A new study takes a look at which approaches are best to bring relief to people with knee osteoarthritis (OA), a condition that affects approximately 20 percent of people over the age of 45 in the United States.
Knee OA can be extremely painful and limit a person’s ability to function. Although there is no cure, numerous treatments are available to reduce symptoms, including over-the-counter and prescription drugs. Exercising and losing weight if a patient is overweight or obese also can help. Total knee replacement surgery is effective but is done only in cases where the disease is advanced and it’s medically necessary.
So, which treatment is best? To help sort out the choices, a group of researchers set out to assess how the available non-surgical drug treatments stack up against each other for providing pain relief and improving physical function. The authors did not address lifestyle changes, like weight loss and exercise. The study was published recently in Journal of American Academy of Orthopaedic Surgeons (JAAOS).
Ranking the Options
The researchers used a technique called network meta-analysis to analyze and rank the results of 56 studies comparing two or more of the following intra-articular (injected into a joint) and oral treatments: intra-articular (IA) hyaluronic acid, intra-articular corticosteroids, intra-articular platelet-rich plasma, intra-articular placebo, acetaminophen, diclofenac, ibuprofen, naproxen, celecoxib LINK diclofenac ibuprofen naproxen, celecoxib and oral placebo.
After crunching the numbers, researchers found naproxen was ranked first compared with all the other treatments for improving both pain and function (followed by IA corticosteroid, IA platelet-rich-plasma, celecoxib and ibuprofen). Naproxen was also ranked first for improving function alone (followed by diclofenac, celecoxib, ibuprofen and IA platelet-rich plasma). And IA corticosteroid injection was ranked first for alleviating pain alone (followed by ibuprofen, IA platelet-rich plasma, naproxen and celecoxib).
“This information can be used by patients with knee OA when deciding what treatments to use,” says lead study author David S. Jevsevar, MD, department chair of orthopedics at Dartmouth-Hitchcock Medical Center, in Lebanon, New Hampshire. “There are multiple treatments out there for management of knee OA. Some work better than others. Some work well for pain, and some work well for function. Our study showed that naproxen works best for both pain and function, and it is one of the least expensive nonsteroidal anti-inflammatory drugs.”
The analysis also found hyaluronic acid injection was no better than placebo for pain and function. (While some guidelines recommend this controversial treatment for knee OA, others are neutral and some recommend against it). “The literature has been clear that IA hyaluronic acid is not as effective as other treatments, although we realized that some patients swear by it,” Dr. Jevsevar says. “Many people who develop a knee OA flare-up will likely get better even if you did nothing. IA hyaluronic acid has an effect just slightly better than placebo injections, and I don’t routinely offer it to my new patients.”
Another treatment that did not fare well? Acetaminophen ranked near the bottom of the list of treatments for pain and function.
What the Study Didn’t Consider
There are some limitations to this study. One is that the researchers did not describe how well each treatment worked on its own. Instead, the study ranked the treatments as they compared to one another, creating a hierarchy from most to least effective treatments. They also did not go into any detail on side effects. For example, well-known side effects of nonsteroidal anti-inflammatory drugs (NSAIDs) – like ibuprofen, diclofenac, celecoxib and naproxen – include cardiovascular and gastrointestinal problems.
“Although the routine use of NSAIDs in chronic arthritic conditions should be done with caution, naproxen appears [in a number of other studies] to have the lowest risk of cardiac events compared with other drugs of this class,” Dr. Jevsevar says.
Furthermore, two of the most effective interventions, weight loss and exercise, were not included in the comparison. “We did not include nonsurgical treatments such as strengthening and low-impact aerobic exercises, physical therapy, weight loss. There is not one single approach to exercise or weight loss treatment, so it would be difficult to compare these strategies in a study like ours, and these strategies already have proven benefits in knee OA,” Dr. Jevsevar said.
Not a “Road Map” for Treatment
“This study is a good start, and a network meta-analysis is a good method for comparing multiple therapies,” says Stuart Silverman, MD, a clinical professor of medicine at Cedars-Sinai and UCLA in Los Angeles. “But I would not use this study as a road map for treating patients, nor would I tell my patients to use it for selecting therapy. Treatment for knee OA should be individualized for each patient. This article did not discuss other effective and recommended nonpharmacologic approaches such as exercise and weight loss. It also did not include a discussion of side effects such as gastrointestinal and cardiovascular effects, other co-existing illnesses patients may have, patient’s age, duration of effect of each treatment and cost-effectiveness,” he explains.
“I and many rheumatologists are aware of the possible side effects of NSAIDs, and therefore usually start with a topical NSAID gel, which was not studied. Only after lack of response to topical gel do we then consider an oral NSAID or COX2 inhibitor,” Dr. Silverman says, adding that he uses pharmacologic management to enable his patients to do exercise to improve function and lose weight.
Karen Sutton, MD, sports medicine surgeon at Hospital for Special Surgery in Stamford, Connecticut, has a different opinion of the study. “The network meta-analysis helps guide our treatment regimen for our osteoarthritis patients. Patients are educated about their care, and if we can give them a formal proven progression of an outline for their treatment, they feel more satisfied when it’s backed by research.”
Author: Alice Goodman