Efficacy and Safety of Tramadol for Knee or Hip Osteoarthritis: A Systematic Review and Network Meta‐Analysis of Randomized Controlled Trials

Abstract

Objective To examine efficacy and safety of tramadol for knee or hip osteoarthritis (OA). Methods PubMed, Embase, Cochrane Library, and Web of Science were searched up to May 2020 for randomized controlled trials (RCTs) comparing any of the following interventions: tramadol 100 mg/day, 200 mg/day, and 300 mg/day, and placebo for knee or hip OA. Pain and function were measured at or near 12 weeks for efficacy. Gastrointestinal, cardiovascular, and central nervous system (CNS) adverse events (AEs), and withdrawals were measured for safety. Bayesian network meta‐analysis was conducted. Results Six RCTs (3,611 participants) were included. Tramadol 100 mg/day (standardized mean difference [SMD] –0.16 [95% confidence interval (95% CI) –0.34, 0.00]), 200 mg/day (SMD –0.21 [95% CI –0.37, –0.06]), and 300 mg/day (SMD –0.30 [95% CI –0.48, –0.14]) were statistically more effective than placebo in pain relief, but only tramadol 300 mg/day was better than placebo in functional improvement (SMD –0.24 [95% CI –0.47, –0.03]). Tramadol 100 mg/day (relative risk [RR] 2.29 [95% credible interval (CrI) 1.22, 4.25]), 200 mg/day (RR 4.35 [95% CrI 2.31, 8.01]), and 300 mg/day (RR 6.02 [95% CrI 3.22, 11.1]) involved a higher risk of gastrointestinal AEs. Similarly, tramadol 100–300 mg/day showed a higher risk of CNS AEs and withdrawals. However, the risk of cardiovascular AEs remained unclear. Conclusion Only tramadol 300 mg/day showed minimal improvement in pain and function but with increasing AEs compared with placebo. Tramadol may not be sufficiently recommended for knee or hip OA based on the presented evidence, especially in patients with the risk of gastrointestinal and CNS AEs.

Osteoarthritis, part of life or a curable disease? A bird's‐eye view

“…If symptom relief is insufficient, the next step(s) may encompass intraarticular injectables, typically corticosteroids, particularly if the symptoms are monoarticular, or, for instance, per oral duloxetine, the latter preferably in the case of coexisting depressive symptoms. Opioids including tramadol are unfortunately frequently prescribed for OA pain, but these have limited effect and are associated with several adverse effects and risk of addiction [70]. Thus, opioids should be avoided unless there is a clear plan for their use and discontinuation.…”

Guidelines for the diagnosis and treatment of knee osteoarthritis with integrative medicine based on traditional Chinese medicine

“…③ Opioids: For patients with acute pain attacks, when acetaminophen and NSAIDs cannot fully relieve pain or there is a drug contraindication, weak opioids can be considered, which are better tolerated and less addictive, such as oral tramadol. Such treatments should be started at a low dose and slowly increased every few days to reduce adverse reactions ( 71 ) (Evidence level: Level I, highly recommended).…”