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Sveaas SH, Smedslund G, Walsh DA, Dagfinrud H. Effects of Analgesics on Self-Reported Physical Function and Walking Ability in People With Hip or Knee Osteoarthritis: A Systematic Review and Meta-Analysis. Phys Ther 2024; 104:pzad160. [PMID: 37980627 PMCID: PMC10902557 DOI: 10.1093/ptj/pzad160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 06/26/2023] [Accepted: 09/15/2023] [Indexed: 11/21/2023]
Abstract
OBJECTIVE Hip and knee osteoarthritis are among the leading causes of global disability, and one of the main aims of the management is to improve physical function. The objective of this review was to investigate the effect of analgesics on physical function (self-reported physical function and walking ability). METHODS A systematic review and meta-analysis of the findings were performed. Randomized controlled trials investigating the effect of analgesics on self-reported physical function and walking ability were included. Analgesics were orally administered acetaminophen, nonsteroidal antiinflammatory drugs (NSAIDs), or opioids. Data were pooled in a random-effects model, and the standardized mean difference (SMD) with 95% CI was calculated (SMDs: 0.2-0.4 = small, 0.5-0.7 = medium, and ≥0.8 = large effect sizes). The quality of the evidence was evaluated according to the Grading of Recommendations Assessment, Development, and Evaluation approach. RESULTS A total of 1454 studies were identified, of which 33 were included. On self-reported physical function, the results showed low- to moderate-quality evidence for a small beneficial effect of acetaminophen (SMD = -0.13 [95% CI = -0.26 to 0.00]), NSAIDs (SMD = -0.32 [95% CI = -0.37 to -0.27]), or opioids (SMD = -0.20 [95% CI = -0.32 to -0.09]). There was moderate-quality evidence for a small effect of NSAIDs on pain during walking (SMD = -0.34 [95% CI = -0.45 to -0.23]). CONCLUSION In people with hip or knee osteoarthritis, there was low- to moderate-quality evidence for small beneficial effects of analgesics on physical function and walking ability. IMPACT Analgesics may improve physical function by reducing pain during exercise and walking.
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Affiliation(s)
- Silje H Sveaas
- Department of Nutrition and Public Health, Faculty of Health and Sport Sciences, University of Agder, Kristiansand , Norway
| | - Geir Smedslund
- Norwegian National Advisory Unit on Rehabilitation in Rheumatology, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - David A Walsh
- Pain Centre Versus Arthritis, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Hanne Dagfinrud
- Norwegian National Advisory Unit on Rehabilitation in Rheumatology, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
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Shi X, Yu W, Zhang W, Wang T, Battulga O, Wang L, Guo C. A comparison of the effects of electroacupuncture versus transcutaneous electrical nerve stimulation for pain control in knee osteoarthritis: a Bayesian network meta-analysis of randomized controlled trials. Acupunct Med 2020; 39:163-174. [PMID: 32567333 DOI: 10.1177/0964528420921193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND To compare the effectiveness of electroacupuncture (EA) and transcutaneous electrical nerve stimulation (TENS) for pain control in knee osteoarthritis (KOA). METHODS Four English (MEDLINE, EMBASE, Cochrane Library and Web of Science) and three Chinese (China Science Journal Citation Report (VIP), Wanfang and China National Knowledge Infrastructure (CNKI)) language databases were searched for eligible randomized controlled trials (RCTs), comparing four approaches: EA, TENS, medication and sham/placebo controls. The primary outcome was pain intensity, measured by visual analogue scale (VAS), numeric-rating scale (NRS) or Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scale. Classic pairwise and Bayesian network meta-analyses were conducted to integrate the treatment efficacy/effectiveness through direct and indirect evidence. RESULTS Thirteen studies were included. In the direct meta-analyses, there was no statistically significant overall effect of EA (mean difference (MD) -4.77, 95% confidence interval (CI) -12.51 to 2.96), while the overall effects of high-frequency transcutaneous electrical nerve stimulation (H-TENS) (MD -16.63, 95% CI -24.57 to -8.69) and medication (MD -7.12, 95% CI -12.07 to -2.17) were statistically significant. In the network meta-analyses, the relative effect of the EA and H-TENS groups (MD 5.07, 95% CI -11.33 to 21.93) on pain control did not differ. Meanwhile, H-TENS demonstrated the highest probability of being the first best treatment, and EA had the second highest probability. CONCLUSION The present analysis indicated that both EA and TENS exert significant pain relieving effects in KOA. Among the four treatments, H-TENS was found to be the optimal treatment choice for the management of KOA pain in the short-term, and EA the second best treatment option. Given that the application of TENS is recommended by various international guidelines for the treatment of KOA, EA may also represent a potentially effective non-pharmacologic therapy.
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Affiliation(s)
- Xiaowei Shi
- Department of Massage, Beijing University of Chinese Medicine Third Affiliated Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Wenjing Yu
- Department of Pediatrics, Beijing University of Chinese Medicine Third Affiliated Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Wei Zhang
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Tong Wang
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Oyunerdene Battulga
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Lijuan Wang
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Changqing Guo
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
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Curtis E, Fuggle N, Shaw S, Spooner L, Ntani G, Parsons C, Corp N, Honvo G, Baird J, Maggi S, Dennison E, Bruyère O, Reginster JY, Cooper C. Safety of Cyclooxygenase-2 Inhibitors in Osteoarthritis: Outcomes of a Systematic Review and Meta-Analysis. Drugs Aging 2019; 36:25-44. [PMID: 31073922 PMCID: PMC6509094 DOI: 10.1007/s40266-019-00664-x] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Objective Our aim was to assess the safety of cyclooxygenase-2 (COX-2) inhibitors in the management of osteoarthritis (OA) in a systematic review and meta-analysis of randomized, placebo-controlled trials. Methods A comprehensive literature search was undertaken in the databases MEDLINE, Cochrane Central Register of Controlled Trials (Ovid CENTRAL) and Scopus. Randomized, double-blind, placebo-controlled, parallel-group trials that assessed adverse events (AEs) with COX-2 inhibitors in patients with OA were eligible for inclusion. Two authors appraised titles, abstracts and full-text papers for suitability and then assessed the studies for random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data and selective outcomes reporting. The primary outcomes of interest were gastrointestinal disorders, cardiac disorders, vascular disorders, nervous system disorders, skin and subcutaneous tissue disorders, hepatobiliary disorders, renal and urinary disorders, as well as overall severe and serious AEs, drug-related AEs and mortality. Secondary outcomes were withdrawals due to AEs (i.e. the number of participants who stopped the treatment due to an AE) and total number of AEs (i.e. the number of patients who experienced any AE at least once). Results Database searches identified 2149 records from which, after exclusions, 40 trials were included in the meta-analysis. The use of COX-2 inhibitors in OA was associated with a significant increased risk of drug-related AEs compared with placebo (relative risk (RR) 1.26, 95% CI 1.09–1.46; I2 = 24%). The risk of upper gastrointestinal complications (including dyspepsia, gastritis and heartburn) was significantly increased with COX-2 inhibitors versus placebo (RR 1.19, 95% CI 1.03–1.38; I2 = 0%), particularly for abdominal pain, which increased by 40% with COX-2 inhibitors (RR 1.40, 95% CI 1.08–1.80; I2 = 0%). The risk of hypertension increased by 45% overall (RR 1.45, 95% CI 1.01–2.10; I2 = 25%); however, when rofecoxib was removed from the analysis the risk of hypertension in the COX-2 inhibitor group was no longer significant (RR 1.21, 95% CI 0.80–1.83; I2 = 20%). The overall risk of heart failure and edema was increased by nearly 70% with COX-2 inhibitors versus placebo (RR 1.68, 95% CI 1.22–2.31; 0%) and this level of risk did not change appreciably when rofecoxib was excluded (RR 1.67, 95% CI 1.21–2.29; 0%). Conclusions In our analysis, COX-2 inhibitors were associated with an increased risk of upper gastrointestinal AEs, especially abdominal pain. We also found an increased risk of cardiovascular AEs with COX-2 inhibitors, namely hypertension, heart failure and edema. Electronic supplementary material The online version of this article (10.1007/s40266-019-00664-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Elizabeth Curtis
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK
| | - Nicholas Fuggle
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK
| | - Sarah Shaw
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK
| | | | - Georgia Ntani
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK
| | - Camille Parsons
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK
| | - Nadia Corp
- Arthritis Research UK Primary Care Centre, Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Germain Honvo
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium.,WHO Collaborating Centre for Public Heath Aspects of Musculoskeletal Health and Aging, Liège, Belgium
| | - Janis Baird
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK
| | - Stefania Maggi
- Aging Program, National Research Council, Neuroscience Institute, Padua, Italy
| | - Elaine Dennison
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK
| | - Olivier Bruyère
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium.,WHO Collaborating Centre for Public Heath Aspects of Musculoskeletal Health and Aging, Liège, Belgium
| | - Jean-Yves Reginster
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium.,WHO Collaborating Centre for Public Heath Aspects of Musculoskeletal Health and Aging, Liège, Belgium.,Chair for Biomarkers of Chronic Diseases, Biochemistry Department, College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK. .,WHO Collaborating Centre for Public Heath Aspects of Musculoskeletal Health and Aging, Liège, Belgium. .,National Institute for Health Research (NIHR) Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK.
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Sowah D, Balat F, Straube S. Work-related outcomes in randomized, double blind, placebo-controlled trials in osteoarthritis - are they adequately reported in journal publications? A systematic review. J Occup Med Toxicol 2018; 13:32. [PMID: 30377437 PMCID: PMC6195965 DOI: 10.1186/s12995-018-0215-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 10/05/2018] [Indexed: 11/10/2022] Open
Abstract
Background Osteoarthritis (OA) has a high prevalence in Western societies and can affect an individual's life in a number of domains, including work. In our experience, treatment trials on OA, however, rarely report work-related outcomes. Here we conducted a systematic review to assess the reporting of work-related outcomes in randomized, double blind, placebo-controlled trials in OA. Our systematic review also compared two search strategies for identifying eligible publications, one where work-related terms were included in the database search string (A) and one where this was not the case and work-related outcomes were identified by searches of full text Portable Document Formats (PDFs) (B). Search strategy A would conventionally be used and would only identify publications where work-related terms were mentioned in the title or abstract. Search strategy B presents the innovation of full text PDF searching and would identify publications were work-related terms were reported in the full text, regardless of whether they are mentioned in the title and abstract or not. We hypothesize that search strategy B identifies more relevant publications than search strategy A. Methods Electronic database searching was performed in Medline (Pubmed) from database inception to February 23, 2017 to identify peer-reviewed articles of randomized, double blind, placebo-controlled treatment trials in OA of the hand, hip, or knee, available as full-text PDFs. For search strategy A, search terms to identify work-related outcomes were included in the database search string, while search strategy B did not have these terms included in the database search string, but instead involved full text PDF searching. We included English language articles only and only those articles where searchable PDFs were available, to enable a comparison between search strategies A and B. Additionally, included studies also needed to report on pain intensity in relation to the work-related outcomes. Results Search strategy A yielded 50 hits combined for hand, hip or knee OA that mentioned some work-related concept in the title or abstract; 12 articles had to be excluded because they were not available as searchable PDFs. Screening of the remaining 38 articles resulted in only two articles that satisfied our inclusion criteria. Search strategy B yielded 986 hits, out of which 201 articles were excluded because searchable full text PDFs were not available. PDF full text searching and further screening resulted in 10 articles that were considered eligible for our review. Conclusions Work-related outcomes are rarely reported in journal publication on randomized, double blind, placebo-controlled trials of hand, hip or knee OA. Searching full text PDFs yields more eligible articles than searching titles and abstracts only.
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Affiliation(s)
- Daniel Sowah
- Division of Preventive Medicine, Department of Medicine, University of Alberta, 5-30 University Terrace, 8303-112 Street, Edmonton, AB T6G 2T4 Canada
| | - Flora Balat
- Division of Preventive Medicine, Department of Medicine, University of Alberta, 5-30 University Terrace, 8303-112 Street, Edmonton, AB T6G 2T4 Canada
| | - Sebastian Straube
- Division of Preventive Medicine, Department of Medicine, University of Alberta, 5-30 University Terrace, 8303-112 Street, Edmonton, AB T6G 2T4 Canada
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Parry EL, Thomas MJ, Peat G. Defining acute flares in knee osteoarthritis: a systematic review. BMJ Open 2018; 8:e019804. [PMID: 30030311 PMCID: PMC6059300 DOI: 10.1136/bmjopen-2017-019804] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 04/10/2018] [Accepted: 05/15/2018] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To identify and critically synthesise definitions of acute flares in knee osteoarthritis (OA) reported in the medical literature. DESIGN Systematic review and narrative synthesis. We searched Medline, EMBASE, Web of science and six other electronic databases (inception to July 2017) for original articles and conference abstracts reporting a definition of acute flare (or synonym) in humans with knee OA. There were no restrictions by language or study design (apart from iatrogenic-induced flare-ups, eg, injection-induced). Data extraction comprised: definition, pain scale used, flare duration or withdrawal period, associated symptoms, definition rationale, terminology (eg, exacerbation or flare), baseline OA severity, age, gender, sample size and study design. RESULTS Sixty-nine articles were included (46 flare design trials, 17 observational studies, 6 other designs; sample sizes: 15-6085). Domains used to define flares included: worsening of signs and symptoms (61 studies, 27 different measurement tools), specifically increased pain intensity; minimum pain threshold at baseline (44 studies); minimum duration (7 studies, range 8-48 hours); speed of onset (2 studies, defined as 'sudden' or 'quick'); requirement for increased medication (2 studies). No definitions included activity interference. CONCLUSIONS The concept of OA flare appears in the medical literature but most often in the context of flare design trials (pain increases observed after stopping usual treatment). Key domains, used to define acute events in other chronic conditions, appear relevant to OA flare and could provide the basis for consensus on a single, agreed definition of 'naturally occurring' OA flares for research and clinical application. PROSPERO REGISTRATION NUMBER CRD42014010169.
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Affiliation(s)
- Emma L Parry
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Martin J Thomas
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
| | - George Peat
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
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Guo R, Chen J. Recent advances in the synthesis of fluorinated hydrazones. RSC Adv 2018; 8:17110-17120. [PMID: 35539278 PMCID: PMC9080406 DOI: 10.1039/c8ra02533a] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 04/27/2018] [Indexed: 01/26/2023] Open
Abstract
Fluorinated compounds are widely used in pharmaceuticals, agrochemicals, and materials.
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Affiliation(s)
- Rui Guo
- Institute of Environment and Health
- Jianghan University
- Wuhan 430056
- P. R. China
- State Key Laboratory of Environmental Chemistry and Ecotoxicology
| | - Junting Chen
- Max-Planck-Institut für Kohlenforschung
- 45470 Mülheim an der Ruhr
- Germany
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Comparing the Safety and Efficacy of Celecoxib for the Treatment of Osteoarthritis in Asian and non-Asian Populations: An Analysis of Data from Two Randomized, Double-blind, Placebo-controlled, Active-comparator Trials. Pain Ther 2017; 6:235-242. [PMID: 28921415 PMCID: PMC5693812 DOI: 10.1007/s40122-017-0081-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Indexed: 11/17/2022] Open
Abstract
Introduction Celecoxib is an effective treatment for pain associated with osteoarthritis. There are differences in patient demographics among ethnic groups, with Asian populations typically smaller in body size. As a consequence, there may be a perception that celecoxib is less effective, or has poorer tolerability in Asian patients. Methods This analysis compares data from two multicenter, randomized, double-blind, placebo-controlled, active-comparator trials of celecoxib for the treatment of osteoarthritis of the knee: one study in Asian patients and the other in a mixed population comprised mostly of non-Asian patients (from which Asian patients were excluded for this analysis). Each trial was of similar design, with patients randomized 2:2:1 to 6 weeks treatment with celecoxib 200 mg once daily, active comparator (naproxen 500 mg twice daily or ibuprofen 800 mg three times daily), or placebo. The primary efficacy endpoint in each trial was the change from baseline to week 6 in the Patient’s Assessment of Arthritis Pain, as measured on a visual analog scale. Results In total, 329 patients were included in the efficacy analysis, 179 in the Asian study and 150 in the non-Asian study. The Asian population was significantly older and smaller in body size (P < 0.0001). There was no significant difference between the Asian and non-Asian populations in change in pain score (95% confidence interval) at study endpoint with celecoxib [−1.1 (−7.7, 5.5); P = 0.7400] or placebo [−5.2 (−14.8, 4.4); P = 0.2870]. There were also no notable differences in safety outcomes between populations. Conclusions Due to the smaller size of some Asian patients with OA, physicians may be tempted to decrease the dose of celecoxib below the therapeutic range recognized by regulatory authorities; these data suggest that dose changes are not necessary. Funding Pfizer Inc.
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Cross M, Dubouis L, Mangin M, Hunter DJ, March L, Hawker G, Guillemin F. Defining Flare in Osteoarthritis of the Hip and Knee: A Systematic Literature Review — OMERACT Virtual Special Interest Group. J Rheumatol 2017; 44:1920-1927. [DOI: 10.3899/jrheum.161107] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2017] [Indexed: 11/22/2022]
Abstract
Objective.Beyond the exacerbation of pain in describing a flare in osteoarthritis (OA), patients and health professionals add other elements that deserve to be fully elucidated, such as effusion, swelling, and mobility limitation. To define and conceptualize the construct flare in OA, the objective was to identify the key variables, or symptoms, that worsen, and to clarify how these variables are described in the literature by patients and clinicians.Methods.A systematic review of the literature was conducted in Medline and PsychINFO. In brief, the search terms used were “osteoarthritis,” “knee,” “hip,” and “flare.” Specific characteristics of included studies were identified, including the type of study design, type of flare assessed, how the flare developed, and what definition of flare was used, including whether the definition was based on qualitative or quantitative analysis.Results.Pain was the major factor in the definition of flare within these studies. Four components of flare were identified: pain, other factors, composite criteria, and global assessment. While the majority of studies reported flare as an increase in pain using standardized outcome measures, only 1 study reported the antecedents and consequences of a pain flare using qualitative methods.Conclusion.The use of flare as an outcome or inclusion criterion in rheumatology trials is a common occurrence; however, this review highlights the wide variation in the definitions of OA flare currently in use and the emphasis on the measurement of pain. This variation in definition does not allow for direct comparison between trials and limits interpretation of evidence.
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Abstract
BACKGROUND Osteoarthritis (OA) is the most common form of arthritis and is caused by degeneration of the joint cartilage and growth of new bone, cartilage and connective tissue. It is often associated with major disability and impaired quality of life. There is currently no consensus on the best treatment to improve OA symptoms. Celecoxib is a selective non-steroidal anti-inflammatory drug (NSAID). OBJECTIVES To assess the clinical benefits (pain, function, quality of life) and safety (withdrawals due to adverse effects, serious adverse effects, overall discontinuation rates) of celecoxib in osteoarthritis (OA). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and clinical trials registers up to April 11, 2017, as well as reference and citation lists of included studies. Pharmaceutical companies and authors of published articles were contacted. SELECTION CRITERIA We included published studies (full reports in a peer reviewed journal) of prospective randomized controlled trials (RCTs) that compared oral celecoxib versus no intervention, placebo or another traditional NSAID (tNSAID) in participants with clinically- or radiologically-confirmed primary OA of the knee or hip, or both knee and hip. DATA COLLECTION AND ANALYSIS Two authors independently performed data extraction, quality assessment, and compared results. Main analyses for patient-reported outcomes of pain and physical function were conducted on studies with low risk of bias for sequence generation, allocation concealment and blinding of participants and personnel. MAIN RESULTS We included 36 trials that provided data for 17,206 adults: 9402 participants received celecoxib 200 mg/day, and 7804 were assigned to receive either tNSAIDs (N = 1869) or placebo (N = 5935). Celecoxib was compared with placebo (32 trials), naproxen (6 trials) and diclofenac (3 trials). Studies were published between 1999 and 2014. Studies included participants with knee, hip or both knee and hip OA; mean OA duration was 7.9 years. Most studies included predominantly white participants whose mean age was 62 (± 10) years; most participants were women. There were no concerns about risk of bias for performance and detection bias, but selection bias was poorly reported in most trials. Most trials had high attrition bias, and there was evidence of selective reporting in a third of the studies. Celecoxib versus placeboCompared with placebo celecoxib slightly reduced pain on a 500-point Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain scale, accounting for 3% absolute improvement (95% CI 2% to 5% improvement) or 12% relative improvement (95% CI 7% to 18% improvement) (4 studies, 1622 participants). This improvement may not be clinically significant (high quality evidence).Compared with placebo celecoxib slightly improved physical function on a 1700-point WOMAC scale, accounting for 4% absolute improvement (95% CI 2% to 6% improvement), 12% relative improvement (95% CI 5% to 19% improvement) (4 studies, 1622 participants). This improvement may not be clinically significant (high quality evidence).There was no evidence of an important difference for withdrawals due to adverse events (Peto OR 0.99, 95% CI 0.85 to 1.15) (moderate quality evidence due to study limitations).Results were inconclusive for numbers of participants experiencing any serious AEs (SAEs) (Peto OR 0.95, 95% CI 0.66 to 1.36), gastro-intestinal events (Peto OR 1.91, 95% CI 0.24 to 14.90) and cardiovascular events (Peto OR 3.40, 95% CI 0.73 to 15.88) (very low quality evidence due to serious imprecision and study limitations). However, regulatory agencies have warned of increased cardiovascular events for celecoxib. Celecoxib versus tNSAIDsThere were inconclusive results regarding the effect on pain between celecoxib and tNSAIDs on a 100-point visual analogue scale (VAS), showing 5% absolute improvement (95% CI 11% improvement to 2% worse), 11% relative improvement (95% CI 26% improvement to 4% worse) (2 studies, 1180 participants, moderate quality evidence due to publication bias).Compared to a tNSAID celecoxib slightly improved physical function on a 100-point WOMAC scale, showing 6% absolute improvement (95% CI 6% to 11% improvement) and 16% relative improvement (95% CI 2% to 30% improvement). This improvement may not be clinically significant (low quality evidence due to missing data and few participants) (1 study, 264 participants).Based on low or very low quality evidence (downgraded due to missing data, high risk of bias, few events and wide confidence intervals) results were inconclusive for withdrawals due to AEs (Peto OR 0.97, 95% CI 0.74 to 1.27), number of participants experiencing SAEs (Peto OR 0.92, 95% CI 0.66 to 1.28), gastro-intestinal events (Peto OR 0.61, 0.15 to 2.43) and cardiovascular events (Peto OR 0.47, 95% CI 0.17 to 1.25).In comparisons of celecoxib and placebo there were no differences in pooled analyses between our main analysis with low risk of bias and all eligible studies. In comparisons of celecoxib and tNSAIDs, only one outcome showed a difference between studies at low risk of bias and all eligible studies: physical function (6% absolute improvement in low risk of bias, no difference in all eligible studies).No studies included in the main comparisons measured quality of life. Of 36 studies, 34 reported funding by drug manufacturers and in 34 studies one or more study authors were employees of the sponsor. AUTHORS' CONCLUSIONS We are highly reserved about results due to pharmaceutical industry involvement and limited data. We were unable to obtain data from three studies, which included 15,539 participants, and classified as awaiting assessment. Current evidence indicates that celecoxib is slightly better than placebo and some tNSAIDs in reducing pain and improving physical function. We are uncertain if harms differ among celecoxib and placebo or tNSAIDs due to risk of bias, low quality evidence for many outcomes, and that some study authors and Pfizer declined to provide data from completed studies with large numbers of participants. To fill the evidence gap, we need to access existing data and new, independent clinical trials to investigate benefits and harms of celecoxib versus tNSAIDs for people with osteoarthritis, with longer follow-up and more direct head-to-head comparisons with other tNSAIDs.
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Affiliation(s)
- Livia Puljak
- University of Split School of MedicineCochrane CroatiaSoltanska 2SplitCroatia21000
| | | | - Davorka Vrdoljak
- School of Medicine in SplitDepartment of Family MedicineSoltanska 2SplitCroatia21000
| | - Filipa Markotic
- University Clinical Hospital MostarCentre for Clinical PharmacologyKralja Tvrtka b.b.MostarBosnia and Herzegovina88000
| | - Ana Utrobicic
- University of Split, School of MedicineCentral Medical LibrarySoltanska 2SplitCroatia21000
| | - Peter Tugwell
- Faculty of Medicine, University of OttawaDepartment of MedicineOttawaONCanadaK1H 8M5
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Smith TO, Zou K, Abdullah N, Chen X, Kingsbury SR, Doherty M, Zhang W, Conaghan PG. Does flare trial design affect the effect size of non-steroidal anti-inflammatory drugs in symptomatic osteoarthritis? A systematic review and meta-analysis. Ann Rheum Dis 2016; 75:1971-1978. [PMID: 26882928 DOI: 10.1136/annrheumdis-2015-208823] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 01/23/2016] [Indexed: 11/03/2022]
Abstract
OBJECTIVES It is thought that the clinical trial benefits of oral non-steroidal anti-inflammatory drugs (NSAIDs) may relate to flare designs. The aim of this study was to examine the difference in NSAID (including cyclooxygenase-2 (COX-2) inhibitors) response in osteoarthritis (OA) trials based on different designs. METHODS Systematic review was undertaken of the databases MEDLINE, EMBASE, AMED, CINAHL and the Cochrane library till February 2015. Randomised controlled trials assessing pain, function and/or stiffness following commencement of NSAIDs in flare and non-flare designs were eligible. Trials were assessed using the Cochrane Risk of Bias tool. Meta-analyses were conducted to assess the effect sizes (ES) of NSAIDs for OA with flare versus non-flare trial designs. RESULTS Fifty-seven studies including 33 263 participants assessing 26 NSAIDs were included. Twenty-two (39%) were flare design, 24 (42%) were non-flare designs, 11 (19%) were possible flare designs. On meta-analysis, there was no statistically significant difference in ES of NSAIDs versus placebo between flare and non-flare trial designs for absolute pain and function or stiffness at immediate-term (1 week), short-term (2-4 week) or longer-term (12-13 week) follow-up periods (p>0.05). However there was a lower ES for mean change in pain in flare and possible flare trials compared with non-flare trials at short-term follow-up (0.36 vs 0.69; p=0.05). CONCLUSIONS Contrary to previous understanding, flare trial designs do not result in an increased treatment effect for NSAIDs in people with OA compared with non-flare design. Whether flare design influences other outcomes such as joint effusion remains unknown.
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Affiliation(s)
- Toby O Smith
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Kun Zou
- Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology, Sichuan, China
| | - Natasya Abdullah
- Division of Rheumatology, Orthopaedics and Dermatology, University of Nottingham, Nottingham, UK
| | - Xi Chen
- Division of Rheumatology, Orthopaedics and Dermatology, University of Nottingham, Nottingham, UK
| | - Sarah R Kingsbury
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds & NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Michael Doherty
- Division of Rheumatology, Orthopaedics and Dermatology, University of Nottingham, Nottingham, UK
| | - Weiya Zhang
- Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, UK
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds & NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
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O'Reilly K, Donohoe G, O'Sullivan D, Coyle C, Mullaney R, O'Connell P, Maddock C, Nulty A, O'Flynn P, O'Connell C, Kennedy HG. Study protocol: a randomised controlled trial of cognitive remediation for a national cohort of forensic mental health patients with schizophrenia or schizoaffective disorder. BMC Psychiatry 2016; 16:5. [PMID: 26759167 PMCID: PMC4711170 DOI: 10.1186/s12888-016-0707-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 01/05/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Evidence is accumulating that cognitive remediation therapy (CRT) is an effective intervention for patients with schizophrenia or schizoaffective disorder. To date there has been no randomised controlled trial (RCT) cohort study of cognitive remediation within a forensic hospital. The goal of this study is to examine the effectiveness of a trial of cognitive remediation for forensic mental health patients with schizophrenia or schizoaffective disorder. METHODS An estimated sixty patients will be enrolled in the study. Participants will be randomised to one of two conditions: CRT with treatment as usual (TAU), or TAU. CRT will consist of 42 individual sessions and 14 group sessions. The primary outcome measure for this study is change in cognitive functioning using the MATRICS Consensus Cognitive Battery (MCCB). Secondary outcomes include change in social and occupational functioning, disorganised symptoms, negative symptoms, violence, participation in psychosocial treatment and recovery. In addition to these effectiveness measures, we will examine patient satisfaction. DISCUSSION Cognitive difficulties experienced by schizophrenia spectrum patients are associated with general functioning, ability to benefit from psychosocial interventions and quality of life. Research into the treatment of cognitive difficulties within a forensic setting is therefore an important priority. The results of the proposed study will help answer the question whether cognitive remediation improves functional outcomes in forensic mental health patients with schizophrenia or schizoaffective disorder. Forensic mental health patients are detained for the dual purpose of receiving treatment and for public protection. There can be conflict between these two roles perhaps causing forensic services to have an increased length of stay compared to general psychiatric admissions. Ultimately a focus on emphasising cognition and general functioning over symptoms may decrease tension between the core responsibilities of forensic mental health services. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02360813. Trial registered Feb 4th 2015 and last updated May 1(st) 2015.
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Affiliation(s)
- Ken O'Reilly
- Department of Psychiatry, Trinity College Dublin, Dublin, Ireland.
- National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland.
| | - Gary Donohoe
- Department of Psychiatry, Trinity College Dublin, Dublin, Ireland.
| | - Danny O'Sullivan
- National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland.
| | - Ciaran Coyle
- National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland.
| | - Ronan Mullaney
- Department of Psychiatry, Trinity College Dublin, Dublin, Ireland.
- National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland.
| | - Paul O'Connell
- Department of Psychiatry, Trinity College Dublin, Dublin, Ireland.
- National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland.
| | - Catherine Maddock
- National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland.
| | - Andrea Nulty
- National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland.
| | - Padraic O'Flynn
- National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland.
| | - Carina O'Connell
- National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland.
| | - Harry G Kennedy
- Department of Psychiatry, Trinity College Dublin, Dublin, Ireland.
- National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland.
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Bannuru RR, McAlindon TE, Sullivan MC, Wong JB, Kent DM, Schmid CH. Effectiveness and Implications of Alternative Placebo Treatments: A Systematic Review and Network Meta-analysis of Osteoarthritis Trials. Ann Intern Med 2015. [PMID: 26215539 DOI: 10.7326/m15-0623] [Citation(s) in RCA: 127] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Placebo controls are essential in evaluating the effectiveness of medical treatments. Although it is unclear whether different placebo interventions for osteoarthritis vary in efficacy, systematic differences would substantially affect interpretation of the results of placebo-controlled trials. OBJECTIVE To evaluate the effects of alternative placebo types on pain outcomes in knee osteoarthritis. DATA SOURCES MEDLINE, EMBASE, Web of Science, Google Scholar, and Cochrane Database from inception through 1 June 2015 and unpublished data. STUDY SELECTION 149 randomized trials of adults with knee osteoarthritis that reported pain outcomes and compared widely used pharmaceuticals against oral, intra-articular, topical, and oral plus topical placebos. DATA EXTRACTION Study data were independently double-extracted; study quality was assessed by using the Cochrane risk of bias tool. DATA SYNTHESIS Placebo effects that were evaluated by using a network meta-analysis with 4 separate placebo nodes (differential model) showed that intra-articular placebo (effect size, 0.29 [95% credible interval, 0.09 to 0.49]) and topical placebo (effect size, 0.20 [credible interval, 0.02 to 0.38]) had significantly greater effect sizes than did oral placebo. This differential model showed marked differences in the relative efficacies and hierarchy of the active treatments compared with a network model that considered all placebos equivalent. In the model accounting for differential effects, intra-articular and topical therapies were superior to oral treatments in reducing pain. When these differential effects were ignored, oral nonsteroidal anti-inflammatory drugs were superior. LIMITATIONS Few studies compared different placebos directly. The study could not decisively conclude whether disease severity and co-interventions systematically differed between trials evaluating different placebos. CONCLUSION All placebos are not equal, and some can trigger clinically relevant responses. Differential placebo effects can substantially alter estimates of the relative efficacies of active treatments, an important consideration for the design of clinical trials and interpretation of their results. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.
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Affiliation(s)
- Raveendhara R. Bannuru
- From Tufts Medical Center, Sackler School of Graduate Biomedical Sciences of Tufts University, Boston, Massachusetts, and Brown University School of Public Health, Providence, Rhode Island
| | - Timothy E. McAlindon
- From Tufts Medical Center, Sackler School of Graduate Biomedical Sciences of Tufts University, Boston, Massachusetts, and Brown University School of Public Health, Providence, Rhode Island
| | - Matthew C. Sullivan
- From Tufts Medical Center, Sackler School of Graduate Biomedical Sciences of Tufts University, Boston, Massachusetts, and Brown University School of Public Health, Providence, Rhode Island
| | - John B. Wong
- From Tufts Medical Center, Sackler School of Graduate Biomedical Sciences of Tufts University, Boston, Massachusetts, and Brown University School of Public Health, Providence, Rhode Island
| | - David M. Kent
- From Tufts Medical Center, Sackler School of Graduate Biomedical Sciences of Tufts University, Boston, Massachusetts, and Brown University School of Public Health, Providence, Rhode Island
| | - Christopher H. Schmid
- From Tufts Medical Center, Sackler School of Graduate Biomedical Sciences of Tufts University, Boston, Massachusetts, and Brown University School of Public Health, Providence, Rhode Island
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Essex MN, O'Connell MA, Behar R, Bao W. Efficacy and safety of nonsteroidal anti-inflammatory drugs in Asian patients with knee osteoarthritis: summary of a randomized, placebo-controlled study. Int J Rheum Dis 2015; 19:262-70. [PMID: 25990559 PMCID: PMC5032971 DOI: 10.1111/1756-185x.12667] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Aim To compare the efficacy, tolerability and safety of celecoxib, naproxen and placebo in Asian patients with osteoarthritis (OA) of the knee. Method Patients of Asian descent with knee OA, aged ≥ 45 years, in a flare state with a functional capacity classification of I–III, received celecoxib 200 mg once daily, naproxen 500 mg twice daily or placebo, for 6 weeks. The change in Patient's Assessment of Arthritis Pain (week 6 vs. baseline) was the primary endpoint. Secondary endpoints, including Patient's and Physician's Global Assessments of Arthritis, Western Ontario and McMaster Universities OA Index (WOMAC), use of complementary and alternative medicines, incidence of treatment‐emergent adverse events (TEAEs) and measurements of upper gastrointestinal tolerability, were also assessed. Results Three hundred and sixty‐seven patients were randomized: 145 to celecoxib, 144 to naproxen and 78 to placebo. Celecoxib was as effective as naproxen in reducing OA pain (least squares mean change from baseline in visual analogue scale score [standard error] −37.1 [2.0] for celecoxib and −37.5 [2.0] for naproxen). Patient's and Physician's Global Assessment of Arthritis, WOMAC scores, Pain Satisfaction Scale and Patient Health Questionnaire‐9 showed statistically significant improvement in active treatment groups versus placebo, with the exception of naproxen WOMAC scores. Treatment‐related TEAEs occurred in 19 (13%), 34 (24%) and six (8%) patients in the celecoxib, naproxen and placebo groups, respectively. Conclusion Celecoxib and naproxen were comparable in their effects to reduce the signs and symptoms of knee OA in Asian patients. Celecoxib was shown to be safe and well tolerated in this patient population.
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Affiliation(s)
| | | | - Regina Behar
- US Medical Affairs, Pfizer Inc, New York, New York, USA
| | - Weihang Bao
- Biostatistics, Pfizer Inc, New York, New York, USA
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Asmus MJ, Essex MN, Brown PB, Mallen SR. Efficacy and tolerability of celecoxib in osteoarthritis patients who previously failed naproxen and ibuprofen: results from two trials. ACTA ACUST UNITED AC 2014. [DOI: 10.2217/ijr.14.45] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Essex MN, Behar R, O'Connell MA, Brown PB. Efficacy and tolerability of celecoxib and naproxen versus placebo in Hispanic patients with knee osteoarthritis. Int J Gen Med 2014; 7:227-35. [PMID: 24876792 PMCID: PMC4037303 DOI: 10.2147/ijgm.s61297] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Celecoxib is an effective treatment for osteoarthritis (OA). However, information on its efficacy and safety profile in different racial/ethnic groups is limited. Noticeable differences among racial groups are found in other disease states, but a thorough investigation of OA is lacking. The objective of this study was to determine if celecoxib 200 mg once daily is as effective as naproxen 500 mg twice daily in the treatment of OA of the knee in Hispanic patients. Methods Hispanic patients aged ≥45 years with knee OA were randomized to receive celecoxib 200 mg once daily, naproxen 500 mg twice daily, or placebo for 6 weeks. The primary efficacy variable was the change in Patient’s Assessment of Arthritis Pain at 6 weeks compared with baseline. Secondary variables were change in Patient’s and Physician’s Global Assessments of Arthritis from baseline to week 6/early termination, change in Western Ontario and McMaster Universities OA Index (WOMAC) from baseline to week 6/early termination, change in American Pain Society pain score, Pain Satisfaction Scale, Patient Health Questionnaire (PHQ-9), and measurements of upper gastrointestinal tolerability. Results In total, 239 patients completed the trial (96 celecoxib, 96 naproxen, 47 placebo). Celecoxib was as effective as naproxen in reducing OA pain (least squares mean change from baseline [standard error] −39.7 [2.7] for celecoxib and −36.9 [2.6] for naproxen). Patient’s and Physician’s Global Assessments of Arthritis, WOMAC scores, upper gastrointestinal tolerability, Pain Satisfaction Scale, and PHQ-9 showed no statistically significant differences between the celecoxib and naproxen groups. The incidence of adverse events and treatment-related adverse events were similar among the treatment groups. Conclusion Celecoxib 200 mg once daily was as effective as naproxen 500 mg twice daily in the treatment of signs and symptoms of knee OA in Hispanic patients. Celecoxib was shown to be safe and well tolerated in this patient population.
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Essex MN, Zhang RY, Berger MF, Upadhyay S, Park PW. Safety of celecoxib compared with placebo and non-selective NSAIDs: cumulative meta-analysis of 89 randomized controlled trials. Expert Opin Drug Saf 2013; 12:465-77. [DOI: 10.1517/14740338.2013.780595] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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