{"id":529,"date":"2015-01-14T20:53:15","date_gmt":"2015-01-14T20:53:15","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=529"},"modified":"2017-08-21T12:04:54","modified_gmt":"2017-08-21T12:04:54","slug":"primary-care-corner-with-geoffrey-modest-md-knee-osteoarthritis-therapies","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/01\/14\/primary-care-corner-with-geoffrey-modest-md-knee-osteoarthritis-therapies\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Knee Osteoarthritis Therapies"},"content":{"rendered":"

By: Dr. Geoffrey Modest<\/strong><\/p>\n

The Annals of Intl Medicine had a recent systematic review (137 studies with 33,243 participants)\u00a0and network meta-analysis of different therapies for knee osteoarthritis, including acetaminophen, diclofenac, ibuprofen, naproxen, celecoxib, intra-articular (IA) steroids, IA hyaluronic acid, oral placebo and IA placebo (see\u00a0Ann Intern Med. 2015;162:46-54\u200b).\u00a0A network meta-analysis is a mathematical construct to assess the data from multiple individual\u00a0head-to-head comparisons and integrate it all\u00a0into a single comparative analysis<\/p>\n

\"824px-Osteoarthritis_left_knee\"Results:<\/p>\n

–median\u00a0age overall was 62, 67% women<\/p>\n

–for pain (129 trials, 32,129 participants), all interventions were\u00a0better than placebo. Size effects ranged from 0.63 for most efficacious treatment (IA hyaluronic acid) to 0.61 for\u00a0IA steroids, 0.52 for diclofenac, 0.44 for ibuprofen, 0.38 for naproxen, 0.33 for celexoxib, 0.29 for IA placebo, and 0.18 for acetaminophen.<\/p>\n

–for function (76 trials, 24,059 participants), all were better than oral placebo except IA steroids. Naproxen, ibuprofen, diclofenac, and celecoxib were statistically better than acetaminophen. IA hyaluronic acid was statistically superior to IA steroids.<\/p>\n

–for stiffness (55 trials, 18267 participants), most of the treatments were not significantly different from each other. Naproxen, ibuprofen, diclofenac, and celecoxib were statistically better than acetaminophen.<\/p>\n

A few issues regarding the limitations of a network analysis.<\/p>\n

–the most evident limitation\u00a0is that there is not a common study comparing all of the different management strategies with a common placebo group. And we know that even comparisons of the same treatments in different studies typically lead to differing results.\u00a0So given that most of the individual trials done in this network analysis included <5 studies, with 9 of\u00a0the\u00a019\u00a0therapy\u00a0comparisons\u00a0having\u00a0only 1 or 2 trials,\u00a0the small differences between many of the results above may well not be statistically or clinically significant.\u00a0And, of note,\u00a0 there were\u00a0very few direct comparisons between IA and oral agents. This is relevant since\u00a0IA steroids are commonly used, yet the only comparison studies with IA steroids was with IA hyaluronic acid and IA placebo.\u00a0Also, even though 67% of the participants were women, some studies had only\/mostly\u00a0men, so one cannot assume that the overall results necessarily apply to women without looking specifically at the studies\u00a0in question.<\/p>\n

–second, they did not include trials with multiple interventions (and, from my experience, that is the most common clinical\u00a0scenario: IA steroids with use of acetaminophen or NSAID as needed, alternating acetaminophen with NSAID, etc).<\/p>\n

–third, the assessments tools use\u00a0in the different analyses (eg, assessment of pain, stiffness, function) were sometimes different in different studies, so the researchers tried to convert these outcomes to more standard scales (eg, WOMAC VAS, or Western Onatario and McMaster Universities OA Index, visual analogue scale), with attendant potential\u00a0errors in these conversions.<\/p>\n

–their conclusion that “for function, all interventions except IA corticosteroids were significantly superior to oral placebo” is a tad suspect\/overstated, since there were no studies (ie, zero) which compared IA steroids to oral placebo. In fact the largest numbers of studies compared celecoxib to\u00a0oral placebo to, IA hyaluronic acid to diclofenac, and IA hyaluronic acid to naproxen and to placebo.\u00a0At least in our health center in Boston, most of these large-comparator therapies are almost never used (with the exception of naproxen).<\/p>\n

—\u00a0my experience with IA steroids for knee OA, which is pretty extensive (probably on the order of 500 injections over many years), is overall impressive. Although some people with OA do not respond or only for a few weeks (especially in those who have had multiple prior injections), a very large percentage do get significant reasonably longterm relief (essentially pain-free and full return of function for\u00a03-12 months) and are spared the significant adverse effects of NSAIDS, especially common in the elderly (who are the ones who mostly get knee OA….). I\u00a0do understand that there are likely placebo effects for IA therapies (as they found above), but in my experience I have seen zero adverse events for knee injections (or any other place I’ve injected, which probably brings my sample size to around 1000….).\u00a0So, IA steroids\u00a0seems to me\u00a0to be mostly very effective (lots of benefits and not apparent risks over several decades).<\/p>\n","protected":false},"excerpt":{"rendered":"

Knee Osteoarthritis Therapies […]<\/p>\n

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