Discontinuing a non-steroidal anti-inflammatory drug (NSAID) in patients with knee osteoarthritis: Design and protocol of a placebo-controlled, noninferiority, randomized withdrawal trial

Effects of 3'-Sialyllactose on Symptom Improvement in Patients with Knee Osteoarthritis: A Randomized Pilot Study

Background/Objectives: 3'-Sialyllactose (3'-SL), a human milk oligosaccharide, has anti-inflammatory effects and is demonstrated to have protective effects against osteoarthritis (OA) in vitro and in vivo. However, this hypothesis remains to be investigated in a clinical setting. Herein, we investigated the effects of 3'-SL on pain and physical function in patients with knee OA. Methods: Sixty patients with knee OA with Kellgren and Lawrence grades (KL-grades) 1-4 and Korean Western Ontario and McMaster Universities Osteoarthritis Index (KWOMAC) scores ≥30 were randomly assigned to the placebo (n = 20), 3'-SL 200 mg (n = 20), and 3'-SL 600 mg (n = 20) groups. For 12 weeks, 3'-SL or placebo was administered to patients once a day. Clinical efficacy was evaluated using a visual analog scale (VAS) for pain and KWOMAC for physical function at baseline and at 6 and 12 weeks. Adverse effects were assessed for 12 weeks. Results: Significant reductions in VAS and KWOMAC scores were observed at 12 weeks compared with the baseline in the 3'-SL group. No severe adverse effects were observed over 12 weeks. Conclusions: 3'-SL reduced pain in patients with knee OA, improved daily life movements, and was safe, suggesting that 3'-SL might be an effective treatment for knee OA without severe side effects.

Topical Diclofenac Solution for Osteoarthritis of the Knee: An Updated Meta-Analysis of Randomized Controlled Trials

This study was performed to assess the efficacy and safety of a topical diclofenac solution in patients with knee osteoarthritis (OA). PubMed, Embase, Cochrane Library, Web of Science, and Scopus databases were searched for randomized controlled trials until June 2020. The WOMAC pain, stiffness, physical function subscales, pain on walking, and the occurrence of adverse events were pooled to comprehensively analyse the efficacy and safety of topical diclofenac solution. All statistical analyses were conducted using Review Manager 5.3 software. Five RCTs were included, which provided high-quality evidence. In comparison to the vehicle control, the mean differences for WOMAC pain, stiffness, and physical function subscales, as well as pain on walking, were all statistically significant in favor of topical diclofenac solution. The safety of topical diclofenac solution was similar to the vehicle control, apart from adverse events involving application-site skin reactions. Topical diclofenac solution is effective and safe for use in patients with knee OA, but may cause minor skin reactions.

Nonsteroidal Anti-inflammatory Drugs vs Cognitive Behavioral Therapy for Arthritis Pain: A Randomized Withdrawal Trial

IMPORTANCE

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed for knee osteoarthritis. However, they are associated with uncertain long-term clinical benefit and significant toxic effects.

OBJECTIVE

To evaluate whether discontinuing NSAIDs and engaging in a telephone-based cognitive behavioral therapy (CBT) program is noninferior to continuing NSAIDs for patients with knee osteoarthritis.

DESIGN, SETTING, AND PARTICIPANTS

The Stopping NSAIDs for Arthritis Pain multicenter randomized withdrawal trial was conducted for 364 patients taking NSAIDs for knee osteoarthritis pain on most days of the week for at least 3 months between September 1, 2013, and September 30, 2018. Analysis was performed on an intent-to-treat basis.

INTERVENTIONS

Participants discontinued their current NSAID and took 15 mg per day of meloxicam daily during a 2-week run-in period. Those who remained eligible were randomized in a 1:1 ratio to receive meloxicam or placebo for 4 weeks (blinded phase 1). Participants receiving meloxicam then continued this medication for 10 weeks, while those receiving placebo participated in a 10-week CBT program (unblinded phase 2).

MAIN OUTCOMES AND MEASURES

The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score at 4 weeks with the noninferiority margin set at 1. Secondary outcomes included the area under the curve of the pain score after 4 weeks as well as the WOMAC pain score, area under the curve of the pain score, WOMAC disability score, and global impression of change after treatment at 14 weeks.

RESULTS

A total of 180 participants (161 men; mean [SD] age, 58. 2 [11.8] years) were randomized to receive placebo followed by CBT, and a total of 184 participants (154 men; mean [SD] age, 58.5 [10.0] years) were randomized to receive meloxicam. After adjustment for baseline pain and study site, the estimated mean difference in WOMAC pain score between the placebo and meloxicam groups after 4 weeks was 1.4 (95% CI, 0.8-2.0; noninferiority test P = .92). At week 14, the adjusted mean difference in WOMAC pain score between the placebo (followed by CBT) and meloxicam groups was 0.8 (95% CI, 0.2-1.4; noninferiority P = .28). There was no statistically significant difference in the global impression of change (mean difference in scores, -0.2; 95% CI, -0.4 to 0.1; P = .15) or lower extremity disability (mean difference in scores, 0.9; 95% CI, -1.4 to 3.2; P = .45) between the 2 groups after 14 weeks.

CONCLUSIONS AND RELEVANCE

Among patients with knee osteoarthritis, placebo and CBT (after placebo) are inferior to meloxicam. However, the WOMAC pain score differences between the 2 groups were small, and there were no statistically significant differences in participants' global impression of change or function after 14 weeks.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01799213.

Application of film-forming solution as a transdermal delivery system of piperine-rich herbal mixture extract for anti-inflammation

Piperine-rich herbal mixture (PHM) used in this study is a traditional Thai medicine that contains 21 oriental herbs. It is called "Sahastara remedy" and is officially included in the Thai National List of Essential Medicine since A.D. 2011. PHM has been used orally to relieve muscle and bone pains. It contains Piper nigrum fruits as a major constituent and also Piper retrofractum fruits, PHM thus has anti-inflammatory activities that mostly come from the bioactivities of piperine consisting of these pepper fruits. Unfortunately, PHM usually causes gastrointestinal side effects. Consequently, a topical product containing an alcoholic extract of PHM (PHM-E), i.e., film-forming solution (FFS) was developed to overcome this drawback. The aims of this study were to investigate the anti-inflammatory activity of PHM-E, to evaluate physicochemical properties and the anti-inflammatory activity of FFS containing PHM-E (PHM-E FFS). Anti-inflammatory activities of PHM-E were investigated in the RAW 264.7 cells. Physicochemical properties, in vitro toxicities and anti-inflammatory activities of PHM-E FFS including its dry film (PHM-E film) were determined. PHM-E showed anti-inflammatory activities with dose dependent manners via inhibition of nitric oxide and prostaglandin E₂ production by the RAW 264.7 cells and promotion of the cell phenotype polarization from M1 to M2. PHM-E FFS had low viscosity and exhibited the Newtonian behavior. It provided elastic PHM-E film with low tensile strength. The release profile of piperine from PHM-E film followed a zero-kinetic model. PHM-E FFS demonstrated compatibility with the skin cells, minimal ocular irritant when accidentally splashing into the eye and moderate-to-high potency for inhibition of inflammatory symptoms in the rats. PHM-E FFS thus had potential for use in the further clinical study to investigate its efficacy and safety in patients.

A Network Pharmacology Study on the Active Ingredients and Potential Targets of Tripterygium wilfordii Hook for Treatment of Rheumatoid Arthritis

Traditional Chinese medicine has specific effect on some chronic diseases in clinic, especially in rheumatic diseases. Tripterygium wilfordii Hook (TWH) is a traditional Chinese medicine commonly used in the treatment of rheumatoid arthritis (RA); the unique therapeutic effect has been confirmed by a large number of research papers. TWH has many compounds that lead to its active compounds. However, the potential targets and pharmacological and molecular mechanism of its action treatment of rheumatic diseases are not entirely clear. Therefore, the network pharmacology approach is needed to further study and explore its treatment mechanism. We have successfully set up 10 networks, including four major networks and other networks. Four major networks include rheumatoid arthritis disease network, compound-compound target network of TWH, TWH compound target-rheumatoid arthritis disease network, and TWH-rheumatoid arthritis disease-mechanism network. Other networks consist of RA disease and TWH related targets clusters, biological processes, and pathways network. Our study successfully predicted, explained, and confirmed the TWH of RA disease molecular synergy and found the potential of RA related targets, cluster, biological process, and pathways. This study not only provides prompts to the researcher who explores pharmacological and biological molecular mechanism of TWH applying to RA disease, but also proves a feasible method for discovering potential activated compounds from Chinese herbs.