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Study protocol for a randomised controlled trial of diacerein versus placebo to treat knee osteoarthritis with effusion-synovitis (DICKENS). Trials 2022; 23:768. [PMID: 36089595 PMCID: PMC9464426 DOI: 10.1186/s13063-022-06715-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/04/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
There is an unmet need for treatments for knee osteoarthritis (OA). Effusion-synovitis is a common inflammatory phenotype of knee OA and predicts knee pain and structural degradation. Anti-inflammatory therapies, such as diacerein, may be effective for this phenotype. While diacerein is recommended for alleviating pain in OA patients, evidence for its effectiveness is inconsistent, possibly because studies have not targeted patients with an inflammatory phenotype. Therefore, we will conduct a multi-centre, randomised, placebo-controlled double-blind trial to determine the effect of diacerein on changes in knee pain and effusion-synovitis over 24 weeks in patients with knee OA and magnetic resonance imaging (MRI)-defined effusion-synovitis.
Methods
We will recruit 260 patients with clinical knee OA, significant knee pain, and MRI-detected effusion-synovitis in Hobart, Melbourne, Adelaide, and Perth, Australia. They will be randomly allocated to receive either diacerein (50mg twice daily) or identical placebo for 24 weeks. MRI of the study knee will be performed at screening and after 24 weeks of intervention. The primary outcome is improvement in knee pain at 24 weeks as assessed by a 100-mm visual analogue scale (VAS). Secondary outcomes include improvement in volumetric (ml) and semi-quantitative (Whole-Organ Magnetic Resonance Imaging Score, 0–3) measurements of effusion-synovitis using MRI over 24 weeks, and improvement in knee pain (VAS) at 4, 8, 12, 16, and 20 weeks. Intention-to-treat analyses of primary and secondary outcomes will be performed as the primary analyses. Per protocol analyses will be performed as the secondary analyses.
Discussion
This study will provide high-quality evidence to determine whether diacerein improves pain, changes disease trajectory, and slows disease progression in OA patients with effusion-synovitis. If diacerein proves effective, this has the potential to significantly benefit the substantial proportion (up to 60%) of knee OA patients with an inflammatory phenotype.
Trial registration
Australian and New Zealand Clinical Trial Registry ACTRN12618001656224. Registered on 08 October 2018.
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Laslett LL, Antony B, Wluka AE, Hill C, March L, Keen HI, Otahal P, Cicuttini FM, Jones G. KARAOKE: Krill oil versus placebo in the treatment of knee osteoarthritis: protocol for a randomised controlled trial. Trials 2020; 21:79. [PMID: 31937352 PMCID: PMC6961372 DOI: 10.1186/s13063-019-3915-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 11/18/2019] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Knee osteoarthritis (OA) is a common and important cause of pain and disability, but interventions aimed at modifying structures visible on imaging have been disappointing. While OA affects the whole joint, synovitis and effusion have been recognised as having a role in the pathogenesis of OA. Krill oil reduces knee pain and systemic inflammation and could be used for targeting inflammatory mechanisms of OA. METHODS/DESIGN We will recruit 260 patients with clinical knee OA, significant knee pain and effusion-synovitis present on MRI in five Australian cities (Hobart, Melbourne, Sydney, Adelaide and Perth). These patients will be randomly allocated to the two arms of the study, receiving 2 g/day krill oil or inert placebo daily for 6 months. MRI of the study knee will be performed at screening and after 6 months. Knee symptoms, function and MRI structural abnormalities will be assessed using validated methods. Safety data will be recorded. Primary outcomes are absolute change in knee pain (assessed by visual analog score) and change in size of knee effusion-synovitis over 24 weeks. Secondary outcomes include improvement in knee pain over 4, 8, 12, 16 and 20 weeks. The primary analyses will be intention-to-treat analyses of primary and secondary outcomes. Per protocol analyses adjusting for missing data and for treatment compliance will be performed as the secondary analyses. DISCUSSION This study will provide high-quality evidence to assess whether krill oil 2 g/day reduces pain and effusion-synovitis size in older adults with clinical knee OA and knee effusion-synovitis. If krill oil is effective and confirmed to be safe, we will provide compelling evidence that krill oil improves pain and function, changes disease trajectory and slows disease progression in OA. Given the lack of approved therapies for slowing disease progression in OA, and moderate cost of krill oil, these findings will be readily translated into clinical practice. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry, ACTRN12616000726459. Registered on 02 June 2016. Universal Trial Number (UTN) U1111-1181-7087.
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Affiliation(s)
- L L Laslett
- Menzies Institute for Medical Research, University of Tasmania, Private Bag 23, Hobart, TAS, 7000, Australia.
| | - B Antony
- Menzies Institute for Medical Research, University of Tasmania, Private Bag 23, Hobart, TAS, 7000, Australia
| | - A E Wluka
- Department of Epidemiology and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, VIC, 3004, Australia
| | - C Hill
- The Queen Elizabeth Hospital, University of Adelaide, Woodville, SA, 5011, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, SA, 5005, Australia
| | - L March
- Royal North Shore Hospital, The University of Sydney, Sydney, NSW, 2006, Australia
| | - H I Keen
- Department of Rheumatology, Fiona Stanley Hospital, Murdoch Drive, Murdoch, WA, 6150, Australia.,Medical School, University of Western Australia, Crawley, 6009, WA, Australia
| | - P Otahal
- Menzies Institute for Medical Research, University of Tasmania, Private Bag 23, Hobart, TAS, 7000, Australia
| | - F M Cicuttini
- Department of Epidemiology and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, VIC, 3004, Australia
| | - G Jones
- Menzies Institute for Medical Research, University of Tasmania, Private Bag 23, Hobart, TAS, 7000, Australia
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Aitken D, Laslett LL, Cai G, Hill C, March L, Wluka AE, Wang Y, Blizzard L, Cicuttini F, Jones G. A protocol for a multicentre, randomised, double-blind, placebo-controlled trial to compare the effect of annual infusions of zoledronic acid to placebo on knee structural change and knee pain over 24 months in knee osteoarthritis patients - ZAP2. BMC Musculoskelet Disord 2018; 19:217. [PMID: 30021646 PMCID: PMC6052532 DOI: 10.1186/s12891-018-2143-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 06/19/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Bisphosphonates are a class of drugs that slow bone loss and are a promising candidate to treat knee osteoarthritis (OA) patients. In a pilot study, we demonstrated that zoledronic acid reduced knee pain and size of subchondral bone marrow lesions (BMLs) over 6 months in knee OA patients with significant knee pain and BMLs. A longer, larger study is required to assess whether decreases in BML size will translate to reductions in cartilage loss over time. We are currently conducting a multicentre, randomised, double-blind, placebo-controlled trial over 24 months that aims to compare the effect of annual infusions of zoledronic acid to placebo on knee structural change (assessed using magnetic resonance imaging (MRI)) and knee pain in knee OA patients. METHODS Two hundred sixty-four patients with clinical knee OA, significant knee pain and subchondral BMLs present on MRI will be recruited in Hobart, Melbourne, Sydney and Adelaide. They will be randomly allocated to the two arms of the study, receiving an annual identical intravenous infusion of either 100 mL of fluid containing zoledronic acid (5 mg/100 mL) or placebo (0.9% NaCl 100 mL), at baseline and 1 year later. MRI of the study knee will be performed at screening, month 6 and 24. Knee structure, symptoms and function will be assessed using validated methods. The primary outcome is absolute change in tibiofemoral cartilage volume (mm3) over 24 months. Secondary outcomes include improvement in knee pain over 3, 6, 12, 18, and 24 months and reductions in BML size over 6 and 24 months. The primary analyses will be intention-to-treat analyses of primary and secondary outcomes. Per protocol analyses will be performed as the secondary analyses. DISCUSSION This study will provide high-quality evidence to assess whether zoledronic acid has a novel disease modifying effect in OA by slowing cartilage loss and reducing pain. If zoledronic acid proves effective, it suggests great potential for cost savings through a delay or reduced need for joint replacement surgery, and potential for great improvements in quality of life for OA suffers. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry: ACTRN12613000039785 , registered on 14 January 2013.
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Affiliation(s)
- Dawn Aitken
- Menzies Institute for Medical Research, University of Tasmania, Private Bag 23, Hobart, TAS 7000 Australia
| | - Laura L. Laslett
- Menzies Institute for Medical Research, University of Tasmania, Private Bag 23, Hobart, TAS 7000 Australia
| | - Guoqi Cai
- Menzies Institute for Medical Research, University of Tasmania, Private Bag 23, Hobart, TAS 7000 Australia
| | - Catherine Hill
- The Queen Elizabeth Hospital, University of Adelaide, Woodville, SA 5011 Australia
- Discipline of Medicine, University of Adelaide, Adelaide, SA 5005 Australia
| | - Lyn March
- The University of Sydney, Royal North Shore Hospital, Sydney, NSW 2006 Australia
| | - Anita E. Wluka
- Department of Epidemiology and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, 3004 Australia
| | - Yuanyuan Wang
- Department of Epidemiology and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, 3004 Australia
| | - Leigh Blizzard
- Menzies Institute for Medical Research, University of Tasmania, Private Bag 23, Hobart, TAS 7000 Australia
| | - Flavia Cicuttini
- Department of Epidemiology and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, 3004 Australia
| | - Graeme Jones
- Menzies Institute for Medical Research, University of Tasmania, Private Bag 23, Hobart, TAS 7000 Australia
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Ude CC, Shamsul BS, Ng MH, Chen HC, Ohnmar H, Amaramalar SN, Rizal AR, Johan A, Norhamdan MY, Azizi M, Aminuddin BS, Ruszymah BHI. Long-term evaluation of osteoarthritis sheep knee, treated with TGF-β3 and BMP-6 induced multipotent stem cells. Exp Gerontol 2018; 104:43-51. [PMID: 29421350 DOI: 10.1016/j.exger.2018.01.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 12/09/2017] [Accepted: 01/16/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Hyaline articular cartilage, which protects the bones of diarthrodial joints from forces associated with load bearing, frictions, and impacts has very limited capacities for self-repair. Over the years, the trend of treatments has shifted to regenerations and researchers have been on the quest for a lasting regeneration. We evaluated the treatment of osteoarthritis by chondrogenically induced ADSCs and BMSCs for a long time functional recovery. METHODS Osteoarthritis was induced at the right knee of sheep by complete resection of ACL and medial meniscus. Stem cells from sheep were induced to chondrogenic lineage. Test sheep received 5 mls single doses of 2 × 107 autologous PKH26-labelled ADSCs or BMSCs, while controls received basal medium. Functional recovery of the knees was evaluated via electromyography. RESULTS Induced ADSCs had 625, 255, 393, 908, 409, 157 and 1062 folds increases of collagen I, collagen II, aggrecan, SOX9, cartilage oligomeric protein, chondroadherin and fibromodullin compare to uninduced cells, while BMSCs had 702, 657, 321, 276, 337, 233 and 1163 respectively; p = .001. Immunocytochemistry was positive for these chondrogenic markers. 12 months post-treatment, controls scored 4 in most regions using ICRS, while the treated had 8; P = .001. Regenerated cartilages were positive to PKH26 and demonstrated the presence of condensing cartilages on haematoxylin and eosin; and Safranin O. OA degenerations caused significant amplitude shift from right to left hind limb. After treatments, controls persisted with significant decreases; while treated samples regained balance. CONCLUSIONS Both ADSCs and BMSCs had increased chondrogenic gene expressions using TGF-β3 and BMP-6. The treated knees had improved cartilage scores; PKH26 can provide elongated tracking, while EMG results revealed improved joint recoveries. These could be suitable therapies for osteoarthritis.
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Affiliation(s)
- C C Ude
- Tissue Engineering Centre, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, Cheras 56000, K.L, Malaysia; Bioartificial Organ and Regenerative Medicine Unit, National Defence University of Malaysia, Sungai Besi Camp 57000, K.L, Malaysia
| | - B S Shamsul
- Tissue Engineering Centre, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, Cheras 56000, K.L, Malaysia
| | - M H Ng
- Tissue Engineering Centre, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, Cheras 56000, K.L, Malaysia
| | - H C Chen
- Faculty of Veterinary Medicine, Universiti Putra Malaysia, 43400 Serdang, Malaysia.
| | - Htwe Ohnmar
- Rehab Unit, Department of Orthopedic & Traumatology, Universiti Kebangsaan Malaysia Medical Center, Jalan Yaacob Latif, Bandar Tun Razak, Cheras 56000, K.L, Malaysia
| | - S N Amaramalar
- Rehab Unit, Department of Orthopedic & Traumatology, Universiti Kebangsaan Malaysia Medical Center, Jalan Yaacob Latif, Bandar Tun Razak, Cheras 56000, K.L, Malaysia
| | - A R Rizal
- Department of Orthopedic & Traumatology, Universiti Kebangsaan Malaysia Medical Center, Jalan Yaacob Latif, Bandar Tun Razak, Cheras 56000, K.L, Malaysia.
| | - A Johan
- Department of Orthopedic & Traumatology, Universiti Kebangsaan Malaysia Medical Center, Jalan Yaacob Latif, Bandar Tun Razak, Cheras 56000, K.L, Malaysia
| | - M Y Norhamdan
- Department of Orthopedic & Traumatology, Universiti Kebangsaan Malaysia Medical Center, Jalan Yaacob Latif, Bandar Tun Razak, Cheras 56000, K.L, Malaysia
| | - M Azizi
- Bioartificial Organ and Regenerative Medicine Unit, National Defence University of Malaysia, Sungai Besi Camp 57000, K.L, Malaysia
| | - B S Aminuddin
- Tissue Engineering Centre, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, Cheras 56000, K.L, Malaysia; ENT Consultant Clinic, Ampang Putri Specialist Hospital, 68000 Ampang, Malaysia
| | - B H I Ruszymah
- Tissue Engineering Centre, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, Cheras 56000, K.L, Malaysia; Department of Physiology, Medical Faculty, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif Bandar Tun Razak Muda Abdul Aziz, Campus, 56000 K.L, Malaysia..
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Jones G. What's new in osteoarthritis pathogenesis? Intern Med J 2016; 46:229-36. [DOI: 10.1111/imj.12763] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 01/31/2015] [Indexed: 01/03/2023]
Affiliation(s)
- G. Jones
- Menzies Institute for Medical Research; University of Tasmania; Hobart Tasmania Australia
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Panova E, Jones G. Benefit–Risk Assessment of Diacerein in the Treatment of Osteoarthritis. Drug Saf 2015; 38:245-52. [DOI: 10.1007/s40264-015-0266-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Jones G, Winzenberg TM, Callisaya ML, Laslett LL. Lifestyle modifications to improve musculoskeletal and bone health and reduce disability--a life-course approach. Best Pract Res Clin Rheumatol 2014; 28:461-78. [PMID: 25481426 DOI: 10.1016/j.berh.2014.07.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This review covers the evidence relating to lifestye modification in the big three musculoskeletal conditions: osteoarthritis, osteoporosis and rheumatoid arthritis. Lifestyle is of considerable importance in the first two and there is emerging evidence for rheumatoid arthritis despite it not traditionally being considered a lifestyle disease.
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Affiliation(s)
- Graeme Jones
- Menzies Research Institute Tasmania, University of Tasmania, Private bag 23, Hobart, Tasmania 7000, Australia.
| | - Tania M Winzenberg
- Menzies Research Institute Tasmania, University of Tasmania, Private bag 23, Hobart, Tasmania 7000, Australia.
| | - Michele L Callisaya
- Menzies Research Institute Tasmania, University of Tasmania, Private bag 23, Hobart, Tasmania 7000, Australia; Department of Medicine, Monash University, 246 Clayton Rd, Clayton, Victoria 3168, Australia.
| | - Laura L Laslett
- Menzies Research Institute Tasmania, University of Tasmania, Private bag 23, Hobart, Tasmania 7000, Australia.
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Neuropathic pain in osteoarthritis: a review of pathophysiological mechanisms and implications for treatment. Semin Arthritis Rheum 2014; 44:145-54. [PMID: 24928208 DOI: 10.1016/j.semarthrit.2014.05.011] [Citation(s) in RCA: 135] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 05/06/2014] [Accepted: 05/09/2014] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Osteoarthritis (OA) is the leading cause of musculoskeletal pain and functional disability worldwide, affecting a growing number of individuals in the western society. Despite various conservative and interventional treatment approaches, the overall management of the condition is problematic, and pain-the major clinical problem of the disease-remains sub-optimally controlled. The objectives of this review are to present the pathophysiologic mechanisms underlying the complexity of pain in OA and to discuss the challenges for new treatment strategies aiming to translate experimental findings into daily clinical practice. METHODS A narrative literature review of studies investigating the existence of a neuropathic component in OA pain was conducted. We searched PubMed, Embase and Scopus for English language publications. A hand-search of reference lists of relevant studies was also performed. RESULTS Recent advances have shed additional light on the pathophysiology of osteoarthritic pain, highlighting the contribution of central pain pathways together with the sensitisation of peripheral joint receptors and changes of the nociceptive process induced by local joint inflammation and structural bone tissue changes. Thus, a neuropathic pain component may be predominant in individuals with minor joint changes but with high levels of pain refractory to analgesic treatment, providing an alternative explanation for osteoarthritic pain perception. CONCLUSION A growing amount of evidence suggests that the pain in OA has a neuropathic component in some patients. The deeper understanding of multiple mechanisms of OA pain has led to the use of centrally acting medicines that may have a benefit on alleviating osteoarthritic pain. The ineffective pain management and the increasing rates of disability associated with OA mandate for change in our treatment paradigm.
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