SummaryObjectiveTo compare the efficacy of topical non-steroidal anti-inflammatory drugs (NSAIDs) with topical capsaicin for pain relief in osteoarthritis (OA).DesignA systematic literature search was conducted for randomised controlled trials (RCTs) examining any topical NSAID or capsaicin in OA. Pain relief at or nearest to 4 weeks was pooled using a random-effects network meta-analysis (NMA) in a Frequentist and Bayesian setting. Analysis was conducted for all trials and for trials using drugs listed as licensed for OA in the British National Formulary (BNF).ResultsThe trial network comprised 28 RCTs (7372 participants), of which 17 RCTs (3174 participants) were included in the as licensed analyses. No RCTs directly compared topical NSAIDs with capsaicin. Placebo was the only common comparator for topical NSAIDs and capsaicin. Frequentist and Bayesian effect size (ES) estimates were in agreement. Topical NSAIDs were statistically superior to placebo overall (ES 0.30, 95% confidence interval [CI] 0.19 to 0.41) and as licensed (ES 0.32, 95% CI 0.24 to 0.39). However, capsaicin was only statistically superior to placebo when used at licensed doses (ES 0.41, 95% CI 0.17 to 0.64). No significant differences were observed in pain relief between topical NSAIDs and capsaicin (overall: ES 0.04, 95% CI −0.26 to 0.33; as licensed: ES-0.09, 95% CI −0.34 to 0.16).ConclusionsCurrent evidence indicates that topical NSAIDs and capsaicin in licensed doses may be equally effective for pain relief in OA. Whether the equivalence varies between individuals remains unknown.
BackgroundThe increased availability of modern imaging in clinical practice has led to its more extensive use. In the field of osteoarthritis (OA), recommendations on the use of imaging in clinical trials have been developed, but there has been less focus on routine clinical management.ObjectivesTo develop evidence-based recommendations for the use of imaging in the clinical management of OA.MethodsA task force convened by the European League Against Rheumatism including rheumatologists, radiologists, generalists, methodologists and patients from 9 countries developed recommendations based on both evidence obtained through systematic literature review (SLR) and expert opinion. The task force initially identified the areas of application of imaging in OA and developed research questions to drive the SLR. Imaging modalities included were conventional radiography, ultrasound, magnetic resonance imaging, computed tomography, radioisotope scan. Anatomical areas of interest were knee, hip, hand and foot. Based on the priorities identified by the task force, the role of imaging in making a diagnosis of OA and identifying OA features (including soft tissue, bone and cartilage involvement), in detecting alternative diagnoses, the impact of imaging on disease management, in defining prognosis (natural history of the disease and response to treatment), in the follow up of the disease and to guide treatment were addressed. Research evidence was searched systematically for each question and separately for each anatomic area using PubMed and Embase.ResultsThe systematic review retrieved 6858 references, after the assessment of 1317 full papers, 380 studies were included. The results of the systematic review were presented to the task force, and consensus recommendations derived. These cover areas such as (exact wording not included for brevity reasons): the lack of need for imaging in diagnosis of patients who present with usual OA symptoms; role of imaging in differential diagnosis; consideration of the challenges in using imaging for routine monitoring of OA where there is no change in clinical status; what should be the feasible first choice modality and what issues were relevant to how images were acquired; how anatomical site of OA may influence use and type of imaging; and the role of imaging and intra-articular injection. Significant gaps in the literature underpinned the recommendations for future research that were also developed.ConclusionsBased on the results of a SLR and expert opinion, recommendations on the use of imaging in the clinical management of OA were developed.Disclosure of InterestNone declared
BackgroundThe role of inflammation in osteoarthritis (OA) is controversial. Some perceive OA as a reparative process where modest inflammation is secondary to largely biomechanical insult.1 In contrast, others believe synovial inflammation to be a central driver of OA pain and progression.2 This has encouraged randomised controlled trials (RCTs) of conventional and biologic disease modifying anti-rheumatic drugs (DMARDs) in OA. However, it is unknown whether these treatments that are primarily used for rheumatoid arthritis are effective for OA.ObjectivesTo examine the efficacy of DMARDs, including biologics, in people with symptomatic OA.MethodsA systematic literature search was conducted (to November 2017) for placebo-controlled RCTs of DMARDs in OA. Data extraction and Cochrane’s risk of bias assessments were conducted independently by two reviewers (MP, AS). Pain relief at treatment peak time-point was combined using a random-effects meta-analysis. All DMARDs were pooled and sensitivity analysis was undertaken for high-quality trials and subgroup analyses for DMARD type, biologic target, joint site, OA subtype, and publication type.Abstract AB0969 – Table 1Subgroup analysisES95% CI Sensitivity analysisHigh-quality trials0.11−0.06 to 0.28Subgroup analysisJointKnee0.34−0.05 to 0.73Hand0.09−0.05 to 0.24OA type (hand OA)Erosive0.19−0.06 to 0.45Non-erosive0.05−0.12 to 0.22Biologic targetIL1-inhibitor0.14−0.16 to 0.45TNF-inhibitor0.17−0.05 to 0.39Publication typeFull text0.27−0.01 to 0.55Conference abstract0.11−0.05 to 0.27ES, effect size; CI, confidence intervalAbstract AB0969 – Figure 1Meta-analysis of DMARDs. ADA: adalimumab; ANK: anakinra; ETN: etanercept; HCQ: hydroxychloroquine: MTX: methotrexate; N: number of participantsResultsEleven RCTs (n=1205), including six (n=757) for conventional and five (n=448) for biologic DMARDs, were included in the meta-analysis (7 full texts, 4 abstracts). Overall, conventional and biologic DMARDs were marginally superior to placebo. However, statistical superiority was not observed in high-quality studies (table 1) or subgroup analysis for conventional or biologic DMARDs separately (figure 1). Furthermore, no differences were observed between erosive versus non-erosive hand OA, hand versus knee OA, anti-IL1 versus anti-TNF biologics, or full text versus abstract-only publications (table 1).ConclusionsNo significant pain relief was observed from either conventional or biologic DMARDs compared to placebo. Combining all DMARDs gave statistical separation from placebo, but this was below the minimal clinically important difference threshold (0.5 SD) used in the UK.3 Furthermore, the analysis is based on peak time point for the intervention, so even at their most effective timepoints these treatments do very little over placebo. Lack of efficacy of DMARDs supports the perspective that inflammation is not an important driver for OA pain and differs fundamentally from that in rheumatoid arthritis.References[1] Felson DT. Osteoarthritis as a disease of mechanics. Osteoarthritis and car...
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