S.P. Verkleij

Defining discriminative pain trajectories in hip osteoarthritis over a 2-year time period

Background Although pain due to osteoarthritis (OA) generally deteriorates over time, there is a large individual variation in the course of pain. This study examines the different longitudinal trajectories of patients with hip pain due to OA. Methods Data from a previously performed randomised controlled trial were used to investigate the course of pain over 2 years in 222 patients with clinically and radiographically determined hip OA. Pain was measured with a visual analogue scale (0–100). Latent class growth analysis was used to determine the number of trajectories of patients with hip pain due to OA. Results Analyses yielded five trajectories of pain due to hip OA. Trajectory 1 (‘mild pain’; n=69) consists of patients with stable mild pain. Patients in trajectory 2 (‘moderate pain’; n=31) fluctuated slightly between moderate and severe pain levels. Trajectory 3 (‘always pain’; n=32) consists of patients with severe pain. Patients in trajectory 4 (‘regularly progressing’; n=48) started with mild pain and progressed slowly to moderate pain. Trajectory 5 (‘highly progressing’; n=42) patients also started with mild pain but quickly progressed to severe pain over 2 years. Compared with the ‘mild pain’ group, patients in the ‘always pain’ group had more severe radiographic hip OA, morning stiffness and decreased range of motion. The ‘highly progressing’ group had more severe radiographic hip OA and morning stiffness. Conclusions Latent class growth analysis applied to longitudinal data of patients with hip OA identified five distinct trajectories of pain. More studies are needed to externally validate these findings.

NSAIDs vs acetaminophen in knee and hip osteoarthritis: A systematic review regarding heterogeneity influencing the outcomes

OBJECTIVE To identify sources of heterogeneity (statistical, methodological, and clinical) in studies evaluating non-steroidal anti-inflammatory drugs (NSAIDs) vs acetaminophen in patients with knee and hip osteoarthritis (OA) to elucidate variations in outcomes. METHOD A database search (1966 to January 2010) was made for (randomized) controlled trials ((R)CTs) comparing NSAIDs vs acetaminophen in knee and hip OA. Extracted data included baseline demographic/clinical characteristics, outcomes at follow-up, and characteristics of study design. Heterogeneity was examined with subgroup analyses by exploring changes in effect size and with I(2) of Higgins. Pain measures were expressed as standardized mean differences. RESULTS 15 RCTs, including 21 comparisons of NSAIDs and acetaminophen were included. Statistical heterogeneity was absent (Cochrans Q-test=14.11; I(2)=0; P=0.78). Moderate clinical heterogeneity was found for comparisons which included both hip and knee OA vs knee OA only (I(2)=51; P=0.09). NSAIDs seemed slightly more effective than acetaminophen if more patients with hip OA were included. However, the pooled effect sizes of comparisons with knee OA vs both knee and hip OA are equal. Low clinical heterogeneity was found for comparisons with low dosage of acetaminophen, normal dosage of NSAIDs, and moderate pain intensity at baseline. Low methodological heterogeneity was found for comparisons with a short duration. CONCLUSION Future trials should present the results of hip and knee OA separately, as moderate clinical heterogeneity was found. There might be differences in effectiveness of NSAIDs vs acetaminophen in patients with hip vs knee OA. No significant methodological and statistical heterogeneity was found in studies evaluating NSAIDs vs acetaminophen.

Longitudinal relation between weight change and quality of life in a community-based population: A prospective cohort study

BACKGROUND Previous cross-sectional studies revealed that obesity is associated with lower health-related quality of life (HRQOL). This study aimed to investigate the longitudinal association between 5-year weight change and HRQOL. METHODS Data from 2414 Dutch men and women was collected. HRQOL was measured with the RAND-36. Weight change was calculated as change in weight between 1998 and 2003. Using generalized estimation equations, we primarily analyzed the influence of weight change on HRQOL for the total population and additionally, by change groups (weight losers, weight maintainers and weight gainers) using regression analysis. All analyses were stratified for gender. RESULTS After 5 years, 598 men (50%) and 646 women (54%) maintained their weight, 177 men (15%) and 163 women (14%) lost >2.5 kg and 410 men (35%) and 379 women (32%) gained >2.5 kg. Longitudinal associations of 5-year weight change and HRQOL were found for mental component score (MCS) in women (β = 0.13; 95% CI: 0.02-0.24), and physical component score (PCS) in men (β = -0.09; 95% CI: -0.17 to -0.00) and women (β = -0.10; 95% CI: -0.19 to -0.01). Categorizing for 5-year weight change showed that weight gainers and weight losers did not significantly differ from weight maintainers on both MCS and PCS for both men and women. CONCLUSION Weight change over 5 years leaded to a slight, though significant reduction on the PCS in both genders. In women, we found a positive association between weight change and MCS.

Defining hip pain trajectories in early symptomatic hip osteoarthritis – 5 year results from a nationwide prospective cohort study (CHECK)

OBJECTIVE To define distinct hip pain trajectories in individuals with early symptomatic hip osteoarthritis (OA) and to determine risk factors for these pain trajectories. METHOD Data were obtained from the nationwide prospective Cohort Hip and Cohort Knee (CHECK) study. Participants with hip pain or stiffness and a completed 5-year follow-up were included. Baseline demographic, anamnestic, physical examination characteristics were assessed. Outcome was annually assessed by the Numeric Rating Scale (NRS) for pain. Pain trajectories were retrieved by latent class growth analysis (LCGA). Multinomial logistic regression was used to calculate risk ratios. RESULTS 545 participants were included. Four distinct pain trajectories were uncovered by LCGA. We found significant differences in baseline characteristics, including body mass index (BMI); symptom severity; pain coping strategies and in criteria for clinical hip OA (American College of Rheumatology (ACR)). Lower education, higher activity limitation scores, frequent use of pain transformation as coping strategy and painful internal hip rotation were more often associated with trajectories characterized by more severe pain. No association was found for baseline radiographic features. CONCLUSION We defined four distinct pain trajectories over 5 years follow-up in individuals with early symptomatic hip OA, suggesting there are differences in symptomatic progression of hip OA. Baseline radiographic severity was not associated with the pain trajectories. Future research should be aimed at measuring symptomatic progression of hip OA with even more frequent symptom assessment.

Effectiveness of diclofenac versus paracetamol in knee osteoarthritis: A randomised controlled trial in primary care

BACKGROUND The effectiveness of diclofenac versus paracetamol in primary care patients with pain caused by knee osteoarthritis is unclear. AIM To assess the effectiveness of diclofenac compared with paracetamol over a period of 2, 4, and 12 weeks in patients with knee osteoarthritis. DESIGN AND SETTING Randomised controlled trial in general practice. METHOD There were 104 patients included in the study, they were aged ≥45 years consulting their GP with knee pain caused by knee osteoarthritis. Patients were randomly allocated to diclofenac (n = 52) or paracetamol (n = 52) for at least 2 weeks. Primary outcomes were daily knee pain severity, and knee pain and function measured with the Knee Injury and Osteoarthritis Outcome Score (KOOS). RESULTS Over a period of 2- and 4-weeks follow-up, no significant difference in daily knee pain was found between the patient groups: estimated differences of 0.5 (95% CI = -0.2 to 1.3) and -0.2 (95% CI = -1.0 to 0.7), respectively. Over the 12-weeks follow-up, no significant differences were found between both groups for KOOS pain: estimated difference of -2.8 (95% CI = -10.7 to 5.1) and KOOS function of -2.7 (-10.6 to 5.0). CONCLUSION Over a period of 2- and 4-weeks follow-up no significant difference in daily measured knee pain severity was found between primary care patients with knee osteoarthritis taking paracetamol or diclofenac. Also, over a period of 12-weeks follow-up no significant differences were found regarding KOOS pain and KOOS function between both groups. Patients more frequently reported minor adverse events after taking diclofenac (64%) than paracetamol (46%).

Diclofenac versus paracetamol bij kniepijn

SamenvattingVerkleij SP, Luijsterburg PA, Willemsen SP, Koes BW, Bohnen AM, Bierma- Zeinstra SM. Diclofenac versus paracetamol bij kniepijn. Huisarts Wet 2015;59(3):102-4.AchtergrondParacetamol is het analgeticum van eerste keus bij artrose maar wordt minder vaak voorgeschreven dan NSAID’s, ook al hebben die meer bijwerkingen. Wij vergeleken de effectiviteit van de NSAID diclofenac met die van paracetamol bij patiënten met knieartrose in de Nederlandse huisartsenpraktijk.MethodeIn een open-labelonderzoek randomiseerden wij 104 patiënten van 45 jaar of ouder die hun huisarts consulteerden met kniepijn vanwege knieartrose naar een groep die diclofenac kreeg voorgeschreven (n = 52) en een groep die paracetamol kreeg (n = 52). De deelnemers gebruikten het middel 2 weken en indien nodig nogmaals 1 à 2 weken. Ze noteerden dagelijks de ernst van de kniepijn op een numerieke pijnschaal (NRS, 0-10). Op 3, 6, 9 en 12 weken na het begin van de medicatie werden de ernst van de kniepijn en eventuele beperkingen in functioneren gemeten met de Knee Osteoarthritis Outcome Score (KOOS, 0-100).ResultatenOp de tienpunts NRS vonden wij de eerste 2 en 4 weken van de medicatie geen significante verschillen tussen paracetamol en diclofenac: het gemiddelde verschil na 2 weken was 0,5 punt (95-BI% –0,2 tot 1,3) en na 4 weken –0,2 punt (95%-BI –1,0 tot 0,7). Ook na 12 weken vonden wij geen verschil: op de KOOS was het gemiddelde verschil in pijn –2,8 punt (95%-BI –10,7 tot 5,1) en in dagelijks functioneren –2,7 punt (95%-BI –10,6 tot 5,0).ConclusieDiclofenac en paracetamol zijn even effectief bij kniepijn. Er is geen verschil in pijn en functionaliteit in de eerste weken dat de patiënt het middel gebruikt, en 12 weken later is dat nog steeds zo. Patiënten die diclofenac gebruiken, rapporteren wel vaker bijwerkingen.

OP0188-PC Pain trajectories in hip osteoarthritis: Results of the dutch cohort hip and cohort knee (CHECK)

Background Pain is the most important complaint reported in osteoarthritis (OA). In hip OA, a recent study showed five distinctive trajectories of pain over a two year follow-up period.[1] The next step is to validate these finding in another study population with a longer follow-up period. Objectives To identify long term trajectories of persons with hip pain due to OA over a 5-year follow-up period. Methods Data from the inception cohort CHECK[2] was used to investigate the course of pain. For this study 208 participants were included who fulfilled the clinical and/or radiographic American College of Rheumatology (ACR) criteria for hip OA. Participants filled out yearly questionnaires during the 5-year follow-up period. Pain severity was measured by an 11-point numeric rating scale (0=no pain;10=unbearable). Latent class growth analysis (LCGA) was used to determine the number of different trajectories of participants with hip pain due to OA. Multinomial regression analysis was used to predict the effect of baseline characteristics of the participants and the probability of membership to a one of the trajectories. Results Analyses yielded 4 distinctive trajectories of pain during the five year follow-up instead of five trajectories in another study sample over two years of follow-up. Participants within trajectory 1 (“mild pain”; n=78) fluctuated slightly within ranges of mild pain. Trajectory 2 (“moderate pain”; n=76) consists of participants who slowly increased within ranges of moderate pain over the 5-year period. Trajectory 3 (“decreasing pain”; n=22) comprised participants who started with severe pain at baseline, but after 5-years their pain decreased. Participants within trajectory 4 (“always pain”; n=32) had constant levels of severe pain. Compared with the “mild pain” group, participants in the “moderate pain” group have a higher body mass index (BMI), more often have morning stiffness of the hip, a decreased hip flexion, and concurrent knee complaints. Participants in the “always pain” group are more likely to be women. Conclusions LCGA identified 4 distinct trajectories in 208 participants with clinically and/or radiographic determined hip OA. Predictors for membership to the “moderate pain” group were BMI, morning stiffness of the hip, decreased hip flexion, and concurrent knee pain. For the “always pain” group this was gender. References Verkleij SPJ, Hoekstra T, Rozendaal RM, Waarsing JH, Koes BW, Luijsterburg PAJ, Bierma-Zeinstra SMA. Defining discriminative pain trajectories in hip osteoarthritis over a two-year time period. Ann Rheum Dis 2012. Wesseling J et al. CHECK (Cohort Hip and Cohort Knee): similarities and differences with the Osteoarthritis Initiative. Ann Rheum Dis 2009;68:1413-9. Disclosure of Interest None Declared

PC0001 Effectiveness of diclofenac versus acetaminophen in primary care patients with knee osteoarthritis: A randomized clinical trial

Background Guidelines recommend acetaminophen as medication of first choice when pain medication is needed. In clinical practice, however, non-steroidal anti-inflammatory drugs (NSAIDs) are widely used as first prescribed medication. Objectives We assessed the effectiveness of diclofenac versus acetaminophen in patients with mild knee osteoarthritis (OA) who consulted their GP. Methods This pragmatic open-label randomized controlled trial, with a 12-weeks follow-up period [1], included 104 patients aged 45 years and older, and fulfilled the clinical American College of Rheumatology (ACR) criteria for knee OA. Patients were randomly allocated to diclofenac (n=52) (maximum daily dose of 150 mg.) or acetaminophen (n=52) (maximum daily dose of 3000 mg.) for max 4-weeks. Primary outcomes were daily knee pain severity measured with an 11-point numeric rating scale (NRS) and the Knee Injury and Osteoarthritis Outcome Score (KOOS) collected with questionnaires at 3, 6, 9, and 12 weeks follow-up and daily knee pain (NRS) collected with a diary (for 4 weeks). Secondary outcome was daily medication intake. Generalized estimated equations analyses were adjusted for age, gender, and baseline pain differences. Results At 12-weeks follow-up, NRS knee pain (β: -0.1; 95% CI: -0.9 to 0.7) and KOOS knee pain (β: -0.3; 95% CI: -7.0 to 6.4) did not differ between the groups (see figure). At 4-weeks follow-up (the end of treatment period), no differences were found regarding daily NRS knee pain and medication intake. Conclusions At 4 and 12 weeks follow-up, there were no differences between the two treatment groups, diclofenac and acetaminophen, in reducing knee pain in patients with knee OA in primary care setting. These results endorse the recommendation of acetaminophen as “first choice medication” in (inter)national guidelines regarding primary care patients with knee OA. References Verkleij SPJ, Luijsterburg PAJ, Koes BW, Bohnen AM, Bierma-Zeinstra SMA. Effectiveness of diclofenac versus acetaminophen in primary care patients with knee osteoarthritis: [NTR1485], DIPA-trial: design of a randomized clinical trial. BMC Musculoskelet Disord. 2010;11:7. Disclosure of Interest None Declared