The efficacy of duloxetine, non-steroidal anti-inflammatory drugs, and opioids in osteoarthritis: a systematic literature review and meta-analysis

Abstract

BackgroundThis meta-analysis assessed the efficacy of duloxetine versus other oral treatments used after failure of acetaminophen for management of patients with osteoarthritis.MethodsA systematic literature review of English language articles was performed in PUBMED, EMBASE, MedLine In-Process, Cochrane Library, and ClinicalTrials.gov between January 1985 and March 2013. Randomized controlled trials of duloxetine and all oral non-steroidal anti-inflammatory drugs and opioids were included if treatment was ≥12 weeks and the Western Ontario and McMaster Universities Index (WOMAC) total score was available. Studies were assessed for quality using the assessment tool from the National Institute for Health and Clinical Excellence guidelines for single technology appraisal submissions.WOMAC baseline and change from baseline total scores were extracted and standardized. A frequentist meta-analysis, meta-regression, and indirect comparison were performed using the DerSimonian-Laird and Bucher methods. Bayesian analyses with and without adjustment for study-level covariates were performed using noninformative priors.ResultsThirty-two publications reported 34 trials (2 publications each reported 2 trials) that met inclusion criteria. The analyses found all treatments except oxycodone (frequentist) and hydromorphone (frequentist and Bayesian) to be more effective than placebo. Indirect comparisons to duloxetine found no significant differences for most of the compounds. Some analyses showed evidence of a difference with duloxetine for etoricoxib (better), tramadol and oxycodone (worse), but without consistent results between analyses. Forest plots revealed positive trends in overall efficacy improvement with baseline scores. Adjusting for baseline, the probability duloxetine is superior to other treatments ranges between 15% to 100%.Limitations of this study include the low number of studies included in the analyses, the inclusion of only English language publications, and possible ecological fallacy associated with patient level characteristics.ConclusionsThis analysis suggests no difference between duloxetine and other post-first line oral treatments for osteoarthritis (OA) in total WOMAC score after approximately 12 weeks of treatment. Significant results for 3 compounds (1 better and 2 worse) were not consistent across performed analyses.

Comparative pain reduction of oral non-steroidal anti-inflammatory drugs and opioids for knee osteoarthritis: systematic analytic review

“…Four previous reviews of these analgesics in the OA literature were identified: Verkleij et al, 27 evaluating short-term effects of NSAIDs and acetaminophen; Bjordal et al, 28 evaluating short-term effects of NSAIDs and opioids; Myers et al, 29 evaluating longer-term effects of NSAIDs and opioids compared to duloxetine; and Bannuru et al, 30 assessing the relative efficacy of analgesics for knee OA. Due to a differences in drugs of interest, pain measurement instrument, and primary outcome, few studies included in our analyses were also included in the aforementioned reviews (one, four, nine, and eight studies overlapped with our analysis and those of Verkleij et al, 27 Bjordal et al, 28 Myers et al, 29 and Bannuru et al 30 respectively). Verkleij et al 27 and Bjordal et al 28 did not restrict studies according to the instrument used to measure pain, while Myers et al 29 limited analyses to studies reporting WOMAC composite scores, which includes subscales for function and stiffness along with a subscale for pain.…”

“…Due to a differences in drugs of interest, pain measurement instrument, and primary outcome, few studies included in our analyses were also included in the aforementioned reviews (one, four, nine, and eight studies overlapped with our analysis and those of Verkleij et al, 27 Bjordal et al, 28 Myers et al, 29 and Bannuru et al 30 respectively). Verkleij et al 27 and Bjordal et al 28 did not restrict studies according to the instrument used to measure pain, while Myers et al 29 limited analyses to studies reporting WOMAC composite scores, which includes subscales for function and stiffness along with a subscale for pain. Bannuru et al 30 included all studies utilizing any measure of pain, function, or stiffness, and through network meta-analysis, derived effect sizes for each analgesic, which cannot be directly compared to the absolute WOMAC Pain reductions we present.…”

Strong opioids for noncancer pain due to musculoskeletal diseases: Not more effective than acetaminophen or NSAIDs

“…Oxycodone (Oxycontin ® , Oxynorm ® ) and hydromorphone (Sophidone ® ) may be even less effective and not superior over a placebo [17]. Anesthesiologists in the US recently suggested a revision of current guidelines to explicitly indicate that the expected pain score decrease after 3 months of strong opioid therapy for noncancer pain was similar to that seen with NSAIDs and only about 0.8 to 1.2/10 points [18].…”

Nem szteroid gyulladáscsökkentők peroralis és transdermalis alkalmazása regionális mozgásszervi fájdalmi szindrómákban

“…Gyulladásos komponens hiányában az NSAID korlátozottan csillapítja a fájdalmat. A perifériás nocicepció és a gerincvelői integráció szintjén minor analgetikumként az acetaminophen/paracetamol, az NSAID-ok és a gyenge opioidok az első vonalban ajánlott készítmények [33]. A leggyakrabban használt gyenge opioidok a tramadol, a dihidrokodein, kodein.…”