WOMAC Meaningful Within-patient Change: Results From 3 Studies of Tanezumab in Patients With Moderate-to-severe Osteoarthritis of the Hip or Knee

Statistical Analysis for Rating Scale in Clinical Trials

In psychiatry clinical trials, an instrument or questionnaire with rating scale is often used to access safety and efficacy of a test treatment under investigation. Statistical analysis based on the collected rating scale is then performed a determine whether there is an improvement in endpoint change from baseline mean scale. This approach needs on absolute change, however, may not actually reflect the performance of the test treatment under study because the change, which may be considered of clinically importance, may fall within the same category in terms of disease severity such as mild, moderate, and severe. In this case, it is suggested, in addition to absolute change approach, a categorical shift analysis be considered to determine whether the endpoint change from baseline has resulted in an improvement in categorical shift, in terms of disease severity shift e.g., from severe to mild or moderate. In this article, we explore the relationship between absolute change approach and categorical shift analysis based on rating scales for assessment of test treatment under study.

Efficacy of a single ultrasound-guided injection of high molecular weight hyaluronic acid combined with collagen tripeptide in patients with knee osteoarthritis and chondrocalcinosis

Introduction

Osteoarthritis (OA) and calcium pyrophosphate deposition (CPPD) often co-exist, this resulting in a clinical condition characterized by amplified inflammation and more severe and faster cartilage degeneration compared to OA alone. Our study aims to explore the efficacy of a therapeutic approach that addresses both conditions, using a combination of a high molecular weight hyaluronic acid (HMWHA) and collagen tripeptide (CTP). Additionally, safety profile and baseline characteristic predictive value were evaluated.

Methods

We conducted a retrospective study on patients diagnosed with symptomatic knee OA (KOA) and CPPD treated by ultrasound (US) guided intraarticular injections of HMWHA-CT in the outpatient clinics of the Interdisciplinary Pain Medicine Unit at Santa Maria Maddalena Hospital, Occhiobello, Italy and in the Rheumatology Unit of the Emergency County Hospital Craiova, Romania (ECH Craiova). All the patients underwent clinical and US evaluation at baseline, 1, 3, and 6 months. From clinical point of view, Numeric Rating Scale (NRS) pain and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were recorded. US data included detection of synovitis, cartilage damage, osteophytes, and CPPD deposits. Clinical efficacy was defined with NRS and WOMAC variations in respect to baseline and using the minimal clinically important difference values: an improvement of 2 point for NRS pain and 10 for the total score for WOMAC.

Results

Twenty-nine patients (34 knees) were injected and evaluated. Overall pain levels, as measured by NRS, demonstrated a consistent decrease in patients across all follow-up intervals, with the most substantial improvement at the 6-month compared to baseline measurements. A significative proportion of patients achieved the minimum clinically detectable improvement, specifically 79% for NRS and 83% for WOMAC (19 and 20 patients, respectively).

Conclusion

Our data showed a significant efficacy of ultrasound guided HMWHA-CT, in patients with KOA and CPPD, thus making it reasonable to consider that the combination of HMWHA and CTP can provide a strong anti-inflammatory effect.

The impact of diabetes status on pain and physical function following total joint arthroplasty for hip and knee osteoarthritis: variation by sex and body mass index

Few studies have examined diabetes impact on total joint arthroplasty (TJA) outcomes, with variable findings. We investigated the association between diabetes and post-TJA physical function and pain, examining whether diabetes impact differs by sex and BMI. Patient sample completed questionnaires within 3 months prior to hip or knee TJA for osteoarthritis (OA) and 1-year post-surgery. Surgical 'non-response' was defined as < 30% improvement in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and physical function at 1-year. Two adjusted logistic regression models were estimated: (1) excluding, (2) including an interaction between diabetes, sex and BMI. The sample (626 hip, 754 knee) was 54.9% female, had mean BMI of 30.1, 13.0% reported diabetes. In adjusted models excluding an interaction, diabetes was not associated with non-response. However, a significant 3-way interaction (physical function: p = 0.003; pain: p = 0.006) between diabetes, sex, and BMI was found and was associated with non-response: non-response probability increased with increasing BMI in men with diabetes, but decreased with increasing BMI in women in diabetes. Findings suggest uncertainty in diabetes impact may be due to differential impacts by sex and BMI. A simple consideration of diabetes as present vs. absent may not be sufficient, with implications for the large TJA population.

Targeting TRP Channels for Pain, Itch and Neurogenic Inflammation

Transient receptor potential (TRP) channels are multifunctional signaling molecules with important roles in health and disease [...].

Meaningful within-patient change for clinical outcome assessments: model-based approach versus cumulative distribution functions

OBJECTIVES

The FDA recommends the use of anchor-based methods and empirical cumulative distribution function (eCDF) curves to establish a meaningful within-patient change (MWPC) for a clinical outcome assessment (COA). In practice, the estimates obtained from model-based methods and eCDF curves may not closely align, although an anchor is used with both. To help interpret their results, we investigated and compared these approaches.

METHODS

Both repeated measures model (RMM) and eCDF approaches were used to estimate an MWPC on a target COA. We used both real-life (ClinicalTrials.gov: NCT02697773) and simulated data sets that included 688 patients with up to six visits per patient, target COA (range 0 to 10), and an anchor measure on patient global assessment of osteoarthritis from 1 (very good) to 5 (very poor). Ninety-five percent confidence intervals for the MWPC were calculated by the bootstrap method.

RESULTS

The distribution of the COA score changes affected the degree of concordance between RMM and eCDF estimates. The COA score changes from simulated normally distributed data led to greater concordance between the two approaches than did COA score changes from the actual clinical data. The confidence intervals of MWPC estimate based on eCDF methods were much wider than that by RMM methods, and the point estimate of eCDF methods varied noticeably across visits.

CONCLUSIONS

Our data explored the differences of model-based methods over eCDF approaches, finding that the former integrates more information across a diverse range of COA and anchor scores and provides more precise estimates for the MWPC.

Assessment of Residual Pain and Dissatisfaction in Total Knee Arthroplasty: Methods Matter

Background

Residual pain after total knee arthroplasty (TKA) refers to knee pain after 3 to 6 months postoperatively. The estimates of the proportion of patients who experience residual pain after TKA vary widely. We hypothesized that the variation may stem from the range of methods used to assess residual pain. We analyzed data from 2 prospective studies to assess the proportion of subjects with residual pain as defined by several commonly used metrics and to examine the association of residual pain defined by each metric with participant dissatisfaction.

Methods

We combined participant data from 2 prospective studies of TKA outcomes from subjects recruited between 2011 and 2014. Residual pain was defined using a range of metrics based on the WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) pain score (0 to 100, in which 100 indicates worst), including the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS). We also examined combinations of MCID and PASS cutoffs. Subjects self-reported dissatisfaction following TKA, and we defined dissatisfied as somewhat or very dissatisfied at 12 months. We calculated the proportion of participants with residual pain, as defined by each metric, who reported dissatisfaction. We examined the association of each metric with dissatisfaction by calculating the sensitivity, specificity, positive predictive value, and Youden index.

Results

We analyzed data from 417 subjects with a mean age (and standard deviation) of 66.3 ± 8.3 years. Twenty-six participants (6.2%) were dissatisfied. The proportion of participants defined as having residual pain according to the various metrics ranged from 5.5% to >50%. The composite metric Improvement in WOMAC pain score ≥20 points or final WOMAC pain score ≤25 had the highest positive predictive value for identifying dissatisfied subjects (0.54 [95% confidence interval, 0.35 to 0.71]). No metric had a Youden index of ≥50%.

Conclusions

Different metrics provided a wide range of estimates of residual pain following TKA. No estimate was both sensitive and specific for dissatisfaction in patients who underwent TKA, underscoring that measures of residual pain should be defined explicitly in reports of TKA outcomes.

Level of Evidence

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A comparison of jade moxibustion and traditional moxibustion in the treatment of knee osteoarthritis: A randomized clinical trial

BACKGROUND

This study was developed to compare the relative clinical efficacy of traditional moxibustion and Jade moxibustion in an effort to define the most effective approaches to treating knee osteoarthritis.

METHODS

In total, 94 patients were randomly assigned at a 1:1 ratio to the traditional moxibustion (TM) and Jade moxibustion (JM) groups. For JM, a jade kneepad was preheated for 3 minutes via electrification, with the jade in the kneepad being pressed onto acupoints when reaching an initial temperature of 46°C. For patients in the TM group, moxa cones were applied to acupoints for treatment. In total, 12 treatments were performed for patients in each group, with treatment being conducted 3 times per week. Study outcomes included 36-item short-form health survey and Western Ontario and McMaster Universities Osteoarthritis Index knee stiffness scores. In addition, serum levels of osteoarthritis-related cytokines were measured.

RESULTS

Overall, 89/94 patients completed this study, including 44 and 45 in the TM and JM groups, respectively. The 36-item short-form health survey physical functioning at weeks 12 and 24 (P = .033, 0.001), role-physical at weeks 4 and 24 (P = .030, 0.014), and role-emotional at week 4 (P = .045) were the only scores to differ significantly between the TM and JM groups. Western Ontario and McMaster Universities Osteoarthritis Index stiffness scores in the JM groups improved significantly relative to baseline at weeks 4, 8, 12, and 24 (all P < .01). The scores in the TM group differed significantly at all time points relative to baseline (all P < .01), with no differences between groups (all P > .05). Serum Interleukin-2 levels were lower in both groups (all P < .01). Cartilage oligomeric matrix protein and monocyte chemotactic protein-1 only differed significantly for patients treated via JM (P < .05, P < .01), with the same also being true for Interleukin-1β and Interleukin-8 in the TM group (all P < .01). No significant differences in other cytokines were observed, nor did they differ significantly between groups (all P > .05).

CONCLUSION

These results suggest that JM treatment can improve knee osteoarthritis patient quality of life, alleviating joint stiffness and restoring joint function with a level of efficacy comparable to TM.

From Meaningful Outcomes to Meaningful Change Thresholds: A Path to Progress for Establishing Digital Endpoints

This paper examines the use of digital endpoints (DEs) derived from digital health technologies (DHTs), focusing primarily on the specific considerations regarding the determination of meaningful change thresholds (MCT). Using DHTs in drug development is becoming more commonplace. There is general acceptance of the value of DHTs supporting patient-centric trial design, capturing data outside the traditional clinical trial setting, and generating DEs with the potential to be more sensitive to change than conventional assessments. However, the transition from exploratory endpoints to primary and secondary endpoints capable of supporting labeling claims requires these endpoints to be substantive with reproducible population-specific values. Meaningful change represents the amount of change in an endpoint measure perceived as important to patients and should be determined for each digital endpoint and given population under consideration. This paper examines existing approaches to determine meaningful change thresholds and explores examples of these methodologies and their use as part of DE development: emphasizing the importance of determining what aspects of health are important to patients and ensuring the DE captures these concepts of interest and aligns with the overarching endpoint strategy. Examples are drawn from published DE qualification documentation and responses to qualification submissions under review by the various regulatory authorities. It is the hope that these insights will inform and strengthen the development and validation of DEs as drug development tools, particularly for those new to the approaches to determine MCTs.

The beneficial role of companion animals in translational pain research

The use of spontaneous painful disease in companion pet animals has been highlighted as one of the changes that could be made to help improve translation of basic science to new therapeutics, acting as a bridge between preclinical and clinical studies, with the goal of accelerating the approval of new therapeutics. This review focuses on the utility of companion pet dogs for translational research by reviewing what outcome measures can be measured, and importantly, the relevance of these outcome measures to human translational research. It also details the practical considerations involved in incorporating companion dogs into human therapeutic development.