyrus. URB597 administration (i.p., 1 mg/kg) reduces hyperalgesia and mechanical allodynia, improves recognition memory and depressive-live behavior, restores LTP and normalizes monoamine levels in the hippocampus. The effect was observed 60-120 min post-treatment and was blocked by AM251, which proves the action of URB597 via the CB₁ receptor. Therefore, our study confirms the role of anandamide in OA-related chronic pain management at the behavioral and hippocampal levels. This article is part of the Special Issue on 'Advances in mechanisms and therapeutic targets relevant to pain'.

Patient characteristics, pain treatment patterns, and incidence of total joint replacement in a US population with osteoarthritis

BACKGROUND

Currently available medications for chronic osteoarthritis pain are only moderately effective, and their use is limited in many patients because of serious adverse effects and contraindications. The primary surgical option for osteoarthritis is total joint replacement (TJR). The objectives of this study were to describe the treatment history of patients with osteoarthritis receiving prescription pain medications and/or intra-articular corticosteroid injections, and to estimate the incidence of TJR in these patients.

METHODS

This retrospective, multicenter, cohort study utilized health plan administrative claims data (January 1, 2013, through December 31, 2019) of adult patients with osteoarthritis in the Innovation in Medical Evidence Development and Surveillance Distributed Database, a subset of the US FDA Sentinel Distributed Database. Patients were analyzed in two cohorts: those with prevalent use of "any pain medication" (prescription non-steroidal anti-inflammatory drugs [NSAIDs], opioids, and/or intra-articular corticosteroid injections) using only the first qualifying dispensing (index date); and those with prevalent use of "each specific pain medication class" with all qualifying treatment episodes identified.

RESULTS

Among 1 992 670 prevalent users of "any pain medication", pain medications prescribed on the index date were NSAIDs (596 624 [29.9%] patients), opioids (1 161 806 [58.3%]), and intra-articular corticosteroids (323 459 [16.2%]). Further, 92 026 patients received multiple pain medications on the index date, including 71 632 (3.6%) receiving both NSAIDs and opioids. Altogether, 20.6% of patients used an NSAID at any time following an opioid index dispensing and 17.2% used an opioid following an NSAID index dispensing. The TJR incidence rates per 100 person-years (95% confidence interval [CI]) were 3.21 (95% CI: 3.20-3.23) in the "any pain medication" user cohort, and among those receiving "each specific pain medication class" were NSAIDs, 4.63 (95% CI: 4.58-4.67); opioids, 7.45 (95% CI: 7.40-7.49); and intra-articular corticosteroids, 8.05 (95% CI: 7.97-8.13).

CONCLUSIONS

In patients treated with prescription medications for osteoarthritis pain, opioids were more commonly prescribed at index than NSAIDs and intra-articular corticosteroid injections. Of the pain medication classes examined, the incidence of TJR was highest in patients receiving intra-articular corticosteroids and lowest in patients receiving NSAIDs.

Human Fetal Cartilage-Derived Progenitor Cells Exhibit Anti-Inflammatory Effect on IL-1β-Mediated Osteoarthritis Phenotypes In Vitro

BACKGROUND

In this study, we have investigated whether human fetal cartilage progenitor cells (hFCPCs) have anti-inflammatory activity and can alleviate osteoarthritis (OA) phenotypes in vitro.

METHODS

hFCPCs were stimulated with various cytokines and their combinations and expression of paracrine factors was examined to find an optimal priming factor. Human chondrocytes or SW982 synoviocytes were treated with interleukin-1β (IL-1β) to produce OA phenotype, and co-cultured with polyinosinic-polycytidylic acid (poly(I-C))-primed hFCPCs to address their anti-inflammatory effect by measuring the expression of OA-related genes. The effect of poly(I-C) on the surface marker expression and differentiation of hFCPCs into 3 mesodermal lineages was also examined.

RESULTS

Among the priming factors tested, poly(I-C) (1 µg/mL) most significantly induced the expression of paracrine factors such as indoleamine 2,3-dioxygenase, histocompatibility antigen, class I, G, tumor necrosis factor- stimulated gene-6, leukemia inhibitory factor, transforming growth factor-β1 and hepatocyte growth factor from hFCPCs. In the OA model in vitro, co-treatment of poly(I-C)-primed hFCPCs significantly alleviated IL-1β-induced expression of inflammatory factors such as IL-6, monocyte chemoattractant protein-1 and IL-1β, and matrix metalloproteinases in SW982, while it increased the expression of cartilage extracellular matrix such as aggrecan and collagen type II in human chondrocytes. We also found that treatment of poly(I-C) did not cause significant changes in the surface marker profile of hFCPCs, while showed some changes in the 3 lineages differentiation.

CONCLUSION

These results suggest that poly(I-C)-primed hFCPCs have an ability to modulate inflammatory response and OA phenotypes in vitro and encourage further studies to apply them in animal models of OA in the future.

Shoulder structure and function: The impact of osteoarthritis and rehabilitation strategies

STUDY DESIGN

Invited review.

BACKGROUND

Shoulder osteoarthritis can result in significant functional deficits. To improve diagnosis and treatment, we must better understand the impact of osteoarthritis on shoulder biomechanics and the known mechanical benefits of currently available treatments.

PURPOSE

The purpose of this paper is to present up-to-date data on the effects of osteoarthritis and rehabilitation on the biomechanical parameters contributing to shoulder function. With this goal, we also reviewed the anatomy and the ranges of motion of the shoulder.

METHODS

A search of electronic databases was conducted. All study designs were included to inform this qualitative, narrative literature review.

RESULTS

This review describes the biomechanics of the shoulder, the impact of osteoarthritis on shoulder function, and the treatment of shoulder osteoarthritis with an emphasis on rehabilitation.

CONCLUSIONS

The shoulder is important for the completion of activities of daily living, and osteoarthritis of the shoulder can significantly reduce shoulder motion and arm function. Although shoulder rehabilitation is an integral treatment modality to improve pain and function in shoulder osteoarthritis, few high-quality studies have investigated the effects and benefits of shoulder physical and occupational therapies. To advance the fields of therapy and rehabilitation, future studies investigating the effects of therapy intensity, therapy duration, and the relative benefits of therapy subtypes on shoulder biomechanics and function are necessary.

Cost Effectiveness of Pharmacological Management for Osteoarthritis: A Systematic Review

BACKGROUND AND OBJECTIVE

Osteoarthritis (OA) is a highly prevalent, disabling disease requiring chronic management that is associated with an enormous individual and societal burden. This systematic review provides a global cost-effectiveness evaluation of pharmacological therapy for the management of OA.

METHODS

Following Center for Reviews and Dissemination (CRD) guidance, a literature search strategy was undertaken using PubMed, EMBASE, Cochrane Library, Health Technology Assessment (HTA) database, and National Health Service Economic Evaluation database (NHS EED) to identify original articles containing cost-effectiveness evaluation of OA pharmacological treatment published before 4 November 2021. Risk of bias was assessed by two independent reviewers using the Joanna Briggs Institute (JBI) critical appraisal checklist for economic evaluations. The Quality of Health Economic Studies (QHES) instrument was used to assess the reporting quality of included articles.

RESULTS

Database searches identified 43 cost-effectiveness analysis studies (CEAs) on pharmacological management of OA that were conducted in 18 countries and four continents, with one study containing multiple continents. A total of four classes of drugs were assessed, including non-steroidal anti-inflammatory drugs (NSAIDs), opioid analgesics, symptomatic slow-acting drugs for osteoarthritis (SYSADOAs), and intra-articular (IA) injections. The methodological approaches of these studies showed substantial heterogeneity. The incremental cost-effectiveness ratios (ICERs) per quality-adjusted life-year (QALY) were (in 2021 US dollars) US$44.40 to US$307,013.56 for NSAIDS, US$11,984.84 to US$128,028.74 for opioids, US$10,930.17 to US$27,799.73 for SYSADOAs, and US$258.36 to US$58,447.97 for IA injections in different continents. The key drivers of cost effectiveness included medical resources, productivity, relative risks, and selected comparators.

CONCLUSION

This review showed substantial heterogeneity among studies, ranging from a finding of dominance to very high ICERs, but most studies found interventions to be cost effective based on specific ICER thresholds. Important challenges in the analysis were related to the standardization and methodological quality of studies, as well as the presentation of results.

The impact of chronic diseases on depressive symptoms among the older adults: The role of sleep quality and empty nest status

BACKGROUND

Depression is the most prevalent mental disorder among older adults. This study aimed to explore the mediating effect of sleep quality on the relationship between chronic diseases and depressive symptoms, and the moderating role of empty nest status in the mediating model.

METHODS

A cross-sectional survey was conducted among 3637 older adults from Taiyuan, China, using a multi-stage random cluster sampling method. The data was collected with the general questionnaire for the elderly, with the Short Form Geriatric Depression Scale (GDS-15), and the Pittsburgh Sleep Quality Index (PSQI). The Bootstrap program and simple slope method were used to test the mediating effect of sleep quality and the moderating effect of empty nest status.

RESULTS

The overall prevalence of depressive symptoms in the population was 33.4%. The mediating effect analysis showed that chronic diseases had a significant direct impact on depressive symptoms in the elderly (β = 0.431, P < 0.001). Sleep quality as a mediation effect of 43.4% between chronic diseases and depressive symptoms was proven. The further moderating effect found that chronic diseases had a more significant impact on the sleep quality of the elderly who are in the empty nest status than those who are not (β = -0.431, P < 0.05 ).

LIMITATIONS

Given the cross-sectional study, the results cannot explain the causal relationships among the study variables.

CONCLUSIONS

Chronic diseases had a major impact on the depressive symptoms of the elderly. Sleep quality mediated the relationship between chronic diseases and depressive symptoms, and the empty nest status moderated the first half of the path in the mediation model. Therefore, to reduce the incidence of the depressive symptoms of the elderly, sleep quality and empty nest status should be the primary concern.

A Retrospective Claims-Based Study Evaluating Clinical and Economic Burden Among Patients With Moderate to Severe Osteoarthritis Pain in the United States

Background: There has been limited evaluation of medication adherence, healthcare resource utilization (HCRU), and healthcare costs over time in patients with osteoarthritis (OA), and stratification by pain severity level has not been reported. Assessing such longitudinal changes may be useful to patients and healthcare providers for tracking disease progression, informing treatment options, and employing strategies to optimize patient outcomes. Objectives: To characterize treatment patterns, HCRU, and costs over time in patients with moderate to severe (MTS) OA pain in the United States. Methods: We conducted a retrospective claims analysis, using IBM® MarketScan® databases, from 2013-2018. Eligible patients were aged ≥45 years with ≥12 months pre-index (baseline) and ≥24 months (follow-up) of continuous enrollment; index date was defined as a physician diagnosis of hip or knee OA. An algorithm was employed to identify MTS OA pain patients, who were propensity score matched with patients having non-MTS OA pain. Data were summarized using descriptive statistics and univariate analyses. Results: After propensity score matching, the overall OA pain cohorts consisted of 186 374 patients each: 61% were female, mean age was 63 years, and two-thirds (65.6%) were of working age (45-65 years). Sleep-related conditions, anxiety, and depression were significantly higher in the MTS OA pain cohort vs non-MTS (P<0.001). At baseline and 12- and 24-month follow-ups, receipt of prescription pain medications, HCRU, and direct medical costs were significantly higher in the MTS OA pain cohort (all P<0.01). Medication adherence was significantly higher in the MTS OA pain cohort for all medication classes except analgesics/antipyretics, which were significantly lower vs the non-MTS OA pain cohort (all P<0.0001). Conclusions: The burden of MTS OA pain is substantial, with patterns that show increasing medication use, HCRU, and costs vs non-MTS OA pain patients over time. Understanding the heterogeneity within the OA population may allow us to further appreciate the true burden of illness for patients in pain.

Exploring patient preference heterogeneity for pharmacological treatments for chronic pain: A latent class analysis

BACKGROUND

Several pharmaceutical treatments for chronic pain caused by osteoarthritis (OA) and chronic low back pain (CLBP) are available or currently under development, each associated with different adverse events (AEs) and efficacy profiles. It is therefore important to understand what trade-offs patients are willing to make when choosing between treatments.

METHODS

A discrete-choice experiment (DCE) was conducted with 437 adults with chronic pain caused by OA and/or CLBP. Respondents were presented with a series of scenarios and asked to choose between pairs of hypothetical treatments, each defined by six attributes: level of symptom control; risks of heart attack, rapidly progressive osteoarthritis and dependency; frequency and mode of administration and cost. Attributes were based on known profiles of oral nonsteroidal anti-inflammatory drugs, opioids and injected nerve growth factor inhibitors, the last of which were under clinical development at the time of the study. Data were analysed using a latent class (LC) model to explore preference heterogeneity.

RESULTS

Overall, respondents considered improving symptom control and reducing risk of physical dependency to be the most important attributes. The LC analysis identified four participant classes: an 'efficacy-focused' class (33.7%), a 'cost-averse' class (29.4%), a 'physical-dependence-averse' class (19.6%) and a 'needle-averse' class (17.3%). Subgroup membership was incompletely predicted by participant age and their responses to comprehension questions.

CONCLUSIONS

Preference heterogeneity across respondents indicates a need for a personalized approach to offering treatment options. Symptom improvement, cost, physical dependence and route of administration might be important to different patients.

SIGNIFICANCE

Multiple treatment options that differ substantially in terms of efficacy and adverse events are available for the management of chronic pain. With a growing emphasis on a patient-centred care model that incorporates patients' priorities and values into treatment decisions, there is a need to understand how individuals with chronic musculoskeletal pain balance the benefits and risks of treatment and how treatment priorities vary among individuals. This study was designed to identify patient preferences for different characteristics of treatments for the management of chronic pain and to investigate how preferences differ among respondents.

Cedrol alleviates the apoptosis and inflammatory response of IL-1β-treated chondrocytes by promoting miR-542-5p expression

Cedrol has been shown to exert anti-tumor, anti-inflammatory, and anti-oxidative effects, but its role in osteoarthritis (OA) is unclear. This study aimed to explore the effect of cedrol in OA. Chondrocytes were isolated from newborn rats and cultured in Dulbecco's modified Eagle's medium (DMEM). Then, Alcian blue staining was used to identify the chondrocytes. IL-1β and cedrol were used to treat chondrocytes. Cell viability and apoptosis were measured by MTT and flow cytometry assays, respectively. The expressions of miR-542-5p, miR-26b-5p, miR-572, miR-138-5p, miR-328-3p, miR-1254, Bcl-2, Bax, iNOS, COX-2, and MMP-13 were detected by quantitative reverse transcription polymerase chain reaction (qRT-PCR) or western blot. NO and PGE2 levels were detected by ELISA. All the cells extracted from the newborn rats were dyed blue, indicating that the cells were chondrocytes. IL-1β could reduce the viability and promote apoptosis and inflammatory response of chondrocytes, while cedrol could reverse the effect of IL-1β. In addition, cedrol could significantly increase the expression of miR-542-5p in IL-1β-treated chondrocytes. Moreover, miR-542-5p inhibitor could partly reverse the effect of cedrol in the apoptosis and inflammation response of chondrocytes. Cedrol alleviated IL-1β-induced apoptosis and inflammatory response of chondrocytes by promoting miR-542-5p expression.

Burden, Treatment Patterns and Unmet Needs of Osteoarthritis in Dubai: a Retrospective Analysis of the Dubai Real-World Claims Database

Introduction

Osteoarthritis (OA) is a degenerative joint disease that impacts 3.3–3.6% of population globally with significant health and societal impact. The current study assessed the disease burden, treatment patterns, and healthcare resource utilisation (HCRU) and costs in patients with OA and subgroups of hip and/or knee OA, in Dubai, United Arab Emirates (UAE).

Methodology

This retrospective longitudinal case–control study collected OA-related data from January 1, 2014 to May 31, 2020 from the Dubai Real-World Claims Database (DRWD). Adults aged at least 18 years old with OA diagnosis and at least two claims and continuous enrolment during the study period were included in the study. The patients with OA were 1:1 matched with individuals without OA. The patients with OA were divided into four cohorts on the basis of an a priori algorithm: OA of the hip and/or knee (cohort 1) and (difficult-to-treat) subsets of patients with moderate-to-severe OA of the hip and/or knee (cohort 2), inadequate response or inability to tolerate at least three pain-related medications (cohort 3), and contraindications to nonsteroidal anti-inflammatory drugs (NSAIDs) (cohort 4).

Results

Disease burden of OA in Dubai and HCRU and treatment costs in patients with OA were evaluated from January 1, 2014 to May 31, 2021. Patients were compared with matched controls in 1:1 ratio. The overall cohort comprised 11,651 patients with a median age of 48 years and predominantly male population (61.6%). HCRU was calculated for each cohort and it was highest (United States dollar [USD] 11,354.39) in cohort 4 (patients with contraindication to NSAIDS); in cohort 3 (inability to respond to at least three pain-related medications), USD 495.30 and USD 765.14 were spent on medication and procedures, respectively. Highest cost burden was seen in cohort 4, USD 3120.49 on consumables and USD 228.18 on services.

Conclusion

Osteoarthritis imposes a substantial healthcare and economic burden in the UAE. The study findings elucidate the unmet need among patients with difficult-to-treat OA and inform development of new therapeutics to alleviate their burden.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-021-00391-z.

Treatment of osteoarthritis with autologous, micro-fragmented adipose tissue: a study protocol for a randomized controlled trial

BACKGROUND

Osteoarthritis is a destructive joint disease that leads to degeneration of cartilage and other morphological changes in the joint. No medical treatment currently exists that can reverse these morphological changes. Intra-articular injection with autologous, micro-fragmented adipose tissue has been suggested to relieve symptoms.

METHODS/DESIGN

The study is a blinded randomized controlled trial with patients allocated in a 1:1 ratio to 2 parallel groups. Patients suffering from pain and functional impairment due to osteoarthritis Kellgren-Lawrence grades 2-3 in the tibiofemoral joint are eligible for inclusion. The intervention group is treated with an intra-articular injection with autologous, micro-fragmented adipose tissue prepared using the Lipogems® system. The control group receives an intra-articular injection with isotonic saline. In total, 120 patients are to be included. The primary outcome is The Knee injury and Osteoarthritis Outcome Score (KOOS4) evaluated at 6 months. Secondary outcomes are KOOS at 3, 12 and 24 months; the Tegner activity score; treatment failure; and work status of the patient. The analysis will be conducted both as intention-to-treat and per-protocol analysis.

DISCUSSION

This trial is the first to investigate the efficacy of autologous, micro-fragmented adipose tissue in a randomized controlled trial. The study uses the patient-reported outcome measure Knee Injury and Osteoarthritis Outcome Score (KOOS4) after 6 months as the primary outcome, as it is believed to be a valid measure to assess the patient's opinion about their knee and associated problems when suffering from osteoarthritis.

Betaine Attenuates Osteoarthritis by Inhibiting Osteoclastogenesis and Angiogenesis in Subchondral Bone

Osteoarthritis (OA) is the most common type of arthritis with no effective therapy. Subchondral bone and overlying articular cartilage are closely associated and function as “osteo-chondral unit” in the joint. Abnormal mechanical load leads to activated osteoclast activity and increased bone resorption in the subchondral bone, which is implicated in the onset of OA pathogenesis. Thus, inhibiting subchondral bone osteoclast activation could prevent OA onset. Betaine, isolated from the Lycii Radicis Cortex (LRC), has been demonstrated to exert anti-inflammatory, antifibrotic and antiangiogenic properties. Here, we evaluated the effects of betaine on anterior cruciate ligament transection (ACLT)-induced OA mice. We observed that betaine decreased the number of matrix metalloproteinase 13 (MMP-13)-positive and collagen X (Col X)-positive cells, prevented articular cartilage proteoglycan loss and lowered the OARSI score. Betaine decreased the thickness of calcified cartilage and increased the expression level of lubricin. Moreover, betaine normalized uncoupled subchondral bone remodeling as defined by lowered trabecular pattern factor (Tb.pf) and increased subchondral bone plate thickness (SBP). Additionally, aberrant angiogenesis in subchondral bone was blunted by betaine treatment. Mechanistically, we demonstrated that betaine suppressed osteoclastogenesis in vitro by inhibiting reactive oxygen species (ROS) production and subsequent mitogen-activated protein kinase (MAPK) signaling. These data demonstrated that betaine attenuated OA progression by inhibiting hyperactivated osteoclastogenesis and maintaining microarchitecture in subchondral bone.

Osteoarthritis and risk of hospitalization for ambulatory care-sensitive conditions: a general population-based cohort study

OBJECTIVE

To determine the association between OA and risk of hospitalization for ambulatory care-sensitive conditions (HACSCs).

METHODS

We included all individuals aged 40-85 years who resided in Skåne, Sweden on 31 December 2005 with at least one healthcare consultation during 1998-2005 (n = 515 256). We identified those with a main diagnosis of OA between 1 January 1998 and 31 December 2016. People were followed from 1 January 2006 until an HACSC, death, relocation outside Skåne, or 31 December 2016 (whichever occurred first). OA status was treated as a time-varying covariate (those diagnosed before 1 January 2006 considered as exposed for whole study period). We assessed relative [hazard ratios (HRs) using Cox proportional hazard model] and absolute (hazard difference using additive hazard model) effects of OA on HACSCs adjusted for potential confounders.

RESULTS

Crude incidence rates of HACSCs were 239 (95% CI: 235, 242) and 151 (150, 152) per 10 000 person-years among OA and non-OA persons, respectively. The OA persons had an increased risk of HACSCs [HR (95% CI) 1.11 (1.09, 1.13)] and its subcategories of medical conditions except chronic obstructive pulmonary disease [HR (95% CI) 0.86 (0.81, 0.90)]. There were 20 (95% CI: 16, 24) more HACSCs per 10 000 person-years in OA compared with non-OA persons. While HRs for knee and hip OA were generally comparable, only knee OA was associated with increased risk of hospitalization for diabetes.

CONCLUSION

OA is associated with an increased risk of HACSCs, highlighting the urgent need to improve outpatient care for OA patients.

Cell Interplay in Osteoarthritis

Osteoarthritis (OA) is a common chronic disease and a significant health concern that needs to be urgently solved. OA affects the cartilage and entire joint tissues, including the subchondral bone, synovium, and infrapatellar fat pads. The physiological and pathological changes in these tissues affect the occurrence and development of OA. Understanding complex crosstalk among different joint tissues and their roles in OA initiation and progression is critical in elucidating the pathogenic mechanism of OA. In this review, we begin with an overview of the role of chondrocytes, synovial cells (synovial fibroblasts and macrophages), mast cells, osteoblasts, osteoclasts, various stem cells, and engineered cells (induced pluripotent stem cells) in OA pathogenesis. Then, we discuss the various mechanisms by which these cells communicate, including paracrine signaling, local microenvironment, co-culture, extracellular vesicles (exosomes), and cell tissue engineering. We particularly focus on the therapeutic potential and clinical applications of stem cell-derived extracellular vesicles, which serve as modulators of cell-to-cell communication, in the field of regenerative medicine, such as cartilage repair. Finally, the challenges and limitations related to exosome-based treatment for OA are discussed. This article provides a comprehensive summary of key cells that might be targets of future therapies for OA.

Moderate to Severe Osteoarthritis Pain and Its Impact on Patients in the United States: A National Survey

Purpose

Osteoarthritis (OA) is one of the most common causes of chronic pain and a leading cause of disability in the US. The objective of this study was to examine the clinical and economic burden of OA by pain severity.

Patients and Methods

We used nationally representative survey data. Adults ≥18 years with self-reported physician-diagnosed OA and experiencing OA pain were included in the study. OA pain severity was measured using the Short Form McGill Pain Questionnaire Visual Analog Scale (SF-MPQ-VAS). Data were collected for demographics, clinical characteristics, health-related quality of life (HRQoL), productivity, OA treatment, adherence to pain medication, and healthcare resource utilization. Univariate analysis was performed to examine differences between respondents with moderate-to-severe OA pain vs those with mild OA pain.

Results

Higher proportions of respondents with moderate-to-severe OA pain (n=3798) compared with mild OA pain (n=2038) were female (69.4% vs 57.3%), <65 years of age (54.8% vs 43.4%), and not employed (70.6% vs 64.5%). Respondents with moderate-to-severe OA pain experienced OA pain daily (80.8% vs 48.8%), were obese (53.0% vs 40.5%), had more comorbidities (sleep disturbance, insomnia, depression, and anxiety), and reported significantly poorer health status and HRQoL, and greater productivity and activity impairment (all P<0.05). Moderate-to-severe OA pain respondents were prescribed significantly more pain medications than mild OA pain respondents (41.0% vs 17.0%) and had higher adherence (75.9% vs 64.1%) yet were less satisfied with their pain medications (all P<0.001). Outpatient and emergency room visits, and hospitalizations in the 6 months prior to the survey were significantly higher in moderate-to-severe OA pain respondents vs those with mild OA pain (all P<0.05).

Conclusion

Patient and clinical burden was significantly greater in moderate-to-severe OA pain respondents vs mild OA pain respondents and may inform decision-making for appropriate resource allocation and effective management strategies that target specific subgroups.

A Double-Blind, Randomized, Placebo-Controlled Trial to Evaluate the Efficacy of a Hydrolyzed Chicken Collagen Type II Supplement in Alleviating Joint Discomfort

Joint pain and disease affects more than one in four adults in the United States. We conducted a double-blind, randomized, placebo-controlled trial to investigate the efficacy of a hydrolyzed chicken collagen type II (HCII) supplement in reducing joint-related discomfort such as pain and stiffness, and in improving mobility. We enrolled adults aged 40–65 (65.5% were women) who had joint discomfort, but had no co-morbidities, and who were not taking pain medications. The participants were randomized to receive either the HCII supplement (n = 47) or a placebo (n = 43) for eight weeks. At the baseline, and at week 4 and week 8, we administered the Western Ontario and McMaster Universities Arthritis Index (WOMAC) survey with three additional wrist-related questions and the Visual Analog Scale for assessments of joint-related symptoms. In the WOMAC stiffness and physical activity domains and in the overall WOMAC score, the HCII group had a significant reduction in joint-related discomforts compared with the placebo group. For example, at week 4, the HCII group had a 36.9% reduction in the overall WOMAC score, compared with a 14.3% reduction in the placebo group (p = 0.027). This HCII product is effective in reducing joint pain and stiffness and in improving joint function among otherwise healthy adults.

Factors Associated with Knee Arthroplasty in a Knee Osteoarthritis Patient Cohort Treated with Intra-articular Injections of Hylan G-F 20

Hylan G-F 20 viscosupplementation can be used to treat knee osteoarthritis pain. This study evaluated time to knee arthroplasty (KA), KA risk factors, and health care resource utilization in patients aged ≥18 years with claims in the Optum Clinformatics Data Mart database (2006-2016) for knee osteoarthritis treated with at least one course of hylan G-F 20. Kaplan-Meier analysis estimated KA risk from osteoarthritis diagnosis and first hylan G-F 20 treatment. KA risk factors were determined using multivariate Cox regression. Among 62,033 patients treated with hylan G-F 20 and/or hylan G-F 20 single intra-articular injection, 60 to 64% did not undergo KA 8 years following first injection. KA risk factors from time of osteoarthritis diagnosis and first hylan G-F 20 treatment were similar: increased age, fewer comorbidities, fewer hylan G-F 20 treatments, female sex, and no ultrasound/fluoroscopy for injection guidance. Patients who underwent KA versus those who did not had more office visits and claims for opioids, nonsteroidal anti-inflammatory drugs, and physical therapy. Patients less likely to undergo KA were younger (<40 years), had more comorbidities, received more courses of hylan G-F 20, were males, or received ultrasound/fluoroscopic injection guidance. Patients who did not receive KA versus those who did used fewer health care resources.

Pain Pharmacotherapy in a Large Cohort of Patients with Osteoarthritis: A Real-World Data Analysis

INTRODUCTION

There is limited evidence on the consumption of analgesics in real-world large cohorts of patients with osteoarthritis (OA), especially in those with comorbidities. We aimed to characterize the use of pharmacological analgesic treatments, evaluate standardized comorbidity rates, and assess treatment trends. Our hypotheses were: (1) OA patients generally consume low and inconsistent pharmacological analgesic treatments; (2) analgesic treatment is often non-congruent with comorbidity-related safety concerns.

METHODS

The study was carried out at the second largest health maintenance organization in Israel. Members aged 18 years or above who were diagnosed with OA before December 31, 2018, were included. Information was obtained from the members' electronic medical record (EMR) including data on dispensed prescriptions, which were used to estimate analgesic consumption.

RESULTS

A total of 180,126 OA patients were included in our analyses; analgesics were dispensed to 64.2% of the patients, with oral NSAIDs and opioids dispensed to 34.1 and 22.9% of the OA population, respectively. Analgesic use increased with time lapsed from OA diagnosis (p < 0.001), up to a median of 59 days covered (IQR, 20-175) after 21 years. Rates of most comorbidities in the OA population were higher compared to the MHS general population. Patients with comorbidities used more NSAIDs and opioids compared to those without them.

CONCLUSIONS

Most OA patients use analgesics, usually oral NSAIDs. Analgesic use remains relatively low throughout the years, indicating that many OA patients are not being treated pharmacologically for pain on a regular basis. Despite having higher rates of several comorbidities compared to MHS general population, many OA patients are still treated with analgesics that can be associated with a worsening in comorbidity.

Osteoarthritis care and risk of total knee arthroplasty among medicare beneficiaries

OBJECTIVE

To examine health care utilization among patients with knee osteoarthritis and test if utilization differed among residents of regions with high and low rates of total knee arthroplasty (TKA).

DESIGN

This was a retrospective cohort study of U.S. Medicare beneficiaries in 2005 - 2010 with knee osteoarthritis. Health care utilization for knee complaints, including rates of physician visits, physical therapy, knee injections and arthroscopy were abstracted from claims files until TKA or the end of study in 2015. Utilization was compared among beneficiaries who lived in regions with high or low rates of TKA.

RESULTS

Among 988,570 beneficiaries with knee osteoarthritis, 327,499 beneficiaries (33.1%) had TKA during follow-up (median 5.6 years). Higher rates of visits for knee complaints were associated with increased risks of arthroplasty, while use of physical therapy, specialist care, and intra-articular treatments were associated with lower risks. Frequency of TKA varied from 26.4% in the lowest quintile region to 42.1% in the highest quintile. Rates of physician visits, physical therapy, specialist care, and use of intra-articular injections varied inversely with arthroplasty quintile. For example, physical therapy was used by 32.5% of beneficiaries in the lowest quintile region and 23.6% in the highest quintile region. Physical therapy was associated with lower TKA rates across all quintiles.

CONCLUSIONS

Dedicated non-surgical osteoarthritis care was infrequently used by elderly Americans with knee osteoarthritis. Non-surgical care was more common in regions with low rates of TKA, suggesting reciprocal emphasis on medical versus surgical treatment across regions.

Real-World Health Care Resource Utilization and Costs Among US Patients with Knee Osteoarthritis Compared with Controls

PURPOSE

To determine the prevalence, healthcare resource utilization and costs (HCRU&C) of knee osteoarthritis (OA) patients versus controls.

PATIENTS AND METHODS

Retrospective, matched-cohort administrative claims analysis using IBM MarketScan databases (2011-2017). Newly diagnosed, adult (18+ yrs) knee OA patients identified by ICD9/10 code were matched 1:1 to controls by age, sex, payer, and geography; alpha level set to 0.05. Prevalence was estimated for 2017. All-cause and knee OA-related HCRU&C reported per-patient-per-year (PPPY) over follow-up period up to 4 years.

RESULTS

Overall 2017 knee OA prevalence was 4% (615,514 knee OA/15.4M adults). A total of 510,605 patients meeting inclusion criteria were matched 1:1 with controls. The knee OA cohort had mean age 60 years and was 58% female. Versus controls, knee OA patients had significantly more PPPY outpatient (84.5 versus 45.0) and pharmacy (29.8 versus 19.8) claims, and significantly higher PPPY outpatient costs ($12,571 versus $6,465), and pharmacy costs ($3,655 versus $2,038). Knee OA patients incurred $7,707 more PPPY total healthcare costs than controls, of which $4,674 (60.6%) were knee OA-related medical claims and $1,926 (25%) were knee OA-related medications of interest. PPPY costs for nonselective NSAIDs, cyclooxygenase-2 (COX-2) inhibitors, intraarticular hyaluronic acid, non-acute opioids, and knee replacement were higher for knee OA patients than controls. Using median and mean all-cause total cost ($9,330 and $24,550, respectively), the estimated sum cost of knee OA patients in MarketScan ranged from $5.7B to $15B annually.

CONCLUSION

This retrospective analysis demonstrated an annual 2017 prevalence of 4.0% (≥18 years) and 13.2% (≥65 years) for newly diagnosed knee OA patients. Compared with controls, all-cause costs were significantly higher for knee OA patients, nearly double that of matched controls, attributable to increased medical and treatment costs and comorbidity treatment burden. Additionally, the estimated annual cost of knee OA treatment was substantial, ranging between $5.7 billion and $15 billion.

The Prevalence of Opioid Analgesic Use in People with Chronic Noncancer Pain: Systematic Review and Meta-Analysis of Observational Studies

OBJECTIVE

To review studies examining the proportion of people with chronic noncancer pain who report consuming opioids and characteristics associated with their use.

DESIGN

Systematic review.

METHODS

We searched databases from inception to February 8, 2020, and conducted citation tracking. We included observational studies reporting the proportion of adults with chronic noncancer pain who used opioid analgesics. Opioids were categorized as weak (e.g., codeine) or strong (e.g., oxycodone). Study risk of bias was assessed, and Grading of Recommendations Assessment, Development and Evaluations provided a summary of the overall quality. Results were pooled using a random-effects model. Meta-regression determined factors associated with opioid use.

RESULTS

Sixty studies (N=3,961,739) reported data on opioid use in people with chronic noncancer pain from 1990 to 2017. Of these 46, 77% had moderate risk of bias. Opioid use was reported by 26.8% (95% confidence interval [CI], 23.1-30.8; moderate-quality evidence) of people with chronic noncancer pain. The use of weak opioids (17.3%; 95% CI 11.9-24.4; moderate-quality evidence) was more common than the use of strong opioids (9.8%; 95% CI, 6.8-14.0; low-quality evidence). Meta-regression determined that opioid use was associated with geographic region (P=0.02; lower in Europe than North America), but not sampling year (P=0.77), setting (P=0.06), diagnosis (P=0.34), or disclosure of funding (P=0.77).

CONCLUSIONS

Our review summarized data from over 3.9 million people with chronic noncancer pain reporting their opioid use. Between 1990 and 2017, one-quarter of people with chronic noncancer pain reported taking opioids, and this proportion did not change over time.

Antidepressant and anticonvulsant prescription rates in patients with osteoarthritis: a population-based cohort study

Objectives

There are signs that antidepressants and anticonvulsants are being prescribed more often for OA patients, despite limited evidence. Our objectives were to examine prescription rates and time trends for antidepressants and anticonvulsants in OA patients, to assess the percentage of long-term prescriptions, and to determine patient characteristics associated with antidepressant or anticonvulsant prescription.

Methods

A population-based cohort study was conducted using the Integrated Primary Care Information database. First, episodic and prevalent prescription rates for antidepressants (amitriptyline, nortriptyline and duloxetine) and anticonvulsants (gabapentinoids) in OA patients were calculated for the period 2008–17. Logistic regression was used to assess which patient characteristics were associated with prescriptions.

Results

In total, 164 292 OA patients were included. The prescription rates of amitriptyline, gabapentin and pregabalin increased over time. The increase in prescription rates for pregabalin was most pronounced. Episodic prescription rate increased from 7.1 to 13.9 per 1000 person-years between 2008 and 2017. Amitriptyline was prescribed most (15.1 episodic prescriptions per 1000 person-years in 2017). Prescription rates of nortriptyline and duloxetine remained stable at 3.0 and 2.0 episodic prescriptions per 1000 person-years, respectively. For ≤3% of patients with incident OA, medication was prescribed long-term (≥3 months). In general, all medication was prescribed more frequently for older patients (except duloxetine), women, patients with OA in ≥2 joints, patients with spinal OA and patients with musculoskeletal disorders.

Conclusion

Prescription rates of amitriptyline, gabapentin and pregabalin increased over time. Since there is little evidence to support prescription in OA, caution is necessary when prescribing.

Utilization of Healthcare Resources in Osteoarthritis: A Cost of Illness Analysis Based on Real-World Data in Italy

Purpose

Understand the demographics and clinical features of patients with osteoarthritis (OA), quantify healthcare resource utilization by OA patients, and estimate the annual direct medical costs per OA patient from a National Health Service (NHS) perspective in Italy.

Patients and Methods

Retrospective observational cohort analysis using data from electronic medical records captured by the Italian IQVIA Longitudinal Patient Database (LPD). Only direct medical costs reimbursed by the NHS were considered. Patients were included if they received at least one diagnosis of OA during the period from January 1 to December 31, 2018. Each patient was observed for 3 years: a 24-month baseline period preceding the index date, and a 12-month follow-up period starting at the index date.

Results

A total of 71,467 patients met inclusion criteria: 43.98% had not been prescribed NSAIDs/opioids, 40.76% had been prescribed NSAIDs, and 15.26% an opioid. Mean age was 71.36 years, and 68.2% of the patients were women. At least one comorbidity was present in 91.34% of the patients; 38.05% were newly diagnosed with OA. During 1-year of follow-up, 173,884 prescriptions with an associated diagnosis of OA were found: 47.36% had been prescribed an NSAID, 9.11% diclofenac, 8.30% codeine+paracetamol, and 7.32% ketoprofen. Nearly 15% of the patients had at least 1 request for a specialist visit and 23.82% had at least 1 request for exams. Orthopedic visits accounted for 60% of all specialist visits. Yearly mean costs per patient were €622, for approximately €2.5 billion per year in direct costs, considering 3.9 million patients with OA in Italy. Protheses were a major driver in annual costs: €143.45 in patients without a prosthesis and €10,090.91 in those with a joint prosthesis.

Conclusion

This real-world analysis of direct costs of care of patients with OA in Italy confirms the substantial economic burden. Direct costs dramatically increased when joint replacement was needed.

Exosomes from IL-1β-Primed Mesenchymal Stem Cells Inhibited IL-1β- and TNF-α-Mediated Inflammatory Responses in Osteoarthritic SW982 Cells

BACKGROUND

Exosomes from mesenchymal stem cells (MSCs) show anti-inflammatory effect on osteoarthritis (OA); however, their biological effect and mechanism are not yet clearly understood. This study investigated the anti-inflammatory effect and mechanism of MSC-derived exosomes (MSC-Exo) primed with IL-1β in osteoarthritic SW982 cells.

METHODS

SW982 cells were treated with interleukin (IL)-1β and tumor necrosis factor (TNF)-α to induce the OA phenotype. The effect of exosomes without priming (MSC-Exo) or with IL-1β priming (MSC-IL-Exo) was examined on the expression of pro- or anti-inflammatory factors, and the amount of IκBα was examined in SW982 cells. Exosomes were treated with RNase to remove RNA. The role of miR-147b was examined using a mimic and an inhibitor.

RESULTS

MSC-IL-Exo showed stronger inhibitory effects on the expression of pro-inflammatory cytokines (IL-1β, IL-6, and monocyte chemoattractant protein-1) than MSC-Exo. The expression of anti-inflammatory factors (SOCS3 and SOCS6) was enhanced by MSCs-IL-Exo. Priming with IL-1β increased RNA content in MSC-IL-Exo, and pretreatment with RNase abolished anti-inflammatory effect in SW982 cells. miR-147b was found in much larger amounts in MSC-IL-Exo than in MSC-Exo. The miR-147b mimic significantly inhibited the expression of inflammatory cytokines, while the miR-147b inhibitor only partially blocked the anti-inflammatory effect of MSC-IL-Exo. MSC-IL-Exo and miR-147b mimic inhibited the reduction of IκBα, an nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) inhibitor, by IL-1β and TNF-α.

CONCLUSION

This study showed that MSC exosomes with IL-1β priming exhibit significantly enhanced anti-inflammatory activity in osteoarthritic SW982 cells. The effect of IL-1β-primed MSC exosomes is mediated by miRNAs such as miR-147b and involves inhibition of the NF-κB pathway.

Treatment and Healthcare Cost Among Patients with Hip or Knee Osteoarthritis: A Cross-sectional Study Using a Real-world Claims Database in Japan Between 2013 and 2019

BACKGROUND AND OBJECTIVES

The guidelines for osteoarthritis (OA) treatment recommend different therapies including pharmacotherapy, and several analgesic options are available for pain management. In Japan, research on hip and knee OA treatment trends is scarce and OA-related healthcare costs are unknown. Therefore, this study aimed to examine the treatment and healthcare cost trends among Japanese patients with hip or knee OA.

METHODS

This was a cross-sectional study held between 2013 and 2019, using a medical claims database. The demographic and treatment characteristics of hip or knee OA patients for each year were descriptively analyzed and the medians for healthcare utilization and all-cause healthcare costs were calculated.

RESULTS

The yearly mean age of 59,218 hip OA and 270,722 knee OA patients ranged from 66.3 to 68.6 years and 71.1 to 73.1 years, respectively. The prevalence of comorbidities was higher in knee OA than hip OA. In both groups, > 70% of patients were female, and the most common treatment was pain-related medication. In hip OA, topical and systemic nonsteroidal anti-inflammatory drugs (NSAIDs) were mostly used throughout the study period (34.1-41.4% and 32.0-40.3%, respectively). Similarly, in knee OA, topical and systemic NSAIDs were used in 58.3-63.3% and 36.5-46.0% patients, respectively. Increase in the use of acetaminophens (10.9% in hip OA and 10.2% in the knee OA) and weak opioids (3.7%, and 3.4%, respectively) from 2013 to 2019 were observed. Most patients were treated as outpatients in both groups. The median all-cause healthcare costs were approximately 35,000 JPY for hip OA and 74,000 JPY for knee OA.

CONCLUSIONS

Although a considerable change in total healthcare cost was not observed in our study, the contents of medical treatment and cost breakdown were greatly altered due to the treatment and cost for OA itself, and the treatment and cost for comorbidities. Similar studies to investigate such a trend may help predict necessary resources and social needs. Thus, further investigation utilizing other databases is needed.

Mesenchymal Stromal Cell-Derived Extracellular Vesicles - Silver Linings for Cartilage Regeneration?

As the world's population is aging, the incidence of the degenerative disease Osteoarthritis (OA) is increasing. Current treatment options of OA focus on the alleviation of the symptoms including pain and inflammation rather than on restoration of the articular cartilage. Cell-based therapies including the application of mesenchymal stromal cells (MSCs) have been a promising tool for cartilage regeneration approaches. Due to their immunomodulatory properties, their differentiation potential into cells of the mesodermal lineage as well as the plurality of sources from which they can be isolated, MSCs have been applied in a vast number of studies focusing on the establishment of new treatment options for Osteoarthritis. Despite promising outcomes in vitro and in vivo, applications of MSCs are connected with teratoma formation, limited lifespan of differentiated cells as well as rejection of the cells after transplantation, highlighting the need for new cell free approaches harboring the beneficial properties of MSCs. It has been demonstrated that the regenerative potential of MSCs is mediated by the release of paracrine factors rather than by differentiation into cells of the desired tissue. Besides soluble factors, extracellular vesicles are the major component of a cell's secretome. They represent novel mechanisms by which (pathogenic) signals can be communicated between cell types as they deliver bioactive molecules (nucleic acids, proteins, lipids) from the cell of origin to the target cell leading to specific biological processes upon uptake. This review will give an overview about extracellular vesicles including general characteristics, isolation methods and characterization approaches. Furthermore, the role of MSC-derived extracellular vesicles in in vitro and in vivo studies for cartilage regeneration will be summarized with special focus on transported miRNA which either favored the progression of OA or protected the cartilage from degradation. In addition, studies will be reviewed investigating the impact of MSC-derived extracellular vesicles on inflammatory arthritis. As extracellular vesicles are present in all body fluids, their application as potential biomarkers for OA will also be discussed in this review. Finally, studies exploring the combination of MSC-derived extracellular vesicles with biomaterials for tissue engineering approaches are summarized.

Animal models of osteoarthritis: characterization of a model induced by Mono-Iodo-Acetate injected in rabbits

Knee Osteoarthritis is a considerable public health concern, both in terms of life quality and treatment financial impacts. To investigate this disease, animal models are deemed a promising alternative. In fact, although a perfect model is generally farfetched, the creation of models that simulate human disease as accurately as possible remains an important research stake. This study aims to highlight the usefulness of the model induced by injected Mono-Iodo-Acetate and to standardize it for the rabbit species. Osteoarthritis was induced by an infra-patellar injection of 0.2 ml of an MIA solution in the left knee of 24 female New Zealand rabbits. The right knee served as a control by receiving an injection of physiological serum. The rabbits were divided into 4 groups of 6 individuals each according to the dose of MIA received per knee. All rabbits were euthanized 30 days after the injection. After sacrifice, the knees were carefully dissected and macroscopic and microscopic scores of cartilage, meniscal and synovial lesions were attributed to each group. Our study followed the laboratory animal care and management guideline published in 2017 by the Canadian Council of Animal Care. The control knees of all rabbits showed no macroscopic or microscopic lesions. The macroscopic lesions: osteophytes, meniscal lesions, fibrillation and erosion of the cartilage and microscopic lesions: disorganization of the chondrocytes, decrease in proteoglycans and synovial inflammation clinically diagnosed in human pathology were all detected and were similarly reproducible among the knees of the same group. Through this work, we highlighted the merits of the arthritis model induced by MIA, namely its simulation of several aspects of human pathology. Further advantages are low cost, speed, reproducibility. This model notably avoids delicate and risky surgical operations.

Gumiganghwal-tang ameliorates cartilage destruction via inhibition of matrix metalloproteinase

ETHNOPHARMACOLOGICAL RELEVANCE

Kyung-Bang Gumiganghwal-tang tablet (GMGHT) is a standardized Korean Medicine that could treat a cold, headache, arthralgia and fever. Although GMGHT has been used for arthritis-related diseases including a sprain, arthralgia, unspecified arthritis and knee arthritis, there is no pre-clinical evidence to treat osteoarthritis (OA). This study determined the drug dosage and the mechanisms of GMGHT for OA.

METHODS

OA was induced by intra-articular monoiodoacetic acid (MIA) injection in Sprague-Dawley rats. As calculated from the human equivalent dose formula, GMGHT was orally administered at the doses of 9.86, 98.6 and 986 mg/kg for 4 weeks. The arthritis score was performed by a blind test, and histological changes in articular cartilage were indicated by hematoxylin and eosin, Safranin O and toluidine blue staining. SW1353 chondrocytes were stimulated by interleukin (IL)-1β recombinant to analyze the expressions of Type II collagen, matrix metalloproteinases (MMPs) and nuclear factor (NF)-κB.

RESULTS

Rough and punctate surfaces of the femoral condyle induced by MIA, were recovered by the GMGHT treatment. The arthritis score was significantly improved in the 968 mg/kg of GMGHT-treated cartilage. Loss of chondrocytes and proteoglycan were ameliorated at the deep zone of the subchondral bone plate by the GMGHT administration in OA rats. The expression of Type II collagen was increased, while MMP-1, -3 and -13 levels were decreased in the GMGHT-treated SW1353 chondrocytes. In addition, the GMGHT treatment regulated NF-κB activation along with IL-6, transforming growth factor-β and IL-12 production.

CONCLUSIONS

GMGHT promoted the recovery of articular cartilage damage by inhibiting MMPs, accompanied with its anti-inflammatory effects in OA. GMGHT might be an alternative therapeutic treatment for OA.

Longitudinal Assessment of Pain Management Among the Employed Japanese Population with Knee Osteoarthritis

Purpose

To assess comorbidity burden and pain-management patterns among working-aged patients with knee osteoarthritis only (KOA/O) and patients with knee osteoarthritis plus osteoarthritis at another site (KOA/+) in Japan.

Patients and Methods

Retrospective claims data analysis was conducted using the Japan Medical Data Center database. Working-aged adults (aged 40 to 71 years) with 5 years of follow-up and diagnosed with knee osteoarthritis (KOA) between January 1, 2011, and December 31, 2012, were evaluated. The first claim with a KOA diagnosis defined the index date. Patients were divided into two mutually exclusive cohorts: KOA/O and KOA/+. Longitudinal pain-management patterns during each year of follow-up were analyzed.

Results

A total of 2542 patients met study criteria: 1575 KOA/O and 967 KOA/+. Mean age and number of comorbidities were higher among the KOA/+ versus KOA/O cohort. Pharmaceutical treatment was received by 91.5% of patients in the KOA/+ compared with 85.1% of patients in the KOA/O cohort during the first year of follow-up. The most common pharmacological treatment received during the first year of follow-up was either topical or oral nonsteroidal anti-inflammatory drugs for both cohorts. During each year of follow-up, the KOA/+ cohort had greater proportion of patients with at least one health-care encounter (ie, hospital admissions, outpatient and pharmacy visits) and higher direct medical costs compared with the KOA/O cohort.

Conclusion

This study demonstrates that a greater proportion of the working population with KOA/+ received pain-related treatment compared with patients with KOA/O. Further studies are necessary to evaluate appropriate pain management for both KOA only and KOA with other sites.

A Real-World Study Using Claims Data to Evaluate Possible Failure of Opioid Treatment Regimens Among Patients with Hip and/or Knee Osteoarthritis in the US

Background

Although opioids may be used in the management of pain in patients with osteoarthritis (OA), there is a dearth of real-world data characterizing opioid regimen failure in these patients.

Objective

Using claims data, this study explored measures that may be potentially indicative of opioid treatment failure and the association of such potential failure with health care resource utilization (HRU) and costs.

Patients and Methods

Using a national employer-sponsored insurance claims database covering the years 2011–2016, this retrospective longitudinal study identified adults with hip/knee osteoarthritis who filled ≥1 opioid prescription (index event) and had continuous health plan enrollment 6 months pre- and ≥12 months post-index. Index opioid regimen intensity was defined in the 3-month post-index period by frequency, average daily dose, and duration of action. Possible index opioid regimen failure was defined as an increase in opioid regimen intensity, addition of a non-opioid pain medication, joint surgery, or opioid-abuse-related events. One-year follow-up HRU and costs were compared between those with possible treatment failure and those without.

Results

Among 271,512 OA patients (61.5% knee; 11.1% hip; 27.4% both), 34.9% met the definition of possible index opioid regimen failure within a year: increased regimen intensity (16.1%), joint surgery (14.0%), addition of non-opioid pain medication (11.4%), and opioid-abuse-related events (1.9%). Rates of possible failure generally increased with higher index regimen intensity. Compared with those who did not fail, those who potentially failed their index treatment regimen had significantly higher HRU (P<0.001), and all-cause ($36,699 vs $15,114) and osteoarthritis-related costs ($17,298 vs $1,967) (both P<0.0001).

Conclusion

Among OA patients treated with opioids, approximately one-third may fail their index opioid regimen within a year and incur significantly higher HRU and costs than those without. Further research is needed to validate these findings with clinical outcomes.

Comorbidities in Osteoarthritis: A Systematic Review and Meta-Analysis of Observational Studies

OBJECTIVE

Osteoarthritis (OA) is a common chronic condition in older individuals, but its association with other chronic conditions is largely unknown. This study aimed to systematically review the literature on comorbidities in individuals with OA compared to those without.

METHODS

We searched 4 databases for observational studies on comorbidities in individuals with OA. Studies of OA only or in comparison with non-OA controls were included. The risk of bias and study quality were assessed using the Newcastle-Ottawa Scale. The prevalence of comorbidities in the OA group and the prevalence ratio (PR) and 95% confidence interval (95% CI) between OA and non-OA groups were calculated.

RESULTS

In all, 42 studies from 16 countries (27 case-only and 15 comparative studies) met the inclusion criteria. The mean age of participants varied from 51 to 76 years. The pooled prevalence of any comorbidity was 67% (95% CI 57-74) in individuals with OA versus 56% (95% CI 44-68) in individuals without OA. The pooled PR for any comorbidity was 1.21 (95% CI 1.02-1.45). The PR increased from 0.73 (95% CI 0.43-1.25) for 1 comorbidity to 1.58 (95% CI 1.03-2.42) for 2, and to 1.94 (95% CI 1.45-2.59) for ≥3 comorbidities. The key comorbidities associated with OA were stroke (PR 2.61 [95% CI 2.13-3.21]), peptic ulcer (PR 2.36 [95% CI 1.71-3.27]), and metabolic syndrome (PR 1.94 [95% CI 1.21-3.12]).

CONCLUSION

Individuals with OA are more likely to have other chronic conditions. The association is dose-dependent in terms of the number of comorbidities, suggesting multimorbidities. Further studies on the causality of this association and clinical implications are needed.

A Longitudinal Study of the Association of Opioid Use with Change in Pain Interference and Functional Limitations in a Nationally Representative Cohort of Adults with Osteoarthritis in the United States

Introduction

Real-world data are sparse on longitudinal associations of opioid use with pain interference with activities (PIA) and daily function with osteoarthritis (OA) in the USA.

Methods

Data from the 2010–2015 Medical Expenditure Panel Surveys were analyzed for community-dwelling adults with OA. Opioid use patterns were defined as persistent, intermittent, and no use. Evaluated outcomes were a change in PIA and functional limitations (activities of daily living [ADL], instrumental ADL [IADL], social and work activities, and cognitive function). Multivariable regression analyses explored the association of persistent/intermittent versus no opioid use with PIA and functional limitations. Results were weighted for the US population.

Results

Among 4172 patients (66.2% female, 80.8% white, mean age 61.7 years), 62.1% reported no PIA change at follow-up, 17.9% worsened, and 20.0% improved. Although 51.0–93.1% of patients reported no functional limitations, 3.8–13.1% worsened (1.1–11.3% improved). Relative to no opioid use, persistent users had higher odds of severe/extreme PIA (adjusted odds ratio [AOR], 2.91; 95% confidence interval [CI], 1.95–4.32; P < 0.001) and moderate PIA (AOR, 2.04; 95% CI, 1.31–3.20; P < 0.01) at follow-up. For patients with baseline functional limitations, persistent opioid users were more likely to report physical and work limitations at follow-up (both P < 0.05). For patients without baseline functional limitations, persistent opioid users had higher odds than those without use of reporting IADL, physical, social, and cognitive limitations at follow-up (all P < 0.05); intermittent users were more likely to report physical and social limitations (both P < 0.05).

Conclusions

Persistent opioid use for pain in patients with OA appeared to be associated with poorer PIA and functional outcomes, regardless of baseline functional status. These findings highlight the importance of patient-reported outcomes for opioid benefit–risk assessment and suggest the need for alternative analgesic approaches.

Impact of Pain Severity and Opioid Use on Health Care Resource Utilization and Costs Among Patients with Knee and Hip Osteoarthritis

BACKGROUND

Osteoarthritis (OA) is the most common form of arthritis. The primary symptom of OA-pain-increases the disease burden by negatively affecting daily activities and quality of life. Opioids are often prescribed for treating pain in patients with OA but have questionable benefit-risk profiles. There is limited evidence on the economic impact of pain severity and opioid use among patients with OA.

OBJECTIVES

To (a) evaluate the association of pain severity with health care resource utilization (HRU) and costs among patients with knee/hip OA and (b) characterize the association of opioid use with HRU and costs while controlling for pain severity.

METHODS

Using deterministically linked health care claims data and electronic health records from the Optum Research Database, this retrospective cohort study included commercial and Medicare Advantage Part D enrollees who were diagnosed with knee/hip OA during the January 1, 2010-December 31, 2016 time period and had ≥ 1 pain score (11-point Likert scale: 0 = no pain, 10 = worst possible pain) between the first OA diagnosis date and October 2016. The index date was the date of the evaluated pain score; HRU and costs were observed over the 3-month postindex period. For patients with multiple pain scores, each episode required a 3-month post-index follow-up period. Generalized estimating equation models, adjusted for multiple observation panels per patient and baseline variables that may contribute to HRU and costs (age, sex, race/ethnicity, region, insurance type, integrated delivery network, body mass index, pain medication use, provider specialty, Charlson Comorbidity Index score, and other select comorbid conditions), were used to estimate all-cause and OA-related costs expressed as per patient per month (PPPM). Comparisons were performed for moderate (score 4-6) and severe (score 7-10) pain episodes versus no/mild pain episodes (score 0-3) and those with baseline opioid use versus those without.

RESULTS

Included were 35,861 patients with knee/hip OA (mean age 66.5 years; 64.7% women) who had 70,716 pain episodes (58% mild, 23% moderate, 19% severe, and 37.0% with baseline opioid use). When controlling for other potential confounding factors, moderate/severe pain episodes were associated with higher all-cause and OA-related HRU than mild pain episodes. Relative to mild pain episodes, moderate/severe pain episodes were also associated with significantly higher adjusted average all-cause PPPM costs ($1,876/$1,840 vs. $1,602), and OA-related PPPM costs ($550/$577 vs. $394; all P < 0.05). Baseline opioid use was associated with significantly higher all-cause PPPM costs versus no opioid use (mild, $1,735 vs. $1,492; moderate, $2,034 vs. $1,755; severe, $2,100 vs. $1,643, all P < 0.001), and a higher likelihood of incurring OA-related costs relative to those without (P < 0.001).

CONCLUSIONS

These results provide evidence of the economic impact of opioid use and inadequate pain control by demonstrating that increased pain severity and opioid use in patients with OA were independently associated with higher HRU and costs. Additional studies should confirm causality between opioid use and HRU and costs, taking into consideration underlying OA characteristics.

DISCLOSURES

Funding for this study was contributed by Regeneron Pharmaceuticals and Teva Pharmaceutical Industries. Wei is an employee at Regeneron Pharmaceuticals, with stock ownership. Gandhi was an employee at Teva Pharmaceutical Industries, with stock ownership, at the time of this study. Blauer-Peterson and Johnson are employees of Optum, which was contracted to conduct the research for this study.

Umbilical cord-derived mesenchymal stem cells for treating osteoarthritis of the knee: a single-arm, open-label study

BACKGROUND

Despite being a common cause of quality-of-life impairment, there are no efficacious therapies that could prevent the progression of knee osteoarthritis (KOA). We conducted an open-label trial of human umbilical cord-derived mesenchymal stem cells (hUC-MSCs) and hyaluronic acid (HA) for treating KOA.

METHODS

This open-label study was conducted from July 2015 to December 2018 at Cipto Mangunkusumo Hospital, Jakarta, Indonesia. Patients diagnosed with KOA were injected three times, comprising of 10 × 106 units of hUC-MSCs in 2-ml secretome implantation and 2-ml hyaluronic acid (HA) injection in the first week, followed with 2-ml HA injection twice in the second and third week.

RESULTS

Twenty-nine subjects (57 knees) were recruited. Seventeen (58.6%) subjects were male, and the mean age was 58.3 ± 9.6 years. Thirty-three (57.9%) knees were classified into Kellgren-Lawrence grade I-II KOA (mild OA). hUC-MSCs significantly decreased pain measured by visual analogue scale in severe KOA from initial to 6th month follow-up [5 ± 2.97 to 3.38 ± 2.44 (p = 0.035)]. The International Knee Documentation Committee score significantly increased at 6th month follow-up (53.26 ± 16.66 to 65.49 ± 13.01, p < 0.001, in subjects with grade I-II and 48.84 ± 18.41 to 61.83 ± 18.83, p = 0.008, in subjects with severe KOA). The Western Ontario and McMaster Universities Osteoarthritis decreased significantly in both groups from initial to 6th month follow-up (from 22.55 ± 15.94 to 13.23 ± 10.29, p = 0.003, and from 27.57 ± 15.99 to 17.92 ± 19.1, p = 0.003, in those with mild and severe KOA, respectively).

CONCLUSIONS

hUC-MSCs could be a potentially new regenerative treatment for KOA. The maximum effect of hUC-MSCs was achieved after 6 months of injection.

LEVEL OF EVIDENCE

Therapeutic level II.

Effects of Osteoarthritis Pain and Concurrent Insomnia and Depression on Health Care Use in a Primary Care Population of Older Adults

OBJECTIVE

To examine independent and combined effects of pain with concurrent insomnia and depression symptoms on the use of health care services in older adults with osteoarthritis (OA).

METHODS

Patients were Group Health Cooperative (GHC) patients with a primary diagnosis of OA (n = 2,976). We used survey data on pain (Graded Chronic Pain Scale), insomnia (Insomnia Severity Index), and depression (Patient Health Questionnaire-8), and health care use extracted from GHC electronic health records (office visits, length of stay, outpatient and inpatient costs, and hip or knee replacement) for 3 years after the survey. Negative binomial, logistic, and generalized linear models were used to assess predictors of health care use.

RESULTS

Approximately 34% and 29% of patients displayed at least subclinical insomnia and at least subclinical depression symptoms, respectively, in addition to moderate-to-severe pain. Pain had the greatest independent effects on increasing all types of health care use, followed by depression (moderate effects) on increased office visits, length of stay, outpatient and inpatient costs, and insomnia (mild effects) on decreased length of stay. No synergistic effects of the 3 symptoms on use of health care services were observed. The combined effects of pain plus insomnia and pain plus depression were significant for all types of health care use and increased greatly with increasing severity of insomnia and depression, except for hip/knee replacement.

CONCLUSION

Pain is the main driver for health care use in patients with OA. In addition to pain, insomnia plus depression jointly increased diverse types of health care use, and these combined effects increased greatly with increasing severity of insomnia and depression. These findings indicate the important role that concurrent symptomatic conditions may play in increasing use of health care services.

Patterns of drug treatment in patients with osteoarthritis and chronic low back pain in Japan: a retrospective database study

Purpose: Musculoskeletal diseases, including osteoarthritis (OA) and low back pain (LBP), are the leading causes of years lived with disability, and are associated with lowered quality-of-life, lost productivity, and increased healthcare costs. However, information publicly available regarding the Japanese real-world usage of prescription medications is limited. This study aimed to describe the clinical characteristics of patients with OA and chronic LBP (CLBP), and to investigate the patterns of medications and opioid use in Japanese real-world settings.

Materials and methods: A retrospective study was conducted using a Japanese administrative claims database between 2013 and 2017. The outcomes were patient characteristics and prescription medications, and they were evaluated separately for OA and CLBP.

Results: The mean age of 118,996 patients with OA and 256,402 patients with CLBP was 68.8±13.1 years and 64.8±16.4 years, respectively. Approximately 90% of patients with OA and CLBP were prescribed non-steroidal anti-inflammatory drugs (NSAIDs). Other prescriptions included hyaluronate injection (35.6%), acetaminophen (21.4%), and steroid injection (20.0%) in patients with OA, and pregabalin (39.0%) and acetaminophen (22.4%) in patients with CLBP. Weak opioids were prescribed to 10.7% and 20.6% of patients with OA and CLBP, respectively. The prescription of COX-2 inhibitors (OA: +6.5%; CLBP: +6.7%) and acetaminophen (OA: +16.4%; CLBP: +14.4%) increased between 2013 and 2017. The first commonly prescribed medication among patients with OA and CLBP were NSAIDs; hyaluronate injection (patients with OA) and pregabalin (patients with CLBP) were also common first-line medications. Acetaminophen, steroid injection (patients with OA), and weak opioids were prescribed more in the later phases of treatment.

Conclusion: Most patients were prescribed limited classes of pain drugs, with NSAIDs being the most common pain medication in Japan for patients with OA and CLBP. Opioid prescription was uncommon, and were weak opioids when prescribed.

Stem Cell-Derived Extracellular Vesicles for Treating Joint Injury and Osteoarthritis

Extracellular vesicles (EVs) are nanoscale particles secreted by almost all cell types to facilitate intercellular communication. Stem cell-derived EVs theoretically have the same biological functions as stem cells, but offer the advantages of small size, low immunogenicity, and removal of issues such as low cell survival and unpredictable long-term behaviour associated with direct cell transplantation. They have been an area of intense interest in regenerative medicine, due to the potential to harness their anti-inflammatory and pro-regenerative effects to induce healing in a wide variety of tissues. However, the potential of using stem cell-derived EVs for treating joint injury and osteoarthritis has not yet been extensively explored. The pathogenesis of osteoarthritis, with or without prior joint injury, is not well understood, and there is a longstanding unmet clinical need to develop new treatments that provide a therapeutic effect in preventing or stopping joint degeneration, rather than merely relieving the symptoms of the disease. This review summarises the current evidence relating to stem cell-derived EVs in joint injury and osteoarthritis, providing a concise discussion of their characteristics, advantages, therapeutic effects, limitations and outlook in this exciting new area.

Umbilical Cord-Derived Mesenchymal Stromal Cells (MSCs) for Knee Osteoarthritis: Repeated MSC Dosing Is Superior to a Single MSC Dose and to Hyaluronic Acid in a Controlled Randomized Phase I/II Trial

Knee osteoarthritis (OA) is a leading cause of pain and disability. Although conventional treatments show modest benefits, pilot and phase I/II trials with bone marrow (BM) and adipose‐derived (AD) mesenchymal stromal cells (MSCs) point to the feasibility, safety, and occurrence of clinical and structural improvement in focal or diffuse disease. This study aimed to assess the safety and efficacy of the intra‐articular injection of single or repeated umbilical cord‐derived (UC) MSCs in knee OA. UC‐MSCs were cultured in an International Organization for Standardization 9001:2015 certified Good Manufacturing Practice‐type Laboratory. Patients with symptomatic knee OA were randomized to receive hyaluronic acid at baseline and 6 months (HA, n = 8), single‐dose (20 × 10⁶) UC‐MSC at baseline (MSC‐1, n = 9), or repeated UC‐MSC doses at baseline and 6 months (20 × 10⁶ × 2; MSC‐2, n = 9). Clinical scores and magnetic resonance images (MRIs) were assessed throughout the 12 months follow‐up. No severe adverse events were reported. Only MSC‐treated patients experienced significant pain and function improvements from baseline (p = .001). At 12 months, Western Ontario and Mc Master Universities Arthritis Index (WOMAC‐A; pain subscale) reached significantly lower levels of pain in the MSC‐2‐treated group (1.1 ± 1.3) as compared with the HA group (4.3 ± 3.5; p = .04). Pain Visual Analog scale was significantly lower in the MSC‐2 group versus the HA group (2.4 ± 2.1 vs. 22.1 ± 9.8, p = .03) at 12 months. For total WOMAC, MSC‐2 had lower scores than HA at 12 months (4.2 ± 3.9 vs. 15.2 ± 11, p = .05). No differences in MRI scores were detected. In a phase I/II trial (NCT02580695), repeated UC‐MSC treatment is safe and superior to active comparator in knee OA at 1‐year follow‐up. stem cells translational medicine2019;8:215&224

Effects of Pain, Insomnia, and Depression on Psychoactive Medication Supply in Older Adults With Osteoarthritis

BACKGROUND

Determinants of prescribing psychoactive medications for symptom management in older adults remain underexamined despite known risks and cautions concerning these medications.

OBJECTIVE

To examine independent and combined effects of pain, concurrent insomnia and depression symptoms on psychoactive medications supplied to older adults with osteoarthritis (OA).

RESEARCH DESIGN

Survey data on pain, insomnia, and depression obtained from OA patients screened for a randomized controlled trial were used to identify predictors of psychoactive medication supply [opioids, sedatives, tricyclic antidepressants (TCAs), and non-TCAs] over a 4-year period.

SUBJECTS

Group Health Cooperative patients with a diagnosis of OA (N=2976).

MEASURES

Survey data on pain (Graded Chronic Pain Scale), insomnia (Insomnia Severity Index), and depression (Patient Health Questionnaire-8); and medications supply assessed from electronic medical records.

RESULTS

In negative binomial models, pain [incidence rate ratio (IRR), 2.8-3.5; P<0.001], insomnia (IRR, 2.0; P<0.001), and depression (IRR, 1.5; P<0.05) each independently predicted opioid supply. Insomnia (IRR, 3.2; P<0.001) and depression (IRR, 3.0; P<0.001) each independently predicted sedative supply. Pain (IRR, 2.1; P<0.05) and insomnia (IRR, 2.0; P<0.05) independently predicted TCA supply, whereas only depression (IRR, 2.2; P<0.001) independently predicted non-TCA supply. Combined effects of pain and insomnia/depression on these medications were additive and increased the rate of medication supply 1.5-7.5 times. Combined effects increased with insomnia or depression severity.

CONCLUSIONS

Concurrent insomnia and depressive symptoms predicted increased supply of opioids, sedatives, and antidepressants after accounting for pain, indicating the importance of sleep and mood disorders as factors increasing supply of these medications.

N-of-1 Randomized Trials of Ultra-Micronized Palmitoylethanolamide in Older Patients with Chronic Pain

BACKGROUND

Ultra-micronized palmitoylethanolamide (um-PEA) represents an attractive option for chronic pain control in complex older patients at higher risk of adverse effects with traditional analgesics.

OBJECTIVE

The aim of this study was to determine the effectiveness of um-PEA versus placebo on chronic pain intensity and function in individual geriatric patients.

DESIGN

We performed randomized, blinded N-of-1 trials with two 3-week um-PEA versus placebo comparisons, separated by 2-week washout periods.

PARTICIPANTS

The study included outpatients aged ≥ 65 years with chronic, non-cancer, non-ischemic pain in the back, joints, or limbs.

INTERVENTION

Patients were randomized to Um-PEA 600 mg or placebo twice daily.

MEASUREMENTS

Pain intensity was measured using an 11-point visual numeric scale. Functional impairment was measured using a Back Pain Functional Scale. Impact of each N-of-1 trial was measured on the clinician's intention to treat and confidence.

RESULTS

Ten of 11 eligible patients consented over 7 months [all female, mean age 83.2 years (SD 4.6)]. Three patients interrupted the trial: one had diarrhea (under placebo), one for low adherence, and one for intercurrent pneumonia. A small statistically significant effect in favor of um-PEA was seen at the mixed method analyses in two patients (effect size equal to 8% of the baseline pain). A statistically significant impact on function was found in one patient. After the trial, um-PEA was prescribed to four patients; in two patients the clinician changed their pre-trial intention to treat; the clinician confidence in the treatment plan either increased (5) or remained the same (2).

CONCLUSIONS

Our experience confirmed that N-of-1 trials may help make personalized evidence-based decisions in complex older patients, with special feasibility considerations. CLINICALTRIALS.GOV: NCT02699281.

CTHRC1 mediates IL‑1β‑induced apoptosis in chondrocytes via JNK1/2 signaling

Osteoarthritis (OA), also known as degenerative joint disease or degenerative arthritis, is characterized by chondrocyte apoptosis. The aim of the present study was to investigate the effects of collagen triple helix repeat containing 1 (CTHRC1) and the c‑Jun N‑terminal kinase (JNK) 1/2 inhibitor SP600125 on rat chondrocytes cultured in vitro with interleukin (IL)‑1β. Chondrocytes were treated with different doses of IL‑1β and cell viability and CTHRC1 expression were assessed using Cell Counting Kit‑8 and western blot assays, respectively. In separate experiments, chondrocytes were treated with CTHRC1‑expressing constructs (pLVX‑Puro‑CTHRC1) and/or SP600125, or IL‑1β with either CTHRC1 short hairpin (sh)RNA constructs (shNRA‑CTHRC1) or SP600125. The expression of CTHRC1, B‑cell lymphoma (Bcl)‑2, Bcl‑2‑associated X protein (Bax), cleaved caspase‑3, poly ADP ribose polymerase (PARP)‑1 and matrix metalloproteinase (MMP)‑13 was measured using reverse transcription‑quantitative polymerase chain reaction and western blotting assays. A Cell Counting Kit‑8 assay was performed to examine cell viability. Annexin V/propidium iodide staining and flow cytometry assays were used to detect chondrocyte apoptosis. The expression of JNK1/2 and phosphorylated JNK1/2 was measured using western blotting. CTHRC1 was highly expressed in patients with OA compared with normal controls. IL‑1β treatment (5, 10 and 20 ng/ml) increased the protein expression of CTHRC1 in a dose‑dependent manner and decreased the viability of chondrocytes in a time‑dependent manner. pLVX‑Puro‑CTHRC1 mimics the effect of IL‑1β on chondrocyte apoptosis and JNK1/2 activity, and this is reversed by SP600125 treatment. However, transfection with shRNA‑CTHRC1 or treatment with SP600125 inhibited IL‑1β‑induced cell apoptosis and JNK1/2 activation. These results indicate that CTHRC1 downregulation may protect chondrocytes from IL‑1β‑induced apoptosis by inactivating the JNK1/2 pathway.