Osteoarthritis

Radiography detected up to 16% of cases of hip osteoarthritis among older patients with frequent hip pain in an analysis of participants in the Framingham Osteoarthritis Study and the Osteoarthritis Initiative.

“In older patients, inadequate recognition of osteoarthritis has consequences. Decreased functional status from osteoarthritis significantly increases morbidity from coronary heart disease, lung disease, diabetes, obesity, falls, frailty, and various other ailments,” said Dr. Chan Kim of Boston University and his associates. “Because many patients with hip pain do not have radiographic hip osteoarthritis, a health professional should continue with the evaluation and treatment of osteoarthritis, despite negative radiographic findings.”

© iStock / ThinkStockPhotos.com

Radiographic pathology often is detected late in the course of knee OA and correlates poorly with knee pain, but few studies have examined these trends for the hip. The researchers analyzed pelvic radiographs and hip pain among 946 participants in the Framingham Osteoarthritis Study and 4,366 participants in the Osteoarthritis Initiative. They defined radiographic hip OA as a Kellgren-Lawrence grade of 2 or more – that is, definite superolateral or superomedial joint space narrowing and a definite osteophyte. They used various clinical symptoms of hip OA for comparison. Participants in both studies were older than 45 years, and tended to be in their early 60s (BMJ 2015 Dec 2. doi: 10.1136/bmj.h5983).

The most sensitive criterion in the study was groin pain, for which radiography was positive in 37% of hips in the Framingham Study and 17% of hips in the Osteoarthritis Initiative, the researchers said. Other clinical criteria were less sensitive, including anterior thigh pain, frequent hip pain, and painful internal rotation. Moreover, about 21%-24% of hips with radiographic OA were frequently painful.

The study did not evaluate MRI findings, the investigators noted. They suggested that such results would resemble those for the knee, in which MRI is “more sensitive than radiography, [but] it is far less specific for abnormalities suggestive of osteoarthritis in most middle-aged and older people.”

The National Institute of Arthritis and Musculoskeletal and Skin Diseases funded the study. The Osteoarthritis Initiative is funded by the National Institutes of Health, Merck Research Laboratories, Novartis, GlaxoSmithKline, and Pfizer. The researchers had no disclosures.

Radiography detected up to 16% of cases of hip osteoarthritis among older patients with frequent hip pain in an analysis of participants in the Framingham Osteoarthritis Study and the Osteoarthritis Initiative.

“In older patients, inadequate recognition of osteoarthritis has consequences. Decreased functional status from osteoarthritis significantly increases morbidity from coronary heart disease, lung disease, diabetes, obesity, falls, frailty, and various other ailments,” said Dr. Chan Kim of Boston University and his associates. “Because many patients with hip pain do not have radiographic hip osteoarthritis, a health professional should continue with the evaluation and treatment of osteoarthritis, despite negative radiographic findings.”

© iStock / ThinkStockPhotos.com

Radiographic pathology often is detected late in the course of knee OA and correlates poorly with knee pain, but few studies have examined these trends for the hip. The researchers analyzed pelvic radiographs and hip pain among 946 participants in the Framingham Osteoarthritis Study and 4,366 participants in the Osteoarthritis Initiative. They defined radiographic hip OA as a Kellgren-Lawrence grade of 2 or more – that is, definite superolateral or superomedial joint space narrowing and a definite osteophyte. They used various clinical symptoms of hip OA for comparison. Participants in both studies were older than 45 years, and tended to be in their early 60s (BMJ 2015 Dec 2. doi: 10.1136/bmj.h5983).

The most sensitive criterion in the study was groin pain, for which radiography was positive in 37% of hips in the Framingham Study and 17% of hips in the Osteoarthritis Initiative, the researchers said. Other clinical criteria were less sensitive, including anterior thigh pain, frequent hip pain, and painful internal rotation. Moreover, about 21%-24% of hips with radiographic OA were frequently painful.

The study did not evaluate MRI findings, the investigators noted. They suggested that such results would resemble those for the knee, in which MRI is “more sensitive than radiography, [but] it is far less specific for abnormalities suggestive of osteoarthritis in most middle-aged and older people.”

The National Institute of Arthritis and Musculoskeletal and Skin Diseases funded the study. The Osteoarthritis Initiative is funded by the National Institutes of Health, Merck Research Laboratories, Novartis, GlaxoSmithKline, and Pfizer. The researchers had no disclosures.

Radiography detected up to 16% of cases of hip osteoarthritis among older patients with frequent hip pain in an analysis of participants in the Framingham Osteoarthritis Study and the Osteoarthritis Initiative.

“In older patients, inadequate recognition of osteoarthritis has consequences. Decreased functional status from osteoarthritis significantly increases morbidity from coronary heart disease, lung disease, diabetes, obesity, falls, frailty, and various other ailments,” said Dr. Chan Kim of Boston University and his associates. “Because many patients with hip pain do not have radiographic hip osteoarthritis, a health professional should continue with the evaluation and treatment of osteoarthritis, despite negative radiographic findings.”

© iStock / ThinkStockPhotos.com

Radiographic pathology often is detected late in the course of knee OA and correlates poorly with knee pain, but few studies have examined these trends for the hip. The researchers analyzed pelvic radiographs and hip pain among 946 participants in the Framingham Osteoarthritis Study and 4,366 participants in the Osteoarthritis Initiative. They defined radiographic hip OA as a Kellgren-Lawrence grade of 2 or more – that is, definite superolateral or superomedial joint space narrowing and a definite osteophyte. They used various clinical symptoms of hip OA for comparison. Participants in both studies were older than 45 years, and tended to be in their early 60s (BMJ 2015 Dec 2. doi: 10.1136/bmj.h5983).

The most sensitive criterion in the study was groin pain, for which radiography was positive in 37% of hips in the Framingham Study and 17% of hips in the Osteoarthritis Initiative, the researchers said. Other clinical criteria were less sensitive, including anterior thigh pain, frequent hip pain, and painful internal rotation. Moreover, about 21%-24% of hips with radiographic OA were frequently painful.

The study did not evaluate MRI findings, the investigators noted. They suggested that such results would resemble those for the knee, in which MRI is “more sensitive than radiography, [but] it is far less specific for abnormalities suggestive of osteoarthritis in most middle-aged and older people.”

The National Institute of Arthritis and Musculoskeletal and Skin Diseases funded the study. The Osteoarthritis Initiative is funded by the National Institutes of Health, Merck Research Laboratories, Novartis, GlaxoSmithKline, and Pfizer. The researchers had no disclosures.

Lateral wedge insoles worn by people with medial knee osteoarthritis (OA) provide a limited amount of immediate biomechanical improvement during walking and may be best suited to people who have biomechanical phenotypes that would benefit the most, according to findings from a systematic review and meta-analysis of studies examining the intraindividual effects of the insoles.

“This review is ... the most definitive, up-to-date and comprehensive analysis on this issue to clarify the effects of lateral wedge insoles on biomechanical risk factors for knee OA progression,” wrote lead investigator John Arnold, Ph.D., of the University of South Australia, Adelaide, and his colleagues (Arthritis Care Res. 2015 Nov 25. doi: 10.1002/acr.22797).

Courtesy National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)

The investigators reviewed 18 studies with a total of 534 participants and found small, but statistically significant reductions in estimates of knee joint loading based on the surrogate measures of external knee adduction moment (EKAM) and the knee adduction angular impulse (KAAI).

Most studies (14) tested full-length insoles, and the remaining four allowed a customized amount based on comfort and/or pain level. Another two used heel wedges, and two others tested both. The inclination angle of the insoles was most commonly 5 degrees, but ranged from 4 to 11 degrees. Some studies used a concomitant medial arch support; these were of a generic design in four studies and were made to order in another three. The lateral wedge insoles were compared against flat insoles, the patients’ own footwear, or standardized footwear.

The pooled effect sizes of both the first and second peak EKAM reductions were small, with standard mean differences of –0.20 to –0.25. For the first EKAM, the effect sizes did not vary according to whether studies used flat insoles or shoes only as comparators, whereas for the eight studies that reported second EKAM outcomes, there was a larger pooled effect size for comparisons against shoe-only than for one study that made flat insole comparisons. The pooled estimate for the standard mean difference in nine studies that reported KAAI was –0.14.

There was only weak evidence for publication bias in all the comparisons for the surrogate measures, and most had a low level of statistical heterogeneity between the outcomes of the studies.

The investigators noted that this meta-analysis of surrogate measures for knee joint loading does not take cumulative loading into account, so that even though the reduction in peak EKAM and KAAI was small, it may amount “to a large cumulative effect imparted on the knee over the course of the day. This should be considered when interpreting the findings of this review and future research on load modifying interventions in knee osteoarthritis.” They said that while EKAM has been associated with OA progression, KAAI has been thought to be a better measure of the duration and magnitude of loading in knee OA and has been associated with medial tibiofemoral cartilage loss over 1-2 years.

“Prescription [for lateral wedge insoles] based on biomechanical response and use of insoles only in individuals who show reductions in knee joint loading (biomechanical phenotypes) appears more appropriate to increase the likelihood of a favorable long-term response regarding the attenuation of structural changes. This would limit their application and benefit to a smaller number of individuals, but is still likely to be significant considering the overall prevalence of knee OA and projected rise due to population aging and rising obesity levels,” the authors concluded.

The investigators had no outside funding source for their systematic review. One of the authors may receive royalties from Salford Insole, a manufacturer of lateral wedge insoles.

[email protected]

Lateral wedge insoles worn by people with medial knee osteoarthritis (OA) provide a limited amount of immediate biomechanical improvement during walking and may be best suited to people who have biomechanical phenotypes that would benefit the most, according to findings from a systematic review and meta-analysis of studies examining the intraindividual effects of the insoles.

“This review is ... the most definitive, up-to-date and comprehensive analysis on this issue to clarify the effects of lateral wedge insoles on biomechanical risk factors for knee OA progression,” wrote lead investigator John Arnold, Ph.D., of the University of South Australia, Adelaide, and his colleagues (Arthritis Care Res. 2015 Nov 25. doi: 10.1002/acr.22797).

Courtesy National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)

The investigators reviewed 18 studies with a total of 534 participants and found small, but statistically significant reductions in estimates of knee joint loading based on the surrogate measures of external knee adduction moment (EKAM) and the knee adduction angular impulse (KAAI).

Most studies (14) tested full-length insoles, and the remaining four allowed a customized amount based on comfort and/or pain level. Another two used heel wedges, and two others tested both. The inclination angle of the insoles was most commonly 5 degrees, but ranged from 4 to 11 degrees. Some studies used a concomitant medial arch support; these were of a generic design in four studies and were made to order in another three. The lateral wedge insoles were compared against flat insoles, the patients’ own footwear, or standardized footwear.

The pooled effect sizes of both the first and second peak EKAM reductions were small, with standard mean differences of –0.20 to –0.25. For the first EKAM, the effect sizes did not vary according to whether studies used flat insoles or shoes only as comparators, whereas for the eight studies that reported second EKAM outcomes, there was a larger pooled effect size for comparisons against shoe-only than for one study that made flat insole comparisons. The pooled estimate for the standard mean difference in nine studies that reported KAAI was –0.14.

There was only weak evidence for publication bias in all the comparisons for the surrogate measures, and most had a low level of statistical heterogeneity between the outcomes of the studies.

The investigators noted that this meta-analysis of surrogate measures for knee joint loading does not take cumulative loading into account, so that even though the reduction in peak EKAM and KAAI was small, it may amount “to a large cumulative effect imparted on the knee over the course of the day. This should be considered when interpreting the findings of this review and future research on load modifying interventions in knee osteoarthritis.” They said that while EKAM has been associated with OA progression, KAAI has been thought to be a better measure of the duration and magnitude of loading in knee OA and has been associated with medial tibiofemoral cartilage loss over 1-2 years.

“Prescription [for lateral wedge insoles] based on biomechanical response and use of insoles only in individuals who show reductions in knee joint loading (biomechanical phenotypes) appears more appropriate to increase the likelihood of a favorable long-term response regarding the attenuation of structural changes. This would limit their application and benefit to a smaller number of individuals, but is still likely to be significant considering the overall prevalence of knee OA and projected rise due to population aging and rising obesity levels,” the authors concluded.

The investigators had no outside funding source for their systematic review. One of the authors may receive royalties from Salford Insole, a manufacturer of lateral wedge insoles.

[email protected]

Lateral wedge insoles worn by people with medial knee osteoarthritis (OA) provide a limited amount of immediate biomechanical improvement during walking and may be best suited to people who have biomechanical phenotypes that would benefit the most, according to findings from a systematic review and meta-analysis of studies examining the intraindividual effects of the insoles.

“This review is ... the most definitive, up-to-date and comprehensive analysis on this issue to clarify the effects of lateral wedge insoles on biomechanical risk factors for knee OA progression,” wrote lead investigator John Arnold, Ph.D., of the University of South Australia, Adelaide, and his colleagues (Arthritis Care Res. 2015 Nov 25. doi: 10.1002/acr.22797).

Courtesy National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)

The investigators reviewed 18 studies with a total of 534 participants and found small, but statistically significant reductions in estimates of knee joint loading based on the surrogate measures of external knee adduction moment (EKAM) and the knee adduction angular impulse (KAAI).

Most studies (14) tested full-length insoles, and the remaining four allowed a customized amount based on comfort and/or pain level. Another two used heel wedges, and two others tested both. The inclination angle of the insoles was most commonly 5 degrees, but ranged from 4 to 11 degrees. Some studies used a concomitant medial arch support; these were of a generic design in four studies and were made to order in another three. The lateral wedge insoles were compared against flat insoles, the patients’ own footwear, or standardized footwear.

The pooled effect sizes of both the first and second peak EKAM reductions were small, with standard mean differences of –0.20 to –0.25. For the first EKAM, the effect sizes did not vary according to whether studies used flat insoles or shoes only as comparators, whereas for the eight studies that reported second EKAM outcomes, there was a larger pooled effect size for comparisons against shoe-only than for one study that made flat insole comparisons. The pooled estimate for the standard mean difference in nine studies that reported KAAI was –0.14.

There was only weak evidence for publication bias in all the comparisons for the surrogate measures, and most had a low level of statistical heterogeneity between the outcomes of the studies.

The investigators noted that this meta-analysis of surrogate measures for knee joint loading does not take cumulative loading into account, so that even though the reduction in peak EKAM and KAAI was small, it may amount “to a large cumulative effect imparted on the knee over the course of the day. This should be considered when interpreting the findings of this review and future research on load modifying interventions in knee osteoarthritis.” They said that while EKAM has been associated with OA progression, KAAI has been thought to be a better measure of the duration and magnitude of loading in knee OA and has been associated with medial tibiofemoral cartilage loss over 1-2 years.

“Prescription [for lateral wedge insoles] based on biomechanical response and use of insoles only in individuals who show reductions in knee joint loading (biomechanical phenotypes) appears more appropriate to increase the likelihood of a favorable long-term response regarding the attenuation of structural changes. This would limit their application and benefit to a smaller number of individuals, but is still likely to be significant considering the overall prevalence of knee OA and projected rise due to population aging and rising obesity levels,” the authors concluded.

The investigators had no outside funding source for their systematic review. One of the authors may receive royalties from Salford Insole, a manufacturer of lateral wedge insoles.

[email protected]

SAN FRANCISCO – Hold off on surgery in patients with presumed septic arthritis if they’re not otherwise too sick and their cultures don’t grow out a pathogenic organism within 48 hours.

The reason is because those patients are likely to have synovial fluid that was contaminated during collection, not a true joint infection.

The advice comes from investigators at Beth Israel Deaconess Medical Center, Boston, who compared 425 monoarticular septic arthritis cases with 25 cases that turned out to be false positives due to synovial fluid contamination; most of the false positives got antibiotics, and three (12%) had joint operations that they did not need.

“Rushing off to the operating room isn’t” always warranted. “You can suspect contamination if patients have milder disease manifestations and cultures grow late,” said investigator Dr. Robert H. Shmerling, clinical chief of Beth Israel’s division of rheumatology.

The findings help determine when – and when not – to be aggressive with patients who present with what looks to be septic arthritis. “No one’s ever really looked at this before,” he said at the annual meeting of the American College of Rheumatology.

“These are very different sorts of patients. Look at the full range of clinical characteristics and lab values, not just the synovial fluid tap. If contamination is suspected, you can wait until the cultures come back or possibly do serial taps before going to the operating room,” said coinvestigator Clara Zhu, a medical student at Boston University.

Patients with true joint infections had higher mean peripheral polymorphonuclear neutrophil percentages (78% vs. 68% in false positives) and synovial fluid polymorphonuclear cell percentages (88% vs. 74% in false positives). True cases also had substantially higher mean synovial fluid white blood cell counts (88,000 vs. 29,000).

Unlike true cases, contaminated synovial fluid took about 4 days to grow out a positive culture, and the most common organisms by far were coagulase-negative staphylococci, typically normal skin bacteria.

Patients with contaminated fluid also tended to be older (71 vs. 59 years), with fewer prior admissions. They were far less likely to have had recent joint procedures and histories of septic arthritis but were more likely to have synovial fluid crystals, as in gout. False positives also left the hospital sooner (7 vs. 11 days) and were less likely to be readmitted within 2 months. They were also less likely to present with fever (19% vs. 37%) but not significantly so.

This “study suggests that contaminated synovial fluid is found in up to 6% of patients with suspected septic arthritis and positive synovial fluid or synovial biopsy cultures. We recommend a conservative approach for patients with ... mild disease manifestations and no growth of pathogenic organisms within the first 48 hours,” the investigators concluded.

The authors have no disclosures, and there was no outside funding for the work.

[email protected]

SAN FRANCISCO – Hold off on surgery in patients with presumed septic arthritis if they’re not otherwise too sick and their cultures don’t grow out a pathogenic organism within 48 hours.

The reason is because those patients are likely to have synovial fluid that was contaminated during collection, not a true joint infection.

The advice comes from investigators at Beth Israel Deaconess Medical Center, Boston, who compared 425 monoarticular septic arthritis cases with 25 cases that turned out to be false positives due to synovial fluid contamination; most of the false positives got antibiotics, and three (12%) had joint operations that they did not need.

“Rushing off to the operating room isn’t” always warranted. “You can suspect contamination if patients have milder disease manifestations and cultures grow late,” said investigator Dr. Robert H. Shmerling, clinical chief of Beth Israel’s division of rheumatology.

The findings help determine when – and when not – to be aggressive with patients who present with what looks to be septic arthritis. “No one’s ever really looked at this before,” he said at the annual meeting of the American College of Rheumatology.

“These are very different sorts of patients. Look at the full range of clinical characteristics and lab values, not just the synovial fluid tap. If contamination is suspected, you can wait until the cultures come back or possibly do serial taps before going to the operating room,” said coinvestigator Clara Zhu, a medical student at Boston University.

Patients with true joint infections had higher mean peripheral polymorphonuclear neutrophil percentages (78% vs. 68% in false positives) and synovial fluid polymorphonuclear cell percentages (88% vs. 74% in false positives). True cases also had substantially higher mean synovial fluid white blood cell counts (88,000 vs. 29,000).

Unlike true cases, contaminated synovial fluid took about 4 days to grow out a positive culture, and the most common organisms by far were coagulase-negative staphylococci, typically normal skin bacteria.

Patients with contaminated fluid also tended to be older (71 vs. 59 years), with fewer prior admissions. They were far less likely to have had recent joint procedures and histories of septic arthritis but were more likely to have synovial fluid crystals, as in gout. False positives also left the hospital sooner (7 vs. 11 days) and were less likely to be readmitted within 2 months. They were also less likely to present with fever (19% vs. 37%) but not significantly so.

This “study suggests that contaminated synovial fluid is found in up to 6% of patients with suspected septic arthritis and positive synovial fluid or synovial biopsy cultures. We recommend a conservative approach for patients with ... mild disease manifestations and no growth of pathogenic organisms within the first 48 hours,” the investigators concluded.

The authors have no disclosures, and there was no outside funding for the work.

[email protected]

SAN FRANCISCO – Hold off on surgery in patients with presumed septic arthritis if they’re not otherwise too sick and their cultures don’t grow out a pathogenic organism within 48 hours.

The reason is because those patients are likely to have synovial fluid that was contaminated during collection, not a true joint infection.

The advice comes from investigators at Beth Israel Deaconess Medical Center, Boston, who compared 425 monoarticular septic arthritis cases with 25 cases that turned out to be false positives due to synovial fluid contamination; most of the false positives got antibiotics, and three (12%) had joint operations that they did not need.

“Rushing off to the operating room isn’t” always warranted. “You can suspect contamination if patients have milder disease manifestations and cultures grow late,” said investigator Dr. Robert H. Shmerling, clinical chief of Beth Israel’s division of rheumatology.

The findings help determine when – and when not – to be aggressive with patients who present with what looks to be septic arthritis. “No one’s ever really looked at this before,” he said at the annual meeting of the American College of Rheumatology.

“These are very different sorts of patients. Look at the full range of clinical characteristics and lab values, not just the synovial fluid tap. If contamination is suspected, you can wait until the cultures come back or possibly do serial taps before going to the operating room,” said coinvestigator Clara Zhu, a medical student at Boston University.

Patients with true joint infections had higher mean peripheral polymorphonuclear neutrophil percentages (78% vs. 68% in false positives) and synovial fluid polymorphonuclear cell percentages (88% vs. 74% in false positives). True cases also had substantially higher mean synovial fluid white blood cell counts (88,000 vs. 29,000).

Unlike true cases, contaminated synovial fluid took about 4 days to grow out a positive culture, and the most common organisms by far were coagulase-negative staphylococci, typically normal skin bacteria.

Patients with contaminated fluid also tended to be older (71 vs. 59 years), with fewer prior admissions. They were far less likely to have had recent joint procedures and histories of septic arthritis but were more likely to have synovial fluid crystals, as in gout. False positives also left the hospital sooner (7 vs. 11 days) and were less likely to be readmitted within 2 months. They were also less likely to present with fever (19% vs. 37%) but not significantly so.

This “study suggests that contaminated synovial fluid is found in up to 6% of patients with suspected septic arthritis and positive synovial fluid or synovial biopsy cultures. We recommend a conservative approach for patients with ... mild disease manifestations and no growth of pathogenic organisms within the first 48 hours,” the investigators concluded.

The authors have no disclosures, and there was no outside funding for the work.

[email protected]

Synovitis and effusion were associated with increases in pain sensitivity at the patella and wrist, respectively, in a study of 1,111 patients with or at risk of knee osteoarthritis (OA).

Radiographs and MRIs were taken of the patients’ knees, and the patients wrists and patellae were subjected to standardized quantitative sensory testing (QST) measures. The QST measures included temporal summation, which is a measure of central pain amplification based on “an augmented response to repetitive mechanical stimulation,” and pressure pain threshold (PPT), a measure of sensitivity to pain evoked by mechanical stimulation of nociceptors. (Lower PPTs represent a greater degree of sensitization or pain sensitivity.) All tests were conducted at baseline and 2 years later.

©KatarzynaBialasiewicz/ Thinkstock.com

Synovitis was associated with a significant decrease in PPT at the patella, while effusion was associated with a decrease in PPT at the wrist. Effusion was additionally associated with risk of incident temporal summation. In contrast to synovitis and effusion, bone marrow lesions were not associated with either temporal summation or decreased pressure pain threshold.

“Our findings support the potential relevance of inflammation in the development and heightening of sensitization in knee osteoarthritis in humans. We found that synovitis was associated with lower PPT and a decrease in PPT at the patella over time, indicating increased pain sensitization or sensitivity. Effusion was associated with development of new temporal summation at the patella, and with a decrease in PPT at the wrist, a site distant to the pathology; both findings suggest the involvement of central sensitization. Thus inflammation appears to influence the development of and perhaps amplification of sensitization,” said Dr. Tuhina Neogi, of the department of medicine at Boston University and her colleagues.

Read the full study in Arthritis & Rheumatology (doi: 10.1002/art.39488).

[email protected]

Synovitis and effusion were associated with increases in pain sensitivity at the patella and wrist, respectively, in a study of 1,111 patients with or at risk of knee osteoarthritis (OA).

Radiographs and MRIs were taken of the patients’ knees, and the patients wrists and patellae were subjected to standardized quantitative sensory testing (QST) measures. The QST measures included temporal summation, which is a measure of central pain amplification based on “an augmented response to repetitive mechanical stimulation,” and pressure pain threshold (PPT), a measure of sensitivity to pain evoked by mechanical stimulation of nociceptors. (Lower PPTs represent a greater degree of sensitization or pain sensitivity.) All tests were conducted at baseline and 2 years later.

©KatarzynaBialasiewicz/ Thinkstock.com

Synovitis was associated with a significant decrease in PPT at the patella, while effusion was associated with a decrease in PPT at the wrist. Effusion was additionally associated with risk of incident temporal summation. In contrast to synovitis and effusion, bone marrow lesions were not associated with either temporal summation or decreased pressure pain threshold.

“Our findings support the potential relevance of inflammation in the development and heightening of sensitization in knee osteoarthritis in humans. We found that synovitis was associated with lower PPT and a decrease in PPT at the patella over time, indicating increased pain sensitization or sensitivity. Effusion was associated with development of new temporal summation at the patella, and with a decrease in PPT at the wrist, a site distant to the pathology; both findings suggest the involvement of central sensitization. Thus inflammation appears to influence the development of and perhaps amplification of sensitization,” said Dr. Tuhina Neogi, of the department of medicine at Boston University and her colleagues.

Read the full study in Arthritis & Rheumatology (doi: 10.1002/art.39488).

[email protected]

Synovitis and effusion were associated with increases in pain sensitivity at the patella and wrist, respectively, in a study of 1,111 patients with or at risk of knee osteoarthritis (OA).

Radiographs and MRIs were taken of the patients’ knees, and the patients wrists and patellae were subjected to standardized quantitative sensory testing (QST) measures. The QST measures included temporal summation, which is a measure of central pain amplification based on “an augmented response to repetitive mechanical stimulation,” and pressure pain threshold (PPT), a measure of sensitivity to pain evoked by mechanical stimulation of nociceptors. (Lower PPTs represent a greater degree of sensitization or pain sensitivity.) All tests were conducted at baseline and 2 years later.

©KatarzynaBialasiewicz/ Thinkstock.com

Synovitis was associated with a significant decrease in PPT at the patella, while effusion was associated with a decrease in PPT at the wrist. Effusion was additionally associated with risk of incident temporal summation. In contrast to synovitis and effusion, bone marrow lesions were not associated with either temporal summation or decreased pressure pain threshold.

“Our findings support the potential relevance of inflammation in the development and heightening of sensitization in knee osteoarthritis in humans. We found that synovitis was associated with lower PPT and a decrease in PPT at the patella over time, indicating increased pain sensitization or sensitivity. Effusion was associated with development of new temporal summation at the patella, and with a decrease in PPT at the wrist, a site distant to the pathology; both findings suggest the involvement of central sensitization. Thus inflammation appears to influence the development of and perhaps amplification of sensitization,” said Dr. Tuhina Neogi, of the department of medicine at Boston University and her colleagues.

Read the full study in Arthritis & Rheumatology (doi: 10.1002/art.39488).

[email protected]

Both overweight and obese patients with knee osteoarthritis (OA) are more likely to get knee replacement surgery, compared with normal-weight patients with knee OA, results of a population-based cohort study of people in Catalonia, Spain, suggest.

The study included 105,189 patients, who had been diagnosed with knee OA between 2006 and 2011. Patients with a history of knee OA or knee replacement in either knee before Jan. 1, 2006, and patients with a history inflammatory arthritis were not included in the study.

© Kokhanchikov / fotolia.com

The patients were followed from the date of knee OA diagnosis until the date they underwent elective knee replacement surgery or until Dec. 31, 2011. (The researchers were unable to follow up with all individuals initially enrolled in the study.) The participants were broken up into the following categories based on their body mass index: normal (BMI was less than 25 kg/m²), overweight (BMI was 25 to less than 30 kg/m²), obese class I (BMI was 30 to less than 35 kg/m²), obese class II (BMI was 35 to less than 40 kg/m²), and obese class III (BMI was greater than or equal to 40 kg/m²).

The risk of knee replacement increased with BMI. For patients with a normal weight, the incidence rates of surgery were 1.35/100 person-years, compared with 3.49/100 person-years in patients in obese class III. Adjusted hazard ratios for knee replacement surgery were 1.41 for overweight, 1.97 for obese class I, 2.39 for obese class II, and 2.67 for obese class III, compared with normal-weight study participants.

An additional finding was a significant interaction between BMI and age on the risk of knee replacement (P is less than .001), with a higher relative hazard associated with obesity among patients aged less than 68 years.

“This research demonstrates that overweight and obesity are strong independent predictors of the clinical progression of knee OA, from disease onset/diagnosis to joint failure and subsequent [knee replacement]. Overweight subjects are at over 40% increased risk of surgery, and those who are obese have a more than doubled risk when compared to subjects with normal weight,” said Kristen M. Leyland, D.Phil., and her colleagues.

Read the full study in Arthritis & Rheumatology (doi: 10.1002/art.39486).

[email protected]

Both overweight and obese patients with knee osteoarthritis (OA) are more likely to get knee replacement surgery, compared with normal-weight patients with knee OA, results of a population-based cohort study of people in Catalonia, Spain, suggest.

The study included 105,189 patients, who had been diagnosed with knee OA between 2006 and 2011. Patients with a history of knee OA or knee replacement in either knee before Jan. 1, 2006, and patients with a history inflammatory arthritis were not included in the study.

© Kokhanchikov / fotolia.com

The patients were followed from the date of knee OA diagnosis until the date they underwent elective knee replacement surgery or until Dec. 31, 2011. (The researchers were unable to follow up with all individuals initially enrolled in the study.) The participants were broken up into the following categories based on their body mass index: normal (BMI was less than 25 kg/m²), overweight (BMI was 25 to less than 30 kg/m²), obese class I (BMI was 30 to less than 35 kg/m²), obese class II (BMI was 35 to less than 40 kg/m²), and obese class III (BMI was greater than or equal to 40 kg/m²).

The risk of knee replacement increased with BMI. For patients with a normal weight, the incidence rates of surgery were 1.35/100 person-years, compared with 3.49/100 person-years in patients in obese class III. Adjusted hazard ratios for knee replacement surgery were 1.41 for overweight, 1.97 for obese class I, 2.39 for obese class II, and 2.67 for obese class III, compared with normal-weight study participants.

An additional finding was a significant interaction between BMI and age on the risk of knee replacement (P is less than .001), with a higher relative hazard associated with obesity among patients aged less than 68 years.

“This research demonstrates that overweight and obesity are strong independent predictors of the clinical progression of knee OA, from disease onset/diagnosis to joint failure and subsequent [knee replacement]. Overweight subjects are at over 40% increased risk of surgery, and those who are obese have a more than doubled risk when compared to subjects with normal weight,” said Kristen M. Leyland, D.Phil., and her colleagues.

Read the full study in Arthritis & Rheumatology (doi: 10.1002/art.39486).

[email protected]

Both overweight and obese patients with knee osteoarthritis (OA) are more likely to get knee replacement surgery, compared with normal-weight patients with knee OA, results of a population-based cohort study of people in Catalonia, Spain, suggest.

The study included 105,189 patients, who had been diagnosed with knee OA between 2006 and 2011. Patients with a history of knee OA or knee replacement in either knee before Jan. 1, 2006, and patients with a history inflammatory arthritis were not included in the study.

© Kokhanchikov / fotolia.com

The patients were followed from the date of knee OA diagnosis until the date they underwent elective knee replacement surgery or until Dec. 31, 2011. (The researchers were unable to follow up with all individuals initially enrolled in the study.) The participants were broken up into the following categories based on their body mass index: normal (BMI was less than 25 kg/m²), overweight (BMI was 25 to less than 30 kg/m²), obese class I (BMI was 30 to less than 35 kg/m²), obese class II (BMI was 35 to less than 40 kg/m²), and obese class III (BMI was greater than or equal to 40 kg/m²).

The risk of knee replacement increased with BMI. For patients with a normal weight, the incidence rates of surgery were 1.35/100 person-years, compared with 3.49/100 person-years in patients in obese class III. Adjusted hazard ratios for knee replacement surgery were 1.41 for overweight, 1.97 for obese class I, 2.39 for obese class II, and 2.67 for obese class III, compared with normal-weight study participants.

An additional finding was a significant interaction between BMI and age on the risk of knee replacement (P is less than .001), with a higher relative hazard associated with obesity among patients aged less than 68 years.

“This research demonstrates that overweight and obesity are strong independent predictors of the clinical progression of knee OA, from disease onset/diagnosis to joint failure and subsequent [knee replacement]. Overweight subjects are at over 40% increased risk of surgery, and those who are obese have a more than doubled risk when compared to subjects with normal weight,” said Kristen M. Leyland, D.Phil., and her colleagues.

Read the full study in Arthritis & Rheumatology (doi: 10.1002/art.39486).

[email protected]

SAN FRANCISCO – Intra-articular ozone injections were effective in reducing pain, improving function, and improving quality of life in patients with knee osteoarthritis in the first randomized study to evaluate this approach.

Patients treated with a series of ozone injections achieved significant improvements on all measures, except for the Timed Up and Go Test, compared with patients given placebo, according to study results presented at the annual meeting of the American College of Rheumatology.

“After 8 weeks of treatment, ozone can give patients with knee osteoarthritis [OA] better quality of life with less pain and more independence in performing daily activities. More studies are needed to validate this option in patients with OA. Intra-articular ozone injections are safe with similar complications to placebo. In elderly people with comorbidities requiring chronic medication, this approach is a good option because it doesn’t interact with medications. The only restriction is anticoagulant therapy, as there may be bleeding at the injection site,” said Dr. Virginia Trevisani, professor at the Federal University of São Paulo.

Alice Goodman/Frontline Medical News

The next series of studies Dr. Trevisani and her coauthors are planning will incorporate MRI imaging to assess the effect of the ozone injections on structural progression in knee OA.

Ozone is thought to have anti-inflammatory effects by reducing oxidative stress. Ozone is being used for medical purposes in countries such as Russia, Germany, and Spain, but it is not currently used clinically in the United States. “You can’t perform these injections in patients without experience. The only requirement is a machine to make ozone that costs about $1,000 USD,” she said.

Before this study, evidence in support of ozone injections in knee OA was anecdotal and from observational studies. The present study is the first randomized trial to evaluate intra-articular ozone injections in patients with knee OA.

The study enrolled 98 patients with documented knee OA between the ages of 60 and 85 years; 63 patients were randomized to intra-articular injections of ozone in the knee with the most pain (one injection per week for 8 consecutive weeks), and 35 were randomized to placebo injections of a small amount of air.

Patients were evaluated at baseline, after 4 and 8 injections, and 8 weeks following the last injection. Two patients in the ozone group withdrew from the study. The only adverse events were three puncture-site wounds – two in the ozone group and one in the placebo group.

Significant improvement was observed on all measures, except for the Timed Up and Go Test (getting up from a chair), at every time point for the ozone injections. Dr. Trevisani said that the ability to get up from a chair without help depends on balance and muscle strength, which may explain why the results were not significant.

Measures of pain on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the visual analog scale improved significantly with ozone, compared with placebo, and by week 16, the P value was .000 for both measures. WOMAC joint stiffness intensity was significantly improved by ozone (P = .075 at week 4; P = .002 at week 8). Quality of life on the Short Form–36 for pain and functional capacity were significantly improved by ozone, compared with placebo (P = .000 at week 16 for both measures).

Dr. Trevisani said ozone injections may be able to delay the need for total joint replacement surgery, and that they are cost effective, compared with surgery and other pharmacologic treatments.

Dr. Trevisani had no relevant financial disclosures.

SAN FRANCISCO – Intra-articular ozone injections were effective in reducing pain, improving function, and improving quality of life in patients with knee osteoarthritis in the first randomized study to evaluate this approach.

Patients treated with a series of ozone injections achieved significant improvements on all measures, except for the Timed Up and Go Test, compared with patients given placebo, according to study results presented at the annual meeting of the American College of Rheumatology.

“After 8 weeks of treatment, ozone can give patients with knee osteoarthritis [OA] better quality of life with less pain and more independence in performing daily activities. More studies are needed to validate this option in patients with OA. Intra-articular ozone injections are safe with similar complications to placebo. In elderly people with comorbidities requiring chronic medication, this approach is a good option because it doesn’t interact with medications. The only restriction is anticoagulant therapy, as there may be bleeding at the injection site,” said Dr. Virginia Trevisani, professor at the Federal University of São Paulo.

Alice Goodman/Frontline Medical News

The next series of studies Dr. Trevisani and her coauthors are planning will incorporate MRI imaging to assess the effect of the ozone injections on structural progression in knee OA.

Ozone is thought to have anti-inflammatory effects by reducing oxidative stress. Ozone is being used for medical purposes in countries such as Russia, Germany, and Spain, but it is not currently used clinically in the United States. “You can’t perform these injections in patients without experience. The only requirement is a machine to make ozone that costs about $1,000 USD,” she said.

Before this study, evidence in support of ozone injections in knee OA was anecdotal and from observational studies. The present study is the first randomized trial to evaluate intra-articular ozone injections in patients with knee OA.

The study enrolled 98 patients with documented knee OA between the ages of 60 and 85 years; 63 patients were randomized to intra-articular injections of ozone in the knee with the most pain (one injection per week for 8 consecutive weeks), and 35 were randomized to placebo injections of a small amount of air.

Patients were evaluated at baseline, after 4 and 8 injections, and 8 weeks following the last injection. Two patients in the ozone group withdrew from the study. The only adverse events were three puncture-site wounds – two in the ozone group and one in the placebo group.

Significant improvement was observed on all measures, except for the Timed Up and Go Test (getting up from a chair), at every time point for the ozone injections. Dr. Trevisani said that the ability to get up from a chair without help depends on balance and muscle strength, which may explain why the results were not significant.

Measures of pain on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the visual analog scale improved significantly with ozone, compared with placebo, and by week 16, the P value was .000 for both measures. WOMAC joint stiffness intensity was significantly improved by ozone (P = .075 at week 4; P = .002 at week 8). Quality of life on the Short Form–36 for pain and functional capacity were significantly improved by ozone, compared with placebo (P = .000 at week 16 for both measures).

Dr. Trevisani said ozone injections may be able to delay the need for total joint replacement surgery, and that they are cost effective, compared with surgery and other pharmacologic treatments.

Dr. Trevisani had no relevant financial disclosures.

SAN FRANCISCO – Intra-articular ozone injections were effective in reducing pain, improving function, and improving quality of life in patients with knee osteoarthritis in the first randomized study to evaluate this approach.

Patients treated with a series of ozone injections achieved significant improvements on all measures, except for the Timed Up and Go Test, compared with patients given placebo, according to study results presented at the annual meeting of the American College of Rheumatology.

“After 8 weeks of treatment, ozone can give patients with knee osteoarthritis [OA] better quality of life with less pain and more independence in performing daily activities. More studies are needed to validate this option in patients with OA. Intra-articular ozone injections are safe with similar complications to placebo. In elderly people with comorbidities requiring chronic medication, this approach is a good option because it doesn’t interact with medications. The only restriction is anticoagulant therapy, as there may be bleeding at the injection site,” said Dr. Virginia Trevisani, professor at the Federal University of São Paulo.

Alice Goodman/Frontline Medical News

The next series of studies Dr. Trevisani and her coauthors are planning will incorporate MRI imaging to assess the effect of the ozone injections on structural progression in knee OA.

Ozone is thought to have anti-inflammatory effects by reducing oxidative stress. Ozone is being used for medical purposes in countries such as Russia, Germany, and Spain, but it is not currently used clinically in the United States. “You can’t perform these injections in patients without experience. The only requirement is a machine to make ozone that costs about $1,000 USD,” she said.

Before this study, evidence in support of ozone injections in knee OA was anecdotal and from observational studies. The present study is the first randomized trial to evaluate intra-articular ozone injections in patients with knee OA.

The study enrolled 98 patients with documented knee OA between the ages of 60 and 85 years; 63 patients were randomized to intra-articular injections of ozone in the knee with the most pain (one injection per week for 8 consecutive weeks), and 35 were randomized to placebo injections of a small amount of air.

Patients were evaluated at baseline, after 4 and 8 injections, and 8 weeks following the last injection. Two patients in the ozone group withdrew from the study. The only adverse events were three puncture-site wounds – two in the ozone group and one in the placebo group.

Significant improvement was observed on all measures, except for the Timed Up and Go Test (getting up from a chair), at every time point for the ozone injections. Dr. Trevisani said that the ability to get up from a chair without help depends on balance and muscle strength, which may explain why the results were not significant.

Measures of pain on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the visual analog scale improved significantly with ozone, compared with placebo, and by week 16, the P value was .000 for both measures. WOMAC joint stiffness intensity was significantly improved by ozone (P = .075 at week 4; P = .002 at week 8). Quality of life on the Short Form–36 for pain and functional capacity were significantly improved by ozone, compared with placebo (P = .000 at week 16 for both measures).

Dr. Trevisani said ozone injections may be able to delay the need for total joint replacement surgery, and that they are cost effective, compared with surgery and other pharmacologic treatments.

Dr. Trevisani had no relevant financial disclosures.

SAN FRANCISCO – Patients with symptomatic knee osteoarthritis who received pharmaceutical-grade chondroitin sulfate for 2 years lost about 20% less cartilage volume than did patients treated with celecoxib, according to a randomized, double-blind trial.

Improvements were limited to the medial tibiofemoral compartment, but even such modest structural effects can significantly decrease rates of total knee replacement over time, said lead investigator Dr. Jean-Pierre Pelletier, who presented the findings at the annual meeting of the American College of Rheumatology.

The 194 participants in the study received chondroitin sulfate, 1,200 mg a day, or celecoxib, 200 mg daily. Joint effusion and pain and function improved markedly in both groups, and they had similar rates of adverse events, said Dr. Pelletier, who is a rheumatologist at Institut de recherche en rhumatologie de Montréal. He discussed the findings and plans for future research in an exclusive video interview.

Bioibérica sponsored the study and makes the chondroitin sulfate that participants received. Dr. Pelletier and his associates had no other disclosures.

SAN FRANCISCO – Patients with symptomatic knee osteoarthritis who received pharmaceutical-grade chondroitin sulfate for 2 years lost about 20% less cartilage volume than did patients treated with celecoxib, according to a randomized, double-blind trial.

Improvements were limited to the medial tibiofemoral compartment, but even such modest structural effects can significantly decrease rates of total knee replacement over time, said lead investigator Dr. Jean-Pierre Pelletier, who presented the findings at the annual meeting of the American College of Rheumatology.

The 194 participants in the study received chondroitin sulfate, 1,200 mg a day, or celecoxib, 200 mg daily. Joint effusion and pain and function improved markedly in both groups, and they had similar rates of adverse events, said Dr. Pelletier, who is a rheumatologist at Institut de recherche en rhumatologie de Montréal. He discussed the findings and plans for future research in an exclusive video interview.

Bioibérica sponsored the study and makes the chondroitin sulfate that participants received. Dr. Pelletier and his associates had no other disclosures.

SAN FRANCISCO – Patients with symptomatic knee osteoarthritis who received pharmaceutical-grade chondroitin sulfate for 2 years lost about 20% less cartilage volume than did patients treated with celecoxib, according to a randomized, double-blind trial.

Improvements were limited to the medial tibiofemoral compartment, but even such modest structural effects can significantly decrease rates of total knee replacement over time, said lead investigator Dr. Jean-Pierre Pelletier, who presented the findings at the annual meeting of the American College of Rheumatology.

The 194 participants in the study received chondroitin sulfate, 1,200 mg a day, or celecoxib, 200 mg daily. Joint effusion and pain and function improved markedly in both groups, and they had similar rates of adverse events, said Dr. Pelletier, who is a rheumatologist at Institut de recherche en rhumatologie de Montréal. He discussed the findings and plans for future research in an exclusive video interview.

Bioibérica sponsored the study and makes the chondroitin sulfate that participants received. Dr. Pelletier and his associates had no other disclosures.

Only four short-term, randomized trials have addressed the safety, efficacy, and tolerability of cannabinoids for treating rheumatic diseases, and all have methodologic weaknesses and a high risk of bias, according to a qualitative review of data published since 1946.

“There is low-quality evidence suggesting that cannabinoids may be associated with improvements in pain and sleep quality in rheumatoid arthritis and fibromyalgia. Clinical positive effects for the studies assessed in this review must be balanced by the reported adverse events,” wrote Dr. Mary-Ann Fitzcharles of McGill University, Montreal, and her colleagues (Arthritis Care Res. 2015 Nov 9. doi: 10.1002/acr.22727).

©Thinkstock.com

The four randomized clinical trials, ranging in duration from 2 to 8 weeks, included one with 58 rheumatoid arthritis patients, two with a total of 71 fibromyalgia patients, and one with 74 osteoarthritis patients. Three trials met their respective primary endpoints and found a statistically significant effect of cannabinoids on pain (in two studies), sleep (in two studies), and improved quality of life (in one study). The investigators noted a high incidence (generally observed in 25%-50% of subjects) of mild to moderate side effects (dizziness, drowsiness, nausea, dry mouth) and many methodologic weaknesses in the evaluated data. The study that tested a fatty acid amide hydrolase inhibitor in osteoarthritis patients was stopped early due to futility. The other three completed studies were associated with an overall high risk of bias.

One of the two fibromyalgia studies was a randomized, double-blind, placebo-controlled trial conducted in 2008 that assessed nabilone in 40 fibromyalgia patients. Nabilone treatment led to significant decreases in the visual analog scale for pain (–2.04, P less than .02) at 4 weeks. A second fibromyalgia trial from 2010 compared amitriptyline to nabilone in 31 subjects and found the latter agent to be superior on the primary endpoint of difference in score on the Insomnia Severity Index (difference = 3.2; 95% confidence interval, 1.2-5.3). A 2006 rheumatoid arthritis trial found that cannabis-based Sativex demonstrated a clinically meaningful advantage over placebo for the primary endpoint of morning pain on movement (difference of –0.95, 95% CI, –1.83 to –0.02; P = .044). No trials assessed herbal cannabis.

“It is not currently possible to recommend this category of treatments as therapy for patients with rheumatic diseases. Any conclusions based on these studies remain tenuous and call for larger, well controlled clinical trials to better understand potential benefits and risks as pertaining to rheumatic conditions,” Dr. Fitzcharles and her coauthors wrote.

No relevant financial disclosures were reported.

[email protected]

Only four short-term, randomized trials have addressed the safety, efficacy, and tolerability of cannabinoids for treating rheumatic diseases, and all have methodologic weaknesses and a high risk of bias, according to a qualitative review of data published since 1946.

“There is low-quality evidence suggesting that cannabinoids may be associated with improvements in pain and sleep quality in rheumatoid arthritis and fibromyalgia. Clinical positive effects for the studies assessed in this review must be balanced by the reported adverse events,” wrote Dr. Mary-Ann Fitzcharles of McGill University, Montreal, and her colleagues (Arthritis Care Res. 2015 Nov 9. doi: 10.1002/acr.22727).

©Thinkstock.com

The four randomized clinical trials, ranging in duration from 2 to 8 weeks, included one with 58 rheumatoid arthritis patients, two with a total of 71 fibromyalgia patients, and one with 74 osteoarthritis patients. Three trials met their respective primary endpoints and found a statistically significant effect of cannabinoids on pain (in two studies), sleep (in two studies), and improved quality of life (in one study). The investigators noted a high incidence (generally observed in 25%-50% of subjects) of mild to moderate side effects (dizziness, drowsiness, nausea, dry mouth) and many methodologic weaknesses in the evaluated data. The study that tested a fatty acid amide hydrolase inhibitor in osteoarthritis patients was stopped early due to futility. The other three completed studies were associated with an overall high risk of bias.

One of the two fibromyalgia studies was a randomized, double-blind, placebo-controlled trial conducted in 2008 that assessed nabilone in 40 fibromyalgia patients. Nabilone treatment led to significant decreases in the visual analog scale for pain (–2.04, P less than .02) at 4 weeks. A second fibromyalgia trial from 2010 compared amitriptyline to nabilone in 31 subjects and found the latter agent to be superior on the primary endpoint of difference in score on the Insomnia Severity Index (difference = 3.2; 95% confidence interval, 1.2-5.3). A 2006 rheumatoid arthritis trial found that cannabis-based Sativex demonstrated a clinically meaningful advantage over placebo for the primary endpoint of morning pain on movement (difference of –0.95, 95% CI, –1.83 to –0.02; P = .044). No trials assessed herbal cannabis.

“It is not currently possible to recommend this category of treatments as therapy for patients with rheumatic diseases. Any conclusions based on these studies remain tenuous and call for larger, well controlled clinical trials to better understand potential benefits and risks as pertaining to rheumatic conditions,” Dr. Fitzcharles and her coauthors wrote.

No relevant financial disclosures were reported.

[email protected]

Only four short-term, randomized trials have addressed the safety, efficacy, and tolerability of cannabinoids for treating rheumatic diseases, and all have methodologic weaknesses and a high risk of bias, according to a qualitative review of data published since 1946.

“There is low-quality evidence suggesting that cannabinoids may be associated with improvements in pain and sleep quality in rheumatoid arthritis and fibromyalgia. Clinical positive effects for the studies assessed in this review must be balanced by the reported adverse events,” wrote Dr. Mary-Ann Fitzcharles of McGill University, Montreal, and her colleagues (Arthritis Care Res. 2015 Nov 9. doi: 10.1002/acr.22727).

©Thinkstock.com

The four randomized clinical trials, ranging in duration from 2 to 8 weeks, included one with 58 rheumatoid arthritis patients, two with a total of 71 fibromyalgia patients, and one with 74 osteoarthritis patients. Three trials met their respective primary endpoints and found a statistically significant effect of cannabinoids on pain (in two studies), sleep (in two studies), and improved quality of life (in one study). The investigators noted a high incidence (generally observed in 25%-50% of subjects) of mild to moderate side effects (dizziness, drowsiness, nausea, dry mouth) and many methodologic weaknesses in the evaluated data. The study that tested a fatty acid amide hydrolase inhibitor in osteoarthritis patients was stopped early due to futility. The other three completed studies were associated with an overall high risk of bias.

One of the two fibromyalgia studies was a randomized, double-blind, placebo-controlled trial conducted in 2008 that assessed nabilone in 40 fibromyalgia patients. Nabilone treatment led to significant decreases in the visual analog scale for pain (–2.04, P less than .02) at 4 weeks. A second fibromyalgia trial from 2010 compared amitriptyline to nabilone in 31 subjects and found the latter agent to be superior on the primary endpoint of difference in score on the Insomnia Severity Index (difference = 3.2; 95% confidence interval, 1.2-5.3). A 2006 rheumatoid arthritis trial found that cannabis-based Sativex demonstrated a clinically meaningful advantage over placebo for the primary endpoint of morning pain on movement (difference of –0.95, 95% CI, –1.83 to –0.02; P = .044). No trials assessed herbal cannabis.

“It is not currently possible to recommend this category of treatments as therapy for patients with rheumatic diseases. Any conclusions based on these studies remain tenuous and call for larger, well controlled clinical trials to better understand potential benefits and risks as pertaining to rheumatic conditions,” Dr. Fitzcharles and her coauthors wrote.

No relevant financial disclosures were reported.

[email protected]

Regular corticosteroid injections over 2 years were relatively safe for osteoarthritic knees in a trial from Tufts Medical Center in Boston, but they did not slow the progression of joint damage or improve patient outcomes.

The findings come at a time when the role of intra-articular steroid shots is up for debate. They are widely used for knee osteoarthritis (OA) in the hopes of reducing cartilage damage from synovitis, but there’s also concern that they might actually harm cartilage and periarticular bone.

The investigators, led by Dr. Timothy McAlindon, chief of rheumatology at Tufts Medical Center, sought to bring some data to the table. “Our objective was to test the potential for disease modification of synovitic knee OA by triamcinolone hexacetonide [THA] in a clinical trial with comprehensive measurement of effects on cartilage and subchondral bone using MRI and DXA [dual-energy x-ray absorptiometry],” they said.

The investigators randomized 140 patients with symptomatic knee OA (Kellgren-Lawrence grade 2 or 3) and synovitis on ultrasound to either 40 mg THA or saline knee injections every 3 months for 2 years. Randomization was blocked and stratified by gender and Kellgren-Lawrence grade. Patients had clinical assessments at each visit and annual MRIs and DXA knee and hip scans.

There were no significant between-group differences over the course of the study in mean changes on Western Ontario and McMaster Universities Arthritis Index pain (–2.2 for THA vs. –2.8 for placebo; P = .3) and function scores (–7.1 for THA vs. –9.2 for placebo; P = .4), and no differences in chair stand (–1.1 for THA vs. –1.6 for placebo; P = .8) or walk time tests (–0.5 for THA vs. –0.03 for placebo; P = .5).

There were no significant differences on MRI or DXA, except that the steroid group had greater cartilage loss and the placebo group greater progression of fibrillation.

“The greater rate of loss of cartilage thickness ... in the treated group was small in magnitude and of uncertain clinical significance,” said Dr. McAlindon.

The mean body mass index in the study was 31.2 kg/m². Just over half the subjects were women, and about two-thirds were white. More than 90% of patients in both groups completed the study.

The work was funded by the National Institutes of Health. The investigators have no relevant disclosures.

[email protected]

Regular corticosteroid injections over 2 years were relatively safe for osteoarthritic knees in a trial from Tufts Medical Center in Boston, but they did not slow the progression of joint damage or improve patient outcomes.

The findings come at a time when the role of intra-articular steroid shots is up for debate. They are widely used for knee osteoarthritis (OA) in the hopes of reducing cartilage damage from synovitis, but there’s also concern that they might actually harm cartilage and periarticular bone.

The investigators, led by Dr. Timothy McAlindon, chief of rheumatology at Tufts Medical Center, sought to bring some data to the table. “Our objective was to test the potential for disease modification of synovitic knee OA by triamcinolone hexacetonide [THA] in a clinical trial with comprehensive measurement of effects on cartilage and subchondral bone using MRI and DXA [dual-energy x-ray absorptiometry],” they said.

The investigators randomized 140 patients with symptomatic knee OA (Kellgren-Lawrence grade 2 or 3) and synovitis on ultrasound to either 40 mg THA or saline knee injections every 3 months for 2 years. Randomization was blocked and stratified by gender and Kellgren-Lawrence grade. Patients had clinical assessments at each visit and annual MRIs and DXA knee and hip scans.

There were no significant between-group differences over the course of the study in mean changes on Western Ontario and McMaster Universities Arthritis Index pain (–2.2 for THA vs. –2.8 for placebo; P = .3) and function scores (–7.1 for THA vs. –9.2 for placebo; P = .4), and no differences in chair stand (–1.1 for THA vs. –1.6 for placebo; P = .8) or walk time tests (–0.5 for THA vs. –0.03 for placebo; P = .5).

There were no significant differences on MRI or DXA, except that the steroid group had greater cartilage loss and the placebo group greater progression of fibrillation.

“The greater rate of loss of cartilage thickness ... in the treated group was small in magnitude and of uncertain clinical significance,” said Dr. McAlindon.

The mean body mass index in the study was 31.2 kg/m². Just over half the subjects were women, and about two-thirds were white. More than 90% of patients in both groups completed the study.

The work was funded by the National Institutes of Health. The investigators have no relevant disclosures.

[email protected]

Regular corticosteroid injections over 2 years were relatively safe for osteoarthritic knees in a trial from Tufts Medical Center in Boston, but they did not slow the progression of joint damage or improve patient outcomes.

The findings come at a time when the role of intra-articular steroid shots is up for debate. They are widely used for knee osteoarthritis (OA) in the hopes of reducing cartilage damage from synovitis, but there’s also concern that they might actually harm cartilage and periarticular bone.

The investigators, led by Dr. Timothy McAlindon, chief of rheumatology at Tufts Medical Center, sought to bring some data to the table. “Our objective was to test the potential for disease modification of synovitic knee OA by triamcinolone hexacetonide [THA] in a clinical trial with comprehensive measurement of effects on cartilage and subchondral bone using MRI and DXA [dual-energy x-ray absorptiometry],” they said.

The investigators randomized 140 patients with symptomatic knee OA (Kellgren-Lawrence grade 2 or 3) and synovitis on ultrasound to either 40 mg THA or saline knee injections every 3 months for 2 years. Randomization was blocked and stratified by gender and Kellgren-Lawrence grade. Patients had clinical assessments at each visit and annual MRIs and DXA knee and hip scans.

There were no significant between-group differences over the course of the study in mean changes on Western Ontario and McMaster Universities Arthritis Index pain (–2.2 for THA vs. –2.8 for placebo; P = .3) and function scores (–7.1 for THA vs. –9.2 for placebo; P = .4), and no differences in chair stand (–1.1 for THA vs. –1.6 for placebo; P = .8) or walk time tests (–0.5 for THA vs. –0.03 for placebo; P = .5).

There were no significant differences on MRI or DXA, except that the steroid group had greater cartilage loss and the placebo group greater progression of fibrillation.

“The greater rate of loss of cartilage thickness ... in the treated group was small in magnitude and of uncertain clinical significance,” said Dr. McAlindon.

The mean body mass index in the study was 31.2 kg/m². Just over half the subjects were women, and about two-thirds were white. More than 90% of patients in both groups completed the study.

The work was funded by the National Institutes of Health. The investigators have no relevant disclosures.

[email protected]

The Food and Drug Administration has approved a low-dose formulation of meloxicam for the treatment of osteoarthritis pain, according to manufacturer, Iroko Pharmaceuticals.

The new medication, Vivlodex, is made using a proprietary technology for producing submicron-size particles of meloxicam that are 10 times smaller than their traditional size, decreasing dissolution time. In a 12-week, phase III trial of 402 osteoarthritis patients aged 40 years or older, Vivlodex in 5- and 10-mg doses achieved efficacy at 33% lower doses than with commercially available meloxicam medications. Vivlodex will be available as a once-daily medication in 5- or 10-mg doses.

Courtesy Wikimedia Commons/FitzColinGerald/Creative Commons License

The FDA and professional medical associations have recommended administering nonsteroidal anti-inflammatory drugs in as small a dose and for as short a duration as possible. Serious adverse events stemming from NSAID treatments are related to dose and risk can increase as treatment continues.

“Meloxicam is the second most commonly prescribed NSAID in the [United States]. The approval of Vivlodex is a welcome option that offers patients an effective, low-dose NSAID,” Dr. Byron Cryer, associate dean at the University of Texas Southwestern Medical Center at Dallas, said in a statement from Iroko.

[email protected]

The Food and Drug Administration has approved a low-dose formulation of meloxicam for the treatment of osteoarthritis pain, according to manufacturer, Iroko Pharmaceuticals.

The new medication, Vivlodex, is made using a proprietary technology for producing submicron-size particles of meloxicam that are 10 times smaller than their traditional size, decreasing dissolution time. In a 12-week, phase III trial of 402 osteoarthritis patients aged 40 years or older, Vivlodex in 5- and 10-mg doses achieved efficacy at 33% lower doses than with commercially available meloxicam medications. Vivlodex will be available as a once-daily medication in 5- or 10-mg doses.

Courtesy Wikimedia Commons/FitzColinGerald/Creative Commons License

The FDA and professional medical associations have recommended administering nonsteroidal anti-inflammatory drugs in as small a dose and for as short a duration as possible. Serious adverse events stemming from NSAID treatments are related to dose and risk can increase as treatment continues.

“Meloxicam is the second most commonly prescribed NSAID in the [United States]. The approval of Vivlodex is a welcome option that offers patients an effective, low-dose NSAID,” Dr. Byron Cryer, associate dean at the University of Texas Southwestern Medical Center at Dallas, said in a statement from Iroko.

[email protected]

The Food and Drug Administration has approved a low-dose formulation of meloxicam for the treatment of osteoarthritis pain, according to manufacturer, Iroko Pharmaceuticals.

The new medication, Vivlodex, is made using a proprietary technology for producing submicron-size particles of meloxicam that are 10 times smaller than their traditional size, decreasing dissolution time. In a 12-week, phase III trial of 402 osteoarthritis patients aged 40 years or older, Vivlodex in 5- and 10-mg doses achieved efficacy at 33% lower doses than with commercially available meloxicam medications. Vivlodex will be available as a once-daily medication in 5- or 10-mg doses.

Courtesy Wikimedia Commons/FitzColinGerald/Creative Commons License

The FDA and professional medical associations have recommended administering nonsteroidal anti-inflammatory drugs in as small a dose and for as short a duration as possible. Serious adverse events stemming from NSAID treatments are related to dose and risk can increase as treatment continues.

“Meloxicam is the second most commonly prescribed NSAID in the [United States]. The approval of Vivlodex is a welcome option that offers patients an effective, low-dose NSAID,” Dr. Byron Cryer, associate dean at the University of Texas Southwestern Medical Center at Dallas, said in a statement from Iroko.

[email protected]