Top POEMs of 2016: Musculoskeletal Conditions

Top 20 POEMs of 2016

All Analgesics Are Better Than Placebo in Patients with Knee or Hip DJD

Clinical question
Which analgesics are most effective in treating patients with degenerative joint disease of the hip or knee?

Bottom line
In patients with hip or knee degenerative joint disease (DJD), all analgesics are more effective than placebo in relieving pain and improving function. Although paracetamol (acetaminophen) is the least effective of all the drugs studied, because of its safety profile it should be the first treatment for these patients. Move on to other agents, if necessary, according to the patient's response. (LOE = 1a-)(www.essentialevidenceplus.com)

Reference
da Costa BR, Reichenbach S, Keller N, et al. Effectiveness of non-steroidal anti-inflammatory drugs for the treatment of pain in knee and hip osteoarthritis: a network meta-analysis. Lancet 2016;387(10033):2093-2105.

Study design: Meta-analysis (randomized controlled trials)

Funding source: Foundation

Setting: Various (meta-analysis)

Synopsis
These authors searched the Cochrane Central Register of Controlled Trials to identify randomized trials comparing nonsteroidal anti-inflammatory drugs, paracetamol, and placebo in patients with DJD of the hips or knees. The studies had to have at least 100 patients in each group. Two researchers independently evaluated each study for inclusion and used discussion to resolve disagreements. The team assessed each study's methodologic quality and extracted data related to pain and function. They ultimately included 74 trials with nearly 59,000 patients, 7 different drugs and 23 different permutations. Across the trials, the mean age of patients ranged from 58 years to 71 years, most patients were women (49% to 90%), and studies most were of short duration (median follow-up 12 weeks; range = 1 week to 52 weeks). None of the studies were at high risk of bias. ALL analgesics, regardless of dose, were more effective than placebo in relieving pain. However, several agents were more likely to provide clinically important relief (diclofenac 150 mg/day; etoricoxib 30 mg/day, 60 mg/day, and 90 mg/day; and rofecoxib 25 mg/day and 50 mg/day). Paracetamol was the least likely to provide meaningful pain relief. Although patients generally functioned better while taking medication, the data on improved function were not particularly robust and no treatment stood out as better than the rest. The authors don't directly assess the harms of treatment. Finally, please recall that rofecoxib has been withdrawn from the worldwide market, and etoricoxib is not available in the United States because of FDA demands for further safety information.

Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI

Opioid Analgesia Hard to Tolerate and Not Effective for Chronic Low Back Pain

Clinical question
Is opioid analgesic treatment effective in patients with low back pain?

Bottom line
Effective pain control in patients with low back pain (LBP) is still elusive. Approximately half of all patients with LBP who take an opioid analgesic will stop treatment because of ineffectiveness or adverse effects. Patients staying the course will experience, on average, a small decrease in pain relative to patients who take placebo (similar to the benefit from nonsteroidal anti-inflammatory drugs) and will not have improved function. (LOE = 1a)(www.essentialevidenceplus.com)

Reference
Shaheed CA, Maher CG, Williams KA, Day R, McLachlan AJ. Efficacy, tolerability, and dose-dependent effects of opioid analgesics for low back pain a systematic review and meta-analysis. JAMA Intern Med. 2016;176(7):958-968.

Study design: Meta-analysis (randomized controlled trials)

Funding source: Government

Setting: Various (meta-analysis)

Synopsis
To identify randomized controlled trials that enrolled patients with nonspecific LBP, published in any language, and evaluated an opioid analgesic, these researchers searched 5 databases including Cochrane CENTRAL, as well as reference lists of identified studies. Two reviewers independently selected studies for inclusion and 2 reviewers independently extracted the data and evaluated study quality. They retrieved 20 studies with an enrollment of 7295 patients; all but one study enrolled patients with chronic LBP. The length of studies was 12 weeks or less. Most of the studies were of moderate to high quality. Based on 13 studies with moderate-quality evidence, opioids reduced pain in the short term, though the mean difference in pain scores was minimal (mean difference: 10.1 on a scale of 0 - 100). This effect size is similar to that for nonsteroidal anti-inflammatory drugs versus placebo for LBP in a prior Cochrane Review. Overall, opioid treatment did not produce clinically important pain relief compared with placebo (ie, a mean difference in pain scores of at least 20), even with doses as high as 240 mg morphine per day. Half of the studies had more than 50% of the enrolled patients drop out, either because of adverse effects or lack of effectiveness. The patients who dropped out were not considered in the estimates of treatment benefit, meaning that the actual overall likelihood of benefit is even smaller in clinical practice. Low-quality studies of disability did not show a reduction in disability using either the Oswestry Disability Index or the Roland Morris Disability Questionnaire. Study results were homogeneous, but there was some evidence of publication bias.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

Little Correlation Between Hip Pain and Radiographic Evidence of Osteoarthritis

Clinical question
Are pelvic x-rays useful for ruling in or ruling out osteoarthritis in patients with hip pain?

Bottom line
Do not rely on hip x-rays to rule in or rule out osteoarthritis in patients with hip pain. The correlation between radiographic indicators of hip arthritis and hip pain is very low. Hip pain is not present in many hips with radiographic evidence of osteoarthritis, and many people with painful hips, including older patients with groin or anterior pain and/or painful internal rotation, will not have indicators on x-ray. (LOE = 1b)(www.essentialevidenceplus.com)

Reference
Kim C, Nevitt MC, Niu J, et al. Association of hip pain with radiographic evidence of hip osteoarthritis: diagnostic test study. BMJ 2015;351:h5983.

Study design: Diagnostic test evaluation

Funding source: Industry + govt

Setting: Outpatient (any)

Synopsis
These authors used data from 2 different cohort studies conducted in the United States. The Framingham study imaged every ambulatory person 50 years or older in a single community, regardless of symptoms. Patients with hip pain were also examined for pain with internal rotation. The second study enrolled ambulatory patients, aged 45 years to 79 years, from 4 cities who had or were at risk of knee osteoarthritis; every patient underwent hip imaging as well. In other words, the participating patients had a wide range of symptoms and possible hip pathology. People with hip pain on most days were classified as having "frequent hip pain." In the Framingham study (n = 946), only 15.6% of patients with frequent hip pain had radiographic evidence of hip arthritis; conversely, only 20.7% of patients who met the criteria for hip osteoarthritis had frequent pain. In the second study group (n = 4366), only 9.1% of patients with frequent pain showed radiographic hip osteoarthritis, and 23.8% of those with radiographic hip osteoarthritis were frequently painful. In patients with hip pain localized to the groin (prevalence = 12.6% - 9.5%), the positive predictive value of the x-ray was only 6.0% to 7.1%. Results were similar with anterior thigh pain and/or painful internal rotation.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

POEMs are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, please see http://www.essentialevidenceplus.com(www.essentialevidenceplus.com).

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