medwireNews: A systematic review and network meta-analysis has compared different drug treatments for pain relief in people with knee or hip osteoarthritis, finding that certain non-steroidal anti-inflammatory drugs (NSAIDs) may have the greatest benefit, while opioids are associated with increased risk for harm.
Bruno da Costa (University of Toronto, Ontario, Canada) and colleagues compared 90 different preparations or doses of NSAIDs (n=68), opioids (n=19), and acetaminophen (n=3) that were evaluated in 192 randomized trials involving a total of 102,829 participants.
As reported in The BMJ, 74.5% of oral NSAID interventions showed statistical superiority over oral placebo, as did 33.3% of topical NSAID, 22.2% of opioid, and 33.3% of acetaminophen regimens.
For seven NSAID interventions, there was at least a 95% probability that the treatment effect exceeded the minimum clinically important difference (MCID) of 0.37 standard deviation units. Of these, five had at least 99% probability, namely diclofenac 150 mg/day, etoricoxib 60 or 90 mg/day, and rofecoxib 25 or 50 mg/day.
“Etoricoxib 60 mg/day and diclofenac 150 mg/day seem to be the most effective oral NSAIDs […], but might not be appropriate in the presence of comorbidities or for long term use,” say the study authors.
They add that that topical diclofenac “was the most promising topical treatment,” with a 92.3% or greater probability of a treatment effect exceeding the MCID irrespective of dose. On the other hand, all opioids had a 53.0% or lower probability of exceeding the MCID.
In the safety analysis, the proportion of interventions with an increased number of participants dropping out due to adverse events (AEs) with treatment versus placebo was 18.5% for oral NSAIDs, 0.0% for topical NSAIDs, 83.3% for opioids, and 33.3% for acetaminophen. The opioid oxymorphone at a dose of 80 mg/day was associated with the highest rates of AEs (88%) and dropouts due to AEs (51%).
“The clinical benefit of opioid treatment, regardless of preparation or dose, does not outweigh the harm it might cause in patients with osteoarthritis,” stress the researchers.
They observe that oral NSAIDs at lower doses, including diclofenac 100–105 mg/day and etoricoxib 30 mg/day, as well as topical diclofenac 70–81 mg/day, were found to have better safety profiles than the maximum recommended doses, while still having more than an 88% likelihood of treatment efficacy exceeding the MCID.
“Physicians could use the results of our analysis to identify the lowest doses of different drug preparations that are effective and safe when first prescribing treatment, as generally recommended by current clinical practice guidelines,” say da Costa and team.
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