European investigators recently reported on a trial comparing the efficacy of pharmaceutical-grade chondroitin sulfate (CS) (800 mg/day) with the NSAID celecoxib (CX) (200 mg/day) and placebo in more than 600 patients with painful knee osteoarthritis (OA).
In this well-designed, well-executed, double-blinded, 3-armed trial, investigators tracked patient pain scores at baseline and at 1-month, 3-month and 6-month intervals. This trial was characterized by strict adherence to blinded protocols, high levels of patient adherence, and meticulous review of patient diaries and adverse-event reports.
Patients in both the CS and CX groups experienced significantly greater pain relief when compared to those in the placebo group at every follow-up time point. In addition to tracking pain via the visual analogue scale (VAS), the investigators included the Lequesene index (LI)—which integrates both pain and function—along with the Minimal-Clinically Important Improvement (MCII) scale. While CX and CS were not superior/inferior to one another, both active treatments provided significant pain improvements relative to placebo according to all three measurements at all time points.
These findings showing the efficacy of pharmaceutical-grade CS are important for orthopaedic surgeons, rheumatologists, and general practitioners. Nonoperative management of knee OA remains an important modality that requires a multimodal approach, typically including NSAIDs and/or acetaminophen. These results suggest that there’s another safe medication that may prove especially helpful for OA patients who cannot tolerate NSAIDs or acetaminophen due to kidney, gastrointestinal, cardiovascular, and/or liver issues.
Richard Yoon, MD is a fellow in orthopaedic traumatology and complex adult reconstruction at Orlando Regional Medical Center.
We stumbled upon three recent studies of knee osteoarthritis (OA) that shed interesting new light on a condition that all orthopaedists deal with.
–A “network” meta-analysis in the Annals of Internal Medicine looked at 137 randomized trials of OA treatments comprising more than 33,000 participants. Treatments analyzed included acetaminophen, diclofenac, ibuprofen, naproxen, celecoxib, intra-articular (IA) steroids, IA hyaluronic acid, oral placebo, and IA placebo. For pain, all active treatments except acetaminophen yielded clinically significant improvement. IA hyaluronic acid came out on top for pain relief, although the authors postulated that an “integrated” placebo effect may explain that finding.
–A cost-modeling study in Arthritis Care & Research, co-authored by JBJS Deputy Editors for Methodology and Biostatistics Jeffrey Katz, MD and Elena Losina, PhD, revealed that the per-patient cost attributable to symptomatic knee OA over 28 years is $12,400. Any expanded indications for total knee arthroplasty (TKA) and a trend toward increased willingness among patients to undergo knee surgery will increase that cost. The researchers found that patients tried nonsurgical regimens for a mean of 13.3 years before opting for TKA, and they stress the need for more effective nonoperative therapies for knee OA.
–Wine drinkers, rejoice! A retrospective case-control study in Arthritis Research & Therapy found that people who drank four to six glasses of wine per week were less likely to develop knee OA than nondrinkers. Meanwhile, beer drinkers may want to switch to wine. The same study found that people who drank 8 to 19 half-pints of suds per week had an increased risk of developing knee OA. Researchers found no link between total alcohol consumption and risk of knee OA. The authors postulate that the resveratrol found in wine may be chondroprotective, and that the linkage between beer and increased blood levels of uric acid may explain the opposite finding. It’s wise to remember that studies investigating one or two dietary items can be less-than-definitive because they are usually retrospective, subject to recall bias, and do not account for complex interactions among many nutrients.